Sir,

We read with interest the clinical study of Almuhtaseb et al1 on real-world outcomes in patients receiving fixed dosing aflibercept for neovascular age-related macular degeneration.

We would like to share our experience with a modified IVAN protocol that seems more cost effective than PRN, Treat-and-extend, and Fixed dosing in comparison to Almuhtaseb’s Table 2 while maintaining MARINA-like outcomes (Figure 1). The IVAN protocol was defined as ‘re-treat with IVI x 3’ in case of disease activity.2 Our modification was to drop the follow-up visits between a course of three consecutive intravitreal injections (IVI) similar to current fixed dosing regimes.

Figure 1
figure 1

VA outcomes with a modified IVAN protocol. ‘This Centre’=North Devon District Hospital.

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Our mean number of doses per year with modified IVAN are 3.6 (Figure 2).

Figure 2
figure 2

Anti-VEGF injection frequency over 7 years (2009–2016).

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Our mean number of outpatient visits with OCT and VA are 10.4 (Figure 3).

Figure 3
figure 3

Anti-VEGF visit frequency over 7 years (2009–2016).

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Aflibercept versus Ranibizumab usage is currently ~50% in our service.

This results in a cost of this pathway of ~£4124 per patient per year. This is significantly cheaper than PRN (£8920), Treat-and-extend (£9968.70), and Fixed dosing (£6919).

A modified IVAN protocol offers the best of both worlds as the element of fixed dosing provides predictability of service demand and patient satisfaction due to the ability to pre-book three consecutive injections. The PRN element reduces the risk of over treatment as well as overall injection frequency. VA outcomes are similar to monthly Ranibizumab (Figure 1).