subfoveal choroidal neovascularization ( cnv ) is a leading cause of visual loss in the geriatric population . peripapillary cnv membranes ( ppcnvm ) have been associated with multiple etiologies [ 2 , 3 ] . while ppcnvm , associated with optic nerve head drusen ( onhd ) , is a well - described entity in the pediatric population , it is not reported in the adult population ( pubmed search november 29 , 2014 ) . herein , we report a case of ppcnvm associated with onhd impacting the macula , which required treatment with an anti - vascular endothelial growth factor ( anti - vegf ) agent . a 75-year - old male presented with a chief complaint of blurry vision in the right eye ( od ) of 3 months duration . the patient 's past medical and ocular history were significant only for herpes zoster ophthalmicus on the left side years prior . on examination , his treatment was initiated with 3 ranibizumab injections , administered every 5 weeks , without any impact on the amount of subfoveal fluid . subsequent treatment with a single aflibercept injection resulted in complete resolution of subfoveal fluid ( fig . the patient 's visual acuity has been stable for 15 months with no recurrence of subfoveal fluid . the association of onhd with macular threatening ppcnvm and its favorable response to anti - vegf agents is already known in the pediatric population [ 2 , 3 , 4 ] . the natural course of ppcnvm is variable and unpredictable ; however , macular threatening ppcnvm requires treatment . while the role of anti - vegf therapy as a treatment for this specific subset of choroidal neovascular membranes was not studied as part of the major neovascular age - related macular degeneration ( amd ) studies , its use for the treatment of other forms of cnv is well established . bevacizumab , ranibizumab and aflibercept are 3 anti - vegf agents used for the treatment of neovascular amd . ranibizumab and bevacizumab are monoclonal antibodies that selectively bind to vegfa [ 7 , 8 ] . aflibercept , however , is a fusion protein composed of the binding domains of vegf receptor 1 , vegf receptor 2 , and the fc portion of igg that selectively binds to vegfa , vegfb , and platelet growth factor ( pigf ) . aflibercept has been shown to have a greater affinity for vegf and a longer half - life than both ranibizumab and bevacizumab . the comparison of age - related macular degeneration treatment trials ( catt )   demonstrated equivalence in efficacy between ranibizumab and bevacizumab in the treatment of wet amd , as did the inhibition of vegf in the age - related choroidal neovascularization ( ivan ) trial . the vegf trap - eye : investigation of efficacy and safety in wet amd ( view 1 and view 2 ) trials   similarly demonstrated an equivalence between ranibizumab and aflibercept in treating wet amd . inadequate response to 1 anti - vegf agent is not uncommon when treating cnv , and , on occasion , changing to an alternate anti - vegf agent has demonstrated efficacy . currently , there are no studies that have investigated the response of aflibercept in treatment - resistant peripapillary cnv , likely due to the rarity of this presentation . previous studies have concluded that aflibercept may provide an efficacious therapeutic response in cases of cnv due to amd that initially failed to respond to bevacizumab and ranibizumab . further studies are required to investigate whether aflibercept is an equally efficacious therapeutic alternative to treatment resistant peripapillary cnv . based upon our experience , an individualized treatment plan for adult patients with ppcnvm , associated with onhd ,