Purpose <p>This study quantifies hyperreflective foci (HRFs) in neovascular age-related macular degeneration (nAMD) before and after anti-VEGF therapy in the initial loading phase using en-face ultra-high-resolution spectral domain OCT (UHR-SD-OCT), investigating their correlation with clinical findings.</p> Study design <p>Retrospective observational study</p> Methods <p>This retrospective study included 30 eyes from 30 patients with treatment-naïve nAMD. The patients received monthly intravitreal injections of anti-VEGF therapy for three months as the initial loading phase. At each visit, comprehensive ophthalmic examinations were conducted. HRFs were quantified using our custom-developed&#xa0;software from an en-face UHR-SD-OCT. The number of HRFs was compared before and after the loading phase and investigated the relationship with best-corrected visual acuity (BCVA), greatest linear dimension (GLD), macular neovascularization (MNV) size and incidence of macular atrophy (MA).</p> Results <p>This evaluation system showed a significant reduction in the number of HRFs after anti-VEGF therapy compared to before the loading phase (p &lt; 0.0001). The number of pre-treatment HRFs significantly correlated with pre-treatment BCVA, GLD, and MNV size. The number of post-treatment HRFs significantly correlated with pre-treatment GLD and pre-treatment MNV size. Additionally, patients who developed MA two years after treatment initiation exhibited significantly higher counts of pre-treatment HRFs compared to those without the MA development (465.7 ± 187.0 vs. 212.9 ± 93.8, p &lt; 0.05).</p> Conclusions <p>Quantification of HRF using en-face UHR-SD-OCT may be a useful clinical biomarker during anti-VEGF therapy in nAMD.</p>