Case 1: Middle-aged patient with difficult-to-extend DME
History and presentation
A 54-year-old male with an 8-year history of type 2 diabetes (T2D; HbA1c, 8 percent) reported blurred vision in the right eye (OD) on 5 June 2023. He was diagnosed with OD diabetic macular oedema (DME) and bilateral (OU) proliferative diabetic retinopathy (PDR).
Baseline visual acuity (VA) OD was 0.5, and optical coherence tomography (OCT) showed a central retinal thickness (CRT) of 404 μm. (Figure 1A)
Treatment and response
The patient received intravitreal (IVT) anti–vascular endothelial growth factor (anti-VEGF) treatment with aflibercept 2 mg for DME OD. He subsequently underwent panretinal photocoagulation for PDR OU.
The patient remained on aflibercept 2 mg from 2023 to 2025, but repeated attempts to extend the treatment interval beyond Q8W were unsuccessful. (Figure 1B) This created a significant treatment burden as he needed to take frequent leave from work for injections.
On 10 March 2025, the patient switched to IVT aflibercept 8 mg, aiming to extend the treatment interval.1 He tolerated the treatment well and did not experience any adverse events (AEs).
On 6 May 2025, 2 months after the first aflibercept 8 mg dose, OCT OD revealed a dry macula and a reduction in CRT from 277 to 262 μm. VA improved from 0.4 to 0.6. (Figure 1C) The patient received the second dose of aflibercept 8 mg on the same day. Treatment interval was gradually extended by 4-week increments, with relatively stable OCT findings and VA observed in August and December 2025. (Figures 1D & 1E)
In January 2026, the patient underwent vitrectomy due to poorly controlled PDR in the left eye (OS), which was not previously treated with any anti-VEGF agents. His OD, which was treated with aflibercept 8 mg, remained stable without the need for surgery, while VA OD further improved to 0.7 and CRT was 243 μm with a Q16W treatment interval. (Figure 1F) The patient is satisfied with his treatment as it requires fewer follow-up visits and is therefore less disruptive to his work. The plan is to further extend treatment interval to Q20W if he remains stable at the next visit in April 2026.
Case 2: Elderly patient with DME and suboptimal fluid control
History and presentation
A 65-year-old female with T2D (HbA1c, 13.5 percent) and moderate non-proliferative diabetic retinopathy presented with blurred vision on 1 April 2020 and was diagnosed with DME OD. Baseline examinations showed VA OD of 0.16 and CRT OD of 588 μm. (Figure 2A)
Treatment and response
The patient received IVT aflibercept 2 mg OD on the same day. After the loading phase, she continued treatment at Q8W interval until 2025. However, despite improved CRT, the macula was not completely dry. As the patient needed to be accompanied by a caregiver for clinic visits, she refused to shorten the treatment interval to Q4W, which would increase the treatment burden. (Figure 2B)
On 19 March 2025, the patient switched to IVT aflibercept 8 mg with the aim of achieving better disease control and a longer treatment interval.1 On 14 May 2025, 2 months after the first aflibercept 8 mg injection, CRT OD improved from 388 to 297 μm, while VA remained stable. (Figure 2C) Following the second dose, the treatment interval was extended to Q12W. Successive OCT OD findings in August and November 2025 demonstrated improvement in CRT and stable VA. (Figures 2D & 2E)
Overall, the patient tolerated aflibercept 8 mg Q12W well and achieved a favourable response. At her latest visit on 5 February 2026, VA improved from 0.1 to 0.4 and CRT decreased from 388 to 224 μm after treatment with IVT aflibercept 8 mg. (Figures 2B & 2F) She remains on a Q12W treatment schedule, with the option of extending to Q16W in the future if OCT findings remain stable. She is satisfied with sustained disease control and the extended interval, which reduces treatment burden for both herself and her caregiver.
