Geographic Atrophy FAQs for General Eye Care Providers
Following the 2023 FDA approval of Syfovre (pegcetacoplan) and Izervay (avacincaptad pegol), treatments aimed at slowing progression of geographic atrophy (GA), the vision-debilitating form of dry age-related macular degeneration (AMD), our clinics have been inundated with inquiries from general eye care providers about optimal management strategies, appropriate timing for referral and treatment, and how to best counsel affected patients. To address these queries, our retina specialists, Drs. Murtaza Adam and Andrew Zheng, provide answers to your most commonly asked questions!
Who is a good candidate for GA treatment?
DR. ADAM: This is a difficult question to answer as the decision making for treating GA is not the same as one would make for treating neovascular AMD. Generally speaking, patients with extrafoveal GA due to dry AMD that are high risk for progression (hyper-FAF at the edge of GA, multifocal GA, presence of reticular pseudodrusen) are the best candidates. However, patients that are functionally monocular and have foveal involving or non-foveal involving GA are also excellent candidates and tend to be motivated to undergo treatment. Additionally, patients with neovascular AMD and concurrent GA are also good candidates because they are familiar with intravitreal injections. Patients with 20/200 or worse vision, advanced glaucoma, limited functionality (patient does not read, drive, watch TV, etc), or a short life expectancy might not be the best candidates for treatment. In the end, if your patient with GA is interested in preserving their central vision for as long as possible, I think treatment is worth serious consideration.
What GA characteristics are associated with faster progression?
DR. ZHENG: As Dr. Adam mentioned, characteristics associated with faster GA progression include multifocal lesions, non-subfoveal lesions, and fundus autofluorescence pattern. Specifically, a hyperautofluorescent ring at the edge of existing geographic atrophy lesions can be an indication of fast-progressing lesions and indicate the direction of progression into healthy tissue. Reticular pseudodrusen (drusen located above the RPE between the RPE neurosensory retina) is also a risk factor for faster GA growth.
What are the risks of anti-complement treatment?
DR. ZHENG: Aside from risks associated with all intravitreal injections (redness, SCH, vitreous floaters, ocular surface irritation IOP elevation, retinal detachment, and endophthalmitis), anti-complement treatment does pose medication-specific risks as well. There is a dose-dependent risk for conversion to neovascular AMD compared to the sham groups in the clinical trials for both of the current FDA approved anti-complement treatments. Intraocular inflammation is also a potential complication, which can be potentially sight-threatening if severe. Lastly, pegcetacoplan had a dose-dependent risk of NAION with a risk as high as 1.7% in the monthly treatment group during clinical trials.
How do I properly educate my patients about anti-complement treatment as a primary eye care provider?
DR. ZHENG: It is important to set realistic expectations for the goal of GA treatments. The goal is not to stop the disease or reverse the damage done. The goal of anti-complement treatment is to slow down the progression of disease and preserve duration of functional vision. Patients should acknowledge prior to treatment that improvement in vision is not the expected outcome. It is also important to discuss the long-term nature of anti-complement treatment. They are potentially receiving this treatment for the rest of their life. However, the medication has an additive effect over time, so the longer the treatment duration, the more efficacious the treatment becomes.
My patient was a good candidate for anti-complement treatment so I referred to CRA. Why did they not receive treatment?
DR. ADAM: The discussion regarding GA treatments is nuanced and requires an understanding of the natural history of GA, as well as the limitations of treatment and associated risks. Sometimes it takes 2 visits for the patients to understand exactly what the benefits of therapy are. Since anti-complement therapy only slows GA progression, some patients do not want to undergo treatment if it will not improve their vision. Others are intimidated by the prospect of intravitreal injections (despite being reassured they are safe and comfortable during treatment). Other factors like the patient’s daily visual function, life expectancy, and understanding that GA will progress with or without treatment can deter patients from starting therapy. Finally, some patients have an interest in clinical trials and elect to go down this path of treatment so they can get access to cutting edge therapies and help push the science of GA treatment forward.
Does CRA currently have any enrolling GA trials?
DR. ADAM: We do! The phase III ReGAIN trial is an exciting study in which patients can receive an subcutaneous treatment that has promise of significantly slowing GA progression. Some patients are highly motivated to enroll in this study because there is hope they can achieve the same or better results as patients receiving anti-complement intravitreal injections.
