Geographic atrophy (GA) is the advanced stage of dry age-related macular degeneration (AMD) and is characterized by a relentless loss of vision. Patients may struggle to understand the mechanism underlying GA, yet, in my experience, they possess an awareness of its prognosis.
During a recent interview, I shared my insights on guiding the conversation with patients with GA.
Speak in Pictures
The recent availability of treatment options for GA ushers in a new era of hope for patients.1,2 Now, the challenge is to educate our patients about dry AMD and GA. Using analogies that paint a picture of what is happening helps patients understand the disease and treatment. And, as we have learned in other retinal pathologies, a picture is worth more than a thousand words. I compare the retinal pigment epithelium to a “vacuum cleaner” to remove waste in the eye.
As we age, this function weakens, causing waste to build up, which leads to GA and vision loss. Using OCT or fundus autofluorescence images of the patient’s retina further enhances their understanding by visually depicting the disease and its progression.
The Balance Between Benefits and Risks
When administering complement inhibitors to treat GA, the goal is to slow lesion progression. We are in the early days of GA treatment, and there are no established biomarkers to identify treatment success or ideal patients. Serial imaging before and after treatment can indicate if a lesion is progressing slower, highlighting treatment effectiveness. Consequently, the challenge of measuring the benefits of complement inhibition underscores the importance of thorough risk education. In clinical trials for the two available complement inhibitors—pegcetacoplan (Syfovre, Apellis) and avacincaptad pegol intravitreal solution (Izervay, Iveric Bio, an Astellas Company)—there was an increased risk of conversion to wet AMD associated with treatment. This fact underscores the need for regular monitoring of any patient who is started on anti-complement therapy, regardless of agent choice.
Informed consent remains crucial throughout the process. The possibility of increased IOP post-injection is a manageable occurrence. I inform patients of the small risks of endophthalmitis and occlusive vasculitis post-injection and respect their decision to proceed with treatment. It should be noted that some cases of occlusive retinal vasculitis have been reported after treatment with pegcetacoplan since its release and use in the general public. To date, at least one case has been confirmed with avacincaptad pegol intravitreal solution.
There are strategies to assess the risk of adverse events and inform our patients, particularly those with bilateral GA. Starting treatment in the eye with poorer vision can serve as a test; if successful then, I am more confident in starting treatment in the eye with better vision.
The Ideal Patient Profile
GA treatment acceptance varies among patients, with roughly one-third unreceptive, one-third somewhat hopeful, and one-third eagerly awaiting treatment. As retina specialists, We prioritize identifying responsive patients, such as those with a family history of vision loss or those undergoing treatment for wet AMD in one eye. However, certain clinical aspects may limit treatment benefits:
- Patients with large GA lesions, although the viability of treatment depends on the size and location of the lesions;
- patients in hospice care; and
- patients with severe dementia.
Lastly, a patient’s lifestyle choices need to be considered and addressed during the conversation about treatment efficacy and disease progression. Advising patients to quit smoking is crucial, as it can make a substantial difference in managing the condition. Additionally, addressing diet, blood pressure, and cholesterol levels is important for overall systemic health and may help slow the progression of GA.
1. Carlton J, Barnes S, Haywood A. Patient perspectives in geographic atrophy (GA): exploratory qualitative research to understand the impact of GA for patients and their families. British and Irish Orthoptic Journal. 2019;15(1):133.
2. Enoch J, Ghulakhszian A, Sekhon M, et al. Exploring patient acceptability of emerging intravitreal therapies for geographic atrophy: a mixed-methods study. Eye. 2023;37:17.
