The 'Loss of Peak Vision' in Branch Retinal Vein Occlusion: Real-World Implications for Stratified Intervention

Branch retinal vein occlusion (BRVO) is the second most common retinal vascular disorder. This study evaluated the real-world visual and anatomical outcomes of intravitreal aflibercept in BRVO, addressing the gap between clinical trials and daily practice, and aimed to identify distinct response phenotypes that predict functional decline.

This retrospective analysis included 96 BRVO patients receiving aflibercept monotherapy over 12 months. Patients were stratified into three groups based on anatomical response: Resolved (sustained dry macula), Recurrent (fluid recurrence after initial resolution), and Persistent (incomplete resolution). The primary outcome was change in best-corrected visual acuity (BCVA).

At 12 months, eyes were Resolved (52%), Recurrent (27%), or Persistent (21%). The Resolved group achieved the best visual outcomes (-0.29 logMAR; 95% CI: -0.38 to -0.20), whereas the Recurrent group showed the least improvement (-0.05 logMAR; 95% CI: -0.22 to 0.12; p = 0.021 vs. Resolved). Despite achieving complete fluid resolution at month 3, this group experienced significant rebound by month 6. Total injections (p = 0.808) and the distribution of treatment strategies did not differ among groups. Baseline BCVA (β = 0.411, 95% CI: 0.202-0.619; p = 0.001) and treat-and-extend (T&E) regimen (β = 0.244, 95% CI: 0.033-0.454; p = 0.025) significantly predicted visual improvement, whereas baseline central macular thickness and systemic factors were not.

In a real-world setting, nearly half of BRVO patients exhibit unstable phenotypes. Despite comparable treatment intensity, cumulative damage from fluid fluctuations causes irreversible visual loss in the Recurrent group. This supports a stratified intervention strategy: evaluating month-3 response to establish strict T&E intervals or early treatment modifications, mitigating preventable vision loss.