<p>Demography and baseline characteristics.</p>

At 12 months, the CMT significantly decreased in both the naïve and refractory groups (both P < 0.001). BCVA significantly improved in naïve eyes (P = 0.003), whereas visual improvement was limited in refractory eyes (P = 0.390). Both groups showed significant reductions in the proportions of eyes with IRCs, SRF, and HRFs (all P < 0.001).

Refractory eyes had higher proportions of baseline DRIL and ELM/EZ disruption (both P < 0.001). In the multivariable GEE model, baseline DRIL (B = 0.044; 95% CI: 0.004 to 0.084; P = 0.031) and ELM/EZ disruption (B = 0.147; 95% CI: 0.069 to 0.225; P < 0.001) remained independently associated with poor 12-month BCVA, whereas the treatment group was not independently associated with 12-month BCVA (P = 0.969).</p> <p>Conclusion</p><p>Faricimab achieved effective retinal fluid control in both naïve and refractory DME.

However, visual recovery was associated with baseline retinal microstructural integrity, with DRIL and ELM/EZ disruption independently associated with poorer 12-month visual outcomes beyond conventional anatomical parameters. In eyes with refractory DME and limited visual improvement, sustained fluid control and reduced treatment burden may remain clinically meaningful outcomes.</p></div>