Antivascular endothelial growth factor (VEGF) agents have revolutionised our treatment paradigms and therapeutic approach to numerous retinal diseases. Intravitreal anti-VEGF therapies are now at the forefront of our armamentarium for the treatment of neovascular age-related macular degeneration (AMD). Three anti-VEGF drugs are now available for use: bevacizumab (Avastin), ranibizumab (Lucentis), aflibercept (Eylea). Two of these drugs are FDA-approved in the USA for the treatment of neovascular AMD: aflibercept and ranibizumab.1–3 On the other hand, bevacizumab, although approved for systemic treatment of various malignancies, is used off-label for ophthalmic applications.4

The comparative efficacy and safety of these drugs in numerous ophthalmic diseases, including neovascular AMD, continues to be actively debated as new data accumulates. The use of bevacizumab, in particular, remains among the most hotly contested topics. Questions about functional and anatomic efficacy, treatment regimens, systemic safety, and compounding safety fuel the energy within the debate.5–8 With those issues in mind, relative cost difference and cost burden maintains this discussion among clinicians, payers and governments. The cost difference in the USA is nearly 35–40-fold less for bevacizumab (∼US$50) compared with ranibizumab (∼US$2000), aflibercept (∼US$1800).9 ,10 For perspective, gold (as of now) is trading at ∼US$1800 an ounce which, as one recent article has mentioned, places the equivalent volume of liquid gold at approximately 5–6 times less than ranibizumab or aflibercept.11 What we want as a medical community is the best investment for our patients’ future vision and health; and to that end, our search continues for answers related to the relative efficacy, safety and value of these drugs so that we can help guide our patients towards the best therapeutic decision for them.

In this issue of British Journal of Ophthalmology, Krebs and colleagues add to the growing body of evidence of comparative medicine …