Individualized treatment strategies, including careful consideration of timing, imaging modalities, and patient-specific factors, are essential for effectively managing geographic atrophy (GA). Ferhina S. Ali, MD, MPH, highlighted the importance of personalized treatment algorithms based on disease severity and patient adherence during long-term therapy in a recent discussion.
Tailoring Treatment to the Patient
Dr. Ali emphasizes an individualized approach, considering the chosen treatment, frequency, disease progression, and patient motivation. Currently available GA treatments include pegcetacoplan (Syfovre; Apellis) and avacincaptad pegol (Izervay; Astellas Pharma Inc). Open communication with patients about treatment options and rationale is crucial.
In cases of bilateral GA where one eye's vision is below 20/200, Dr. Ali prioritizes treating the eye with better vision, particularly if the fovea is not yet affected. Treatment frequency is typically every 4 to 6 weeks, based on patient convenience and 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 noted.
Case Examples
Case 1: Dry AMD and GA
An 89-year-old woman with bilateral dry age-related macular degeneration (AMD) and GA presented with progressive vision loss in the left eye and multifocal GA adjacent to the fovea in the right eye. Visual acuities were 20/70 and counting fingers in the right and left eyes, respectively.
Initially, pegcetacoplan was started in the right eye after discussing potential ocular inflammation risks. Dr. Ali commented, "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." She would now consider treating the worse eye first, followed by the better eye if the worse eye responds well.
Case 2: Progressive GA
An 84-year-old man with pseudophakia was referred for progressive GA treatment. He reported more scotomatous vision changes in the right eye and was interested in new treatments. Visual acuities were 20/16 and 20/40 in the right and left eyes, respectively.
Treatment with avacincaptad pegol was initiated at 6-week intervals. The patient experienced slight vision improvement. "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," Dr. Ali explained.
The Importance of Ongoing Management
GA is progressive, even with complement inhibitor treatment. The goal is to slow disease progression. Dr. Ali emphasized the importance of ongoing patient conversations about the progressive nature of GA as clinicians gain a better understanding of how and when to use these treatments. The patient in Case 2 continues to receive treatment at 6-week intervals and is tolerating the injections well.
