John W. Kitchens, MD: How does the approval of geographic atrophy (GA) treatments compare with the early treatments for wet age-related macular degeneration (AMD), which eventually advanced to the era of anti-VEGF therapy?
Miguel Busquets, MD: The FDA approval of complement mediators for the treatment of GA signaled a significant transformation in our capacity to practice medicine. Looking at the history of wet AMD, our field was thrilled to have access to photodynamic therapy (PDT) and pegaptanib sodium (Macugen) as the first treatments for this disease. Although these treatments didn’t improve vision, they allowed us to begin controlling wet AMD and slowing its progression.
We face a similar dynamic in GA treatments today. Even if the efficacy and outcomes of GA treatments haven’t reached their full potential, we still have an opportunity to treat patients who were previously untreatable.
Treating wet AMD patients with PDT and pegaptanib also led to deeper relationships with those patients who would eventually benefit from anti-VEGF treatment. We didn’t give up on those patients, and that meant a lot to them. We can similarly set up GA patients for success by managing their disease with the treatments we currently have at our disposal.
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Esther Kim, MD: I think of complement inhibitors for GA as signaling the end of the beginning, not the beginning of the end. We have somewhere to start, which is why the approval of these drugs is so exciting.
Dr. Kitchens: I’d like to hear about the patients in your clinic who you initially treated for GA.
Dr. Kim: Many of my earliest patients with GA who received treatment were patients with wet AMD who, despite complying with suggested anti-VEGF regimens, continued to lose vision due to concomitant GA.
Although these patients were frustrated that a new therapy would not restore sight in the way anti-VEGF agents could, they were comfortable with the concept of regular intravitreal injections, and were therefore easy to get on board.
Now I am seeing a second wave of patients: those who have been referred by comprehensive ophthalmologists and optometrists who have identified that referral to a retina specialist is warranted. This is a credit to our referring providers, as they have effectively educated themselves to spot nascent GA.
These patients present a new challenge, as we must build relationships with them and gain their trust before we tell them that, despite the likelihood of losing vision over time, the drugs that we have at our disposal are the best guard against progression of GA.
Dr. Kitchens: How do you use imaging to educate patients about their disease?
Dr. Kim: A picture says a thousand words. You can descriptively tell a patient with extrafoveal disease that future encroachment of their fovea will lead to vision loss, but they seem to instinctively understand the stakes and likely progression of GA when you show them an OCT or fundus autofluorescence image of their GA lesions. At that point, most of my patients opt for complement inhibition therapy.
We must stay positive with our patients once they understand the prognosis. Rather than bluntly stating that they will slowly lose vision, I frame the discussion around the fact that two FDA-approved therapies exist, and that they have been shown to slow the progression of disease. I always make it clear that they cannot expect to experience returned vision, but that these treatments are a significant improvement over non-intervention.
