Now that treatment options are clinically available for geographic atrophy (GA) secondary to age-related macular degeneration (AMD), managing patients’ expectations for outcomes remains paramount.

In clinical trials, complement inhibition therapy has been shown to slow the progression of atrophy by 25% to 34%.1,2 Importantly, however, neither available agent has been shown to reverse existing atrophy, nor to restore vision. Therefore, the goal of treatment is to stabilize the disease to every extent possible, and thereby, maintain visual function for as long as possible.

Navigating Patient Communication

Patients with GA typically arrive in my clinic complaining of visual symptoms—metamorphopsia, blind spots, or scotomas—that have been progressive over time. Yet, because vision loss typically does not occur until late in the disease process, these patients often have preserved functional vision and good visual acuity. This scenario presents a unique challenge for clinicians: while these are the patients who will benefit the most from complement inhibition therapy, the relative lack of symptoms can lead to hesitancy about starting treatment.

Whenever possible, I like to use results from OCT and fundus autofluorescence imaging to demonstrate where their blind spots are. If I have follow-up data, I will also show patients their disease progression over time. Using imaging in this way, as an educational tool, can help facilitate a discussion about starting treatment.

Furthermore, although GA is a progressive disease, the presentation is heterogenous, and the rate of progression is highly individualized. As such, I tailor the conversation about the goal of treatment based on the presenting anatomy and the prognosis for future lesion growth. With patients whose GA has not yet entered the foveal region, we will discuss how to preserve functional vision for as long as possible. When the fovea has already been affected, the conversation shifts to how we will work together to limit the size of the blind spot.

Establishing Rapport: Setting Expectations and Discussing Risks

One thing we have learned from longer-term follow-up from the pivotal trials of the two complement inhibitors is that there appears to be greater benefit the longer patients are on therapy.3,4 As a result, having patients involved in the decision making to initiate treatment, and, ultimately, having them adhere to treatment when they will not appreciate any positive change in their visual acuity, is critical for long-term success.

In my experience, getting patients to commit to long-term complement inhibition therapy starts by setting realistic expectations for outcomes. It is vitally important that patients understand that managing GA is like dealing with a speeding train: complement inhibition therapy can slow its progress, but it will not stop it entirely. Patients should also be aware of the risks associated with these medications. Although rare, injection-related complications, such as bleeding, infections of the eye, retinal tears, and detachments, have been reported. There is a risk of conversion to wet AMD, which occurs in about 2% of patients, as well.

Another aspect of the treatment conversation that bears mentioning relates to being honest with patients who would not benefit from therapy for whatever reason. It’s difficult to tell patients they have end-stage disease, and, from a medical standpoint, there is not much we can do. However, I try to direct these discussions toward positive developments in this space, as it is a very active area of research. There are numerous active clinical trials available for this patient population, including stem cell therapy and gene therapy. I also suggest using low vision aids to help them function with their remaining vision. Above all, I make sure to reinforce the value of supportive care, monitoring disease progression, and working together to maintain independence as long as possible.

Final Pearls

My advice to fellow practitioners would be, if you have patients in your clinic who are complaining of progressive vision loss from dry AMD with GA, to start the discussion about potential treatment options. Prior to the availability of treatment, we could not be proactive about treating dry AMD. Now with the advent of complement inhibition therapy, we can at least slow the progression. Our goal is to remind patients they are not alone in this fight against GA, and we are here to help them maintain independence and remain comfortable for as long as possible.

1. Heier JS, Lad EM, Holz FG, et al. Pegcetacoplan for the treatment of geographic atrophy secondary to age-related macular degeneration (OAKS and DERBY): Two multicentre, randomised, double-masked, sham-controlled, phase 3 trials. Lancet. 2023;402:1434-1448

2. Khanani AM, Patel SS, Staurenghi G, et al; GATHER2 trial investigators. Efficacy and safety of avacincaptad pegol in patients with geographic atrophy (GATHER2): 12-month results from a randomised, double-masked, phase 3 trial. Lancet. 2023;402(10411):1449-1458.

3. Wykoff CC, Holz FG, Chiang A, et al; OAKS, DERBY, and GALE Investigators. Pegcetacoplan treatment for geographic atrophy in age-related macular degeneration over 36 Months: Data from OAKS, DERBY, and GALE. Am J Ophthalmol. 2025;276:350-364.

4. Gahn G, Kaiser PK, Khanani AM, et al. The 18-month efficacy of avacincaptad pegol in geographic atrophy: Pooled results from GATHER1 and GATHER2. Invest Ophthalmol Vis Sci. 2024;65(7):4400.