Expanding the treatment of geographic atrophy (GA) to a broader patient population presents several challenges, particularly in balancing the benefits of early intervention with the practicalities of treatment burden and patient adherence. There are several strategies that retina specialists can use when evaluating their patient population for candidates who would most benefit from complement inhibitor treatments.
Early Intervention Versus Patient Adherence: The Dilemma in GA Treatment
Recent data from the pegcetacoplan (SYFOVRE, Apellis) GALE extension trial and the two-year data from the GATHER 2 study of avacincaptad pegol (IZERVAY, Astellas) suggest that treatment efficacy improves with prolonged treatment duration.1,2 Therefore, initiating treatment for patients with earlier-stage GA and continuing treatment could significantly benefit them over the long term, as these medications are designed to prevent disease progression rather than reverse it. However, retinal specialists are hesitant to prescribe complement inhibitors due to the treatment burden associated with a long-term commitment to injections. Despite improved outcomes over time, convincing patients to adhere to a long-term frequent injection schedule is challenging, particularly for those with minimal functional impairment. In contrast, patients who have already lost significant vision in one eye due to GA may be more receptive to frequent treatments, as they understand the consequences of lesion progression better than bilateral early-stage patients.
Leveraging Imaging Data to Optimize Treatment Decisions
A key challenge in treating GA is identifying which patients might benefit the most from the available therapies. Factors like multifocal lesions, proximity to the center point, and perilesional autofluorescence—indicating cells adjacent to the lesion are actively dying but could potentially be saved—are worth considering. In addition, tracking the growth trajectory of the lesions over time is informative. Many patients already have historical autofluorescence or near-infrared OCT images from prior visits, making historical imaging data crucial for patient assessment. By comparing current images to those taken 6 months or a year earlier, clinicians can illustrate the progression of the disease to patients, emphasizing the enlargement of lesions and the potential benefits of slowing this process with treatment.
Patient Support and Education in Managing GA
Beyond medical considerations, patient selection also involves practical factors, such as the patient's ability to understand the treatment regimen and consistently attend appointments for injections, which are critical for successful outcomes. Educating patients early in their GA journey about the importance of continuous treatment is crucial. Many patients already manage chronic systemic conditions; therefore, emphasizing the progressive nature of GA and its potential functional impacts—such as difficulties with reading—can help convey the necessity of treatment. It is also important to discuss low vision services, which can provide support even for those with minimal impairment. Referrals to specialists who can assist in optimizing remaining vision and coping strategies makes the conversation about the disease more constructive and focused on a path forward for this debilitating retinal disease.
1. Eichenbaum D, Heier JS, Steinle N, et al. Update on pegcetacoplan for GA: clinical studies and real-world experience. Presented at: American Society for Retina Specialists; July 17-20, 2024; Stockholm, Sweden
2. Khanani AM, Patel SS, Staurenghi G, et al. GATHER2: Two-Year Data. Presented at: American Academy of Ophthalmology 127th Annual Meeting; November 3–6, 2023; SanFrancisco, CA