Discussion
DME is a leading cause of vision loss in patients with diabetes.2 Anti-VEGF agents such as aflibercept 2 mg are well-established first-line treatment options for DME. However, as shown in our two cases, frequent injections can be burdensome for patients and their caregivers due to conflicts with work or personal commitments. 3 Suboptimal responses after attempts to extend treatment intervals are also common.4
By providing a fourfold higher molar dose that may prolong ocular VEGF inhibition, aflibercept 8 mg improves and sustains disease control while allowing extension of treatment intervals in patients with stable or difficult-to-extend DME. This is supported by results of PHOTON, a randomized, double-masked, phase II/III noninferiority study that evaluated the efficacy and safety of aflibercept 8 mg in DME treatment. A total of 658 previously treated or treatment-naïve patients with DME were randomized 2:1:1 to receive aflibercept 8 mg Q12W (n=328) or Q16W (n=163), or aflibercept 2 mg Q8W (n=167), following initial monthly dosing.5
At 96 weeks, both aflibercept 8 mg Q12W and Q16W showed noninferior best-corrected VA (BCVA) gains vs aflibercept 2 mg Q8W (least square mean BCVA change from baseline, +8.8 and +7.5 letters, respectively, vs +8.4 letters). Even with fewer injections, aflibercept 8 mg Q12W or Q16W achieved similar CRT vs aflibercept 2 mg Q8W. Among patients receiving aflibercept 8 mg, 88 percent of the Q12W group and 83 percent of the Q16W group maintained their assigned intervals. At week 96, 43 and 47 percent of those in the Q12W and Q16W groups qualified for ≥Q20W intervals, and 24 and 32 percent qualified for Q24W intervals, respectively.6
Given the chronic nature of DME and the need for long‑term therapy, initiating durable, rapid-acting anti‑VEGF agents can plausibly reduce early undertreatment and overall treatment burden. In patient 1, who is in full-time employment, multiple attempts to extend treatment intervals beyond Q8W with aflibercept 2 mg failed, resulting in a significant treatment burden. After switching to aflibercept 8 mg, he achieved a Q16W interval, with VA improving from 0.4 to 0.7, and CRT reducing from 277 to 243 μm. (Figures 1B & 1F) Case 1 shows that patients requiring frequent treatment may benefit from earlier initiation of aflibercept 8 mg. In case 2, despite regular aflibercept 2 mg Q8W, fluid control was suboptimal, and treatment intensification was not feasible due to caregiver burden. In addition to extending the treatment interval to Q12W, the patient achieved clinically meaningful visual improvement: VA rose from 0.1 to 0.4 and the macula became substantially drier, with CRT decreasing from 388 to 224 μm. (Figures 2B & 2F) Both cases may be eligible for further interval extension, which could reduce the burden for both patients and caregivers.
Neither of our patients reported any AEs during treatment with aflibercept 8 mg. This is consistent with PHOTON, which showed a comparable safety profile for aflibercept 8 mg and 2 mg. Ocular AEs in the study eyes were similar across treatment groups, with no cases of endophthalmitis reported and low rates of intraocular inflammation (<2 percent in both groups) through week 96.6
Aflibercept 8 mg was administered with a greater injection volume than aflibercept 2 mg, but no clinically relevant changes in intraocular pressure were reported in PHOTON.6 As a precaution, paracentesis before initiating aflibercept 8 mg injections may be considered in patients with advanced glaucoma.
The durable response observed with aflibercept 8 mg supports routine management by reducing the risk of recurrence in patients who prefer a pro re nata (PRN) regimen. However, the treat-and-extend (T&E) regimen generally yields better visual outcomes. For patients who opt for a T&E regimen after the initial monthly doses, treatment adjustments (ie, extension or shortening) are typically in 1-month intervals. In patients on a T&E regimen, aflibercept 8 mg provides an opportunity to extend treatment intervals to up to Q24W, as shown in PHOTON, markedly reducing treatment burden for patients and caregivers.6
Based on the PHOTON study and my clinical experience, aflibercept 8 mg is not only an effective option for patients who have difficulty extending intervals or who have suboptimal fluid control with other IVTs, but also a first-line treatment for treatment‑naïve patients. Initiating aflibercept 8 mg can achieve early, durable disease control and reduce injection frequency, potentially to Q24W. These benefits can reduce the treatment burden for both patients and caregivers, which is important given DME’s chronic nature and the need for long‑term therapy.
