AAOpt 2026: Aflibercept 8 mg extends RVO dosing as Amsler misses AMD damage

Aflibercept 8 mg (Eylea HD; Regeneron) matched aflibercept 2 mg for visual acuity gains in macular edema following retinal vein occlusion (RVO), with up to 3 fewer injections through 64 weeks in the QUASAR trial.¹ Raman Bhakhri, OD, FAAO, presented the data at the American Academy of Optometry Annual Meeting, held in Anaheim, California, alongside posters on Amsler grid limits in age-related macular degeneration (AMD) and a retinal embolic event revealing severe carotid stenosis.^1-3

For optometrists comanaging retinal disease, the posters span detection, urgent referral, and the treatment course patients face after referral. All three were presented at the American Academy of Optometry annual meeting.

QUASAR trial results for aflibercept 8 mg in RVO

QUASAR (NCT05850520) was a 64-week, randomized, double-masked, noninferiority phase 3 trial.¹ Patients were randomized 1:1:1 to aflibercept 8 mg every 8 weeks after 3 monthly doses (8q8/3; n = 293) or 5 monthly doses (8q8/5; n = 298), or 2 mg every 4 weeks (2q4; n = 301). Protocol criteria allowed interval shortening or extension, with a minimum interval of every 4 weeks.

Both 8-mg regimens met the primary end point of noninferior best-corrected visual acuity change at week 36, using a 4-letter margin. Least squares mean differences vs 2q4 were −0.1 letters (95% CI, −2.0 to 1.9) for 8q8/3 and +0.8 letters (95% CI, −1.1 to 2.7) for 8q8/5 (both P <.001). Gains were maintained through week 64, and the 8-mg safety profile was consistent with the established profile of aflibercept 2 mg.

Least squares mean differences in injections through week 64 were −3.2 (95% CI, −3.5 to −3.0) for 8q8/3 and −2.2 (95% CI, −2.4 to −2.0) for 8q8/5. At week 64, 81.4% of the 8q8/3 group and 78.5% of the 8q8/5 group had a last completed interval of 12 weeks or longer, compared with 67.8% with 2q4.¹ Fewer patients required monthly dosing with 8 mg (4.8% and 3.5% vs 13%), and 40.5% of the 8q8/3 group were assigned 20-week intervals.

How well does the Amsler grid reflect structural damage in AMD?

Daniel Rafla, MOptom, MPhil, and colleagues at the Centre for Eye Health in Sydney, Australia, compared en face optical coherence tomography (OCT) with recorded Amsler charts in eyes with intermediate or late AMD.² The study group included 42 eyes with a positive Amsler change, and 80 Amsler-negative eyes matched for age, acuity, and disease stage served as controls. After correcting Amsler results for retinal projection, investigators superimposed functional defects onto annotated OCT scans to quantify concordance.

Only 2.73% of total area (IQR, 1.13%-8.16%) in Amsler-positive eyes showed defects on both OCT and the Amsler grid. Most defective areas were structure-only, with a median of 42.44% (IQR, 19.74%-69.63%) abnormal on OCT but normal on Amsler. The groups did not differ significantly in OCT structural damage or in diabetes, dry eye, floaters, or cataract (P > .05).

Amsler-positive eyes differed from controls in visual acuity (P = .001). The authors concluded Amsler changes track more closely with patient-perceived visual dysfunction than with comorbidities, possibly reflecting perceptual filling-in. As Amsler-positive eyes were significantly different from Amsler-negative eyes for visual acuity and reported changes to vision (P = .650), the data suggest that none of the OCT factors contributed to the presence of functional defects in Amsler-positive eyes.

Branch retinal artery occlusion as a warning sign for stroke

Emily Gibson, OD, described a 71-year-old man with type 2 diabetes, hypertension, peripheral vascular disease, and chronic kidney disease who reported a gray area in his vision beginning one day earlier.³ Dilated examination of the right eye showed 5 plaques at arterial bifurcations across the inferotemporal and superonasal arcades with retinal whitening, consistent with multifocal branch retinal artery occlusion (BRAO). OCT showed inferior inner retinal thickening, and visual acuity was 20/25-2 in the affected eye.

Gibson sent the patient directly to the emergency department for stroke workup. CT angiography revealed 80% right and 60% left carotid bifurcation stenosis plus high-grade right vertebral artery stenosis, and the patient underwent urgent endarterectomy.³

Gibson cited a 13.9% incidence of ischemic stroke after BRAO from recent literature and urged same-day vascular referral for these patients.^3,4 Because plaques spanned 2 arcades and the patient had diabetes, Gibson planned gonioscopy and fundus examination beginning at 1 month to monitor for neovascularization.

For optometrists, the Rafla data suggest Amsler findings alone may understate disease extent in intermediate or late AMD, supporting OCT-based monitoring.² The Gibson case reinforces BRAO as a same-day referral, and the QUASAR data may help optometrists set expectations for injection burden after referral to a retina specialist.^1,3

References

1. Bhakhri R. Aflibercept 8 mg in macular edema following retinal vein occlusion (MEfRVO): 64-week results from the QUASAR trial. Poster presented at: Academy 2026 Anaheim; October 1, 2026; Anaheim, CA.

2. Rafla D, Phu J, Nivison-Smith L, Khuu S. Amsler chart under-represents extent of structural damage in AMD: a novel quantitative structure-function analysis. Poster presented at: Academy 2026 Anaheim; October 1, 2026; Anaheim, CA.

3. Gibson E. A window to the carotids: multifocal branch retinal artery occlusion unmasking occult stroke risk. Poster presented at: Academy 2026 Anaheim; October 2, 2026; Anaheim, CA.

4. Pothikamjorn T, Charnnarong C, Susantitaphong P, Jariyakosol S. Incidence and risk factors associated with ischemic cerebrovascular disease in patients with retinal artery occlusion: a systematic review and meta-analysis. Sci Rep. 2025;15:33244.