New treatment options provide effective management of geographic atrophy
In a recent Modern Retina case-based discussion, Ferhina S. Ali, MD, MPH, discussed how to effectively manage geographic atrophy (GA).
(Image credit: AdobeStock/Viacheslav Yakobchuk)
In a recent Modern Retina case-based discussion, Ferhina S. Ali, MD, MPH, an assistant professor of ophthalmology at New York Medical College in Valhalla, discussed how to effectively manage geographic atrophy (GA) by considering treatment timing, imaging modalities, phase 3 trial data, personalized treatment algorithms based on disease severity, and encouraging patient adherence during long-term therapy.
In her practice, Ali uses an individual treatment approach for each patient with consideration of the specific treatment chosen and frequency, historic disease progression, and patient motivation, she explained. The current GA treatments commercially available are pegcetacoplan (Syfovre; Apellis) and avacincaptad pegol (Izervay; Astellas Pharma Inc). In the case-based discussion, she emphasized her discussions with patients about the various treatments now available for GA and the rationale for the choice of a particular treatment.
A strategy she uses in patients with bilateral GA in whom the more affected eye has vision below 20/200 is to focus ongoing treatment on the eye with better vision, in which the fovea is not yet affected, and initially provide treatment in the more affected eye. She tends to administer treatment every 4 to 6 weeks based on patients’ ability to travel to the office on a regular basis and their preferences.
“Over time, I am guided toward that treatment frequency by the increased information about the effectiveness of the GA drugs over longer periods and extension data from clinical trials. There is the potential to see increasing drug effects over time and more with increasing treatment frequency. When determining treatment frequency, this makes the most sense for my patients who are extremely motivated,” she commented. She described 2 cases of motivated patients that showed the importance of monitoring for choroidal neovascularization and addressing progressive vision loss and patient education.
Case 1: Dry AMD and GA
An 89-year-old woman was referred with bilateral dry age-related macular degeneration (AMD) and GA. She has had progressive vision loss in the left eye over several years, with loss of central vision and multifocal GA adjacent to the fovea in the better-seeing right eye. The visual acuities (VAs) in the right and left eyes, respectively, were 20/70 and counting fingers.
Following discussion with the patient about the potential for ocular inflammation, pegcetacoplan, which was available at that time, was started in the right eye. “As more has been learned about the potential risks of intraocular inflammation with pegcetacoplan and that it is most likely to occur after the first injection, if I were to see this patient again today, I think that the drug is still an excellent choice,” Ali commented. However, she explained, she would now consider that this patient receive treatment first in the worse eye and then proceed with ongoing treatments in the right eye, provided that the left eye responded well.
Case 2: Progressive GA
An 84-year-old man with pseudophakia was referred for treatment of progressive GA and desired information about new treatments. He takes Age-Related Eye Disease Study vitamins (Bausch + Lomb) and has a family history of AMD. The VAs in the right and left eyes, respectively, were 20/16 and 20/40.
The patient reported more scotomatous vision changes in the right eye and was interested in treatment based on a discussion of the risks and benefits. Ali started treatment with avacincaptad pegol at intervals of 6 weeks.
Examination showed that the vision improved slightly. “We know that there is some degree of variation in the central VA that can be captured with Snellen measurements and the variability from visit to visit in these patients with GA. Often they are [older], with some component of dry eye that can contribute to that variability,” she said.
A consideration here is that GA is progressive both without treatment and with treatment with a complement inhibitor. However, the goal is to slow disease progression. Ali emphasized that the progressive nature of GA should be addressed in ongoing patient conversations as clinicians continue to understand better how and when to use these treatments and how to have conversations with patients about them. This patient continues to receive treatment at 6-week intervals and is tolerating the injections.
