a 55-year - old male patient presented to us with complaints of decreased vision and metamorphopsia , in the left eye for three weeks . he was treated in the past elsewhere with intravitreal bevacizumab thrice for cnvm secondary to age - related macular degeneration ( amd ) , at four - weekly intervals . his best corrected visual acuity was 20/120 , in the left eye with normal anterior segment findings . posterior segment clinical examination and optical coherence tomography ( oct ) revealed subfoveal cnvm of half disc diameter ( dd ) size , with minimal subretinal blood [ fig . the need for a repeat intravitreal injection of bevacizumab was explained to the patient . upon refusal for the same , the option of surgical removal was discussed with the patient . following a detailed informed consent six months postoperative , his preoperative vision of 20/120 was maintained and no intra- or postoperative complications were encountered [ fig . 1 c and d ] . ( a and b ) case 1 color fundus photograph and oct showing small subfoveal cnvm with minimal subretinal hemorrhage despite previous intravitreal injections of bevacizumab . ( c and d ) two months post surgical cnvm removal color fundus photograph and oct showing absence of cnvm with some scarring and restoration of normal foveal contour with stabilized vision a 58-year - old male patient , a known case of neovascular amd , was treated with intravitreal bevacizumab four weeks prior to his first visit to us , elsewhere . he was dissatisfied with the treatment and reported no subjective improvement post injection . at presentation , his visual acuity was 20/120 in the right eye with a subfoveal cnvm with hemorrhage , of size 1 dd [ fig . 2 a and b ] . , he underwent surgical removal of the cnvm . at six months postoperative duration , he maintained a vision of 20/120 without any intra- or postoperative complications [ fig . ( a and b ) case 2 color fundus photograph and oct showing small subfoveal cnvm with subretinal hemorrhage despite previous intravitreal injections of bevacizumab . ( c and d ) one month post surgical cnvm removal color fundus photograph and oct showing absence of cnvm with some scarring and restoration of normal foveal contour with stabilized vision a 35-year - old male patient with idiopathic cnvm os , was treated by us with two injections of intravitreal bevacizumab , at three month intervals . posterior segment clinical examination and oct revealed active subfoveal cnvm , sized 1.5 - 2 dd with some sub - retinal hemorrhage . the need for repeated injection was explained to the patient . on refusal for the same , , he underwent the surgical procedure with vision stabilizing to 20/120 at final follow - up , six months post surgery . standard 20-gauge three - port pars plana vitrectomy including posterior hyaloid removal was done . through a small retinotomy away from the center of the fovea , cnvm removal was performed with a long beaked forceps . screening of the periphery was carried out followed by a fluid air exchange and closure . a 55-year - old male patient presented to us with complaints of decreased vision and metamorphopsia , in the left eye for three weeks . he was treated in the past elsewhere with intravitreal bevacizumab thrice for cnvm secondary to age - related macular degeneration ( amd ) , at four - weekly intervals . his best corrected visual acuity was 20/120 , in the left eye with normal anterior segment findings . posterior segment clinical examination and optical coherence tomography ( oct ) revealed subfoveal cnvm of half disc diameter ( dd ) size , with minimal subretinal blood [ fig . the need for a repeat intravitreal injection of bevacizumab was explained to the patient . upon refusal for the same , the option of surgical removal was discussed with the patient . following a detailed informed consent six months postoperative , his preoperative vision of 20/120 was maintained and no intra- or postoperative complications were encountered [ fig . 1 c and d ] . ( a and b ) case 1 color fundus photograph and oct showing small subfoveal cnvm with minimal subretinal hemorrhage despite previous intravitreal injections of bevacizumab . ( c and d ) two months post surgical cnvm removal color fundus photograph and oct showing absence of cnvm with some scarring and restoration of normal foveal contour with stabilized vision a 58-year - old male patient , a known case of neovascular amd , was treated with intravitreal bevacizumab four weeks prior to his first visit to us , elsewhere . he was dissatisfied with the treatment and reported no subjective improvement post injection . at presentation , his visual acuity was 20/120 in the right eye with a subfoveal cnvm with hemorrhage , of size 1 dd [ fig . 2 a and b ] . , he underwent surgical removal of the cnvm . at six months postoperative duration , he maintained a vision of 20/120 without any intra- or postoperative complications [ fig . 2 c and d ] . ( a and b ) case 2 color fundus photograph and oct showing small subfoveal cnvm with subretinal hemorrhage despite previous intravitreal injections of bevacizumab . ( c and d ) one month post surgical cnvm removal color fundus photograph and oct showing absence of cnvm with some scarring and restoration of normal foveal contour with stabilized vision a 35-year - old male patient with idiopathic cnvm os , was treated by us with two injections of intravitreal bevacizumab , at three month intervals . posterior segment clinical examination and oct revealed active subfoveal cnvm , sized 1.5 - 2 dd with some sub - retinal hemorrhage . the need for repeated injection was explained to the patient . on refusal for the same , , he underwent the surgical procedure with vision stabilizing to 20/120 at final follow - up , six months post surgery . standard 20-gauge three - port pars plana vitrectomy including posterior hyaloid removal was done . through a small retinotomy away from the center of the fovea , cnvm removal was performed with a long beaked forceps . screening of the periphery was carried out followed by a fluid air exchange and closure . certain clinical or histopathological features may diminish the efficacy of intravitreal anti - vegf agents on cnvms . patients who do not respond satisfactorily to these agents face a dilemma due to the pros and cons of the treatment , as outlined above . surgical cnvm removal was studied by the submacular surgery trial ( sst ) group which began a decade back when the only established modality of treatment was laser photocoagulation . the study concluded that submacular surgery did not improve or preserve visual acuity for 24 months in more eyes than just observation , however , at one - year follow - up , 34% eyes had stabilized or improved vision in cases of neovascular amd . eyes eligible for sst had large membranes with poor visual acuity and no previous treatment . our three cases had relatively smaller membranes with no scarring , patients who refused repeat intravitreal injections , and desired an alternative treatment for their condition . the duration between surgical treatment and the last injection was 75 days , 30 days and 150 days respectively in the three cases . the sst group reported that 77% eyes had some residual blood after surgery and in a small proportion of cases it was severe enough to cause elevation of the retina . in our experience intraoperatively , the cnvms were non / minimally vascular and did not bleed from the bed while removal . we postulate that this may be an effect of the previous anti - vegf priming to the membrane . to conclude , we observed that surgical removal of cnvm may have a role in stabilizing deteriorating vision in selected cases of small non - scarred classic cnvm , when repeated intravitreal anti - vegf injections are declined by the patient . if surgery is planned , anti - vegf may also reduce the risk of hemorrhage during surgical excision .
intravitreal anti - vascular endothelial growth factor ( vegf ) agents have obtained acceptance as the mainstay in the management strategy of subfoveal choroidal neovascular membranes ( cnvm ) due to varying etiologies . 
 few drawbacks include need for repeated intravitreal injections , with its adjunct risks , and the lack of a predefined treatment end point , which can cause doubts and uncertainty in the mind of the patient . 
 furthermore , it remains a significant financial burden for the patient.herein we report our data of three patients who were reluctant for further re - injections of anti - vegf agents and were therefore offered surgical removal of the cnvm by submacular surgery as an alternative treatment plan .