One of the salient lessons we are learning as more patients are treated with complement inhibition therapy for geographic atrophy (GA) is that earlier treatment translates into a better chance of slowing down disease progression and extending patients’ quality of life with the vision they still have. However, there is often a disconnect between patients’ visual acuity and when they begin treatment. Here, I will discuss how I bridge this gap through patient education, various visual assessment methods, and setting patient expectations regarding treatment.
Early Functional Impact of GA
GA can appear asymptomatic in its earliest stages, yet still subtly impair everyday activities and ultimately limit patients’ independence. In early stages, patients often report difficulty with reading or seeing in dim light before any change appears on a Snellen chart, which highlights the importance of patient-reported symptoms for early detection. In fact, Snellen visual acuity is an imperfect measure of our patients’ actual functioning at home, and so I rely on what patients are telling me about what they are experiencing with their vision. By listening closely to what patients are saying, I can guide the conversation around the benefits of treatment. After all, we’re not treating optical coherence tomographies (OCTs), and we’re not treating photos; we’re treating the patients sitting in front of us, and I believe they are exceptionally attuned to what they are experiencing.
Vision Assessment Methods
Despite its limitations, I still perform Snellen visual acuity tests on each patient, as it remains our primary tool due to its speed and workflow integration. However, for high-risk GA patients, I also rely on low luminance visual acuity (LLVA) testing, which offers a quick, objective measure to validate patient concerns about night vision. More detailed assessments, such as contrast sensitivity and microperimetry, are highly informative but are typically reserved for our clinical trials due to their increased time and staffing demands.
Educating Early-Stage Patients
To help bridge the knowledge gap between patients and early-stage disease progression, I rely on available data through imaging and published research. For example, I will show patients their fundus autofluorescence (FAF) and OCT images to highlight early biomarkers like incomplete retinal pigment epithelial and outer retinal atrophy (iRORA) and subretinal drusenoid deposits, which is helpful for them to understand their disease progression and any high-risk features they possess.
I also reference published literature and discuss available FDA-approved complement inhibitor treatments such as pegcetacoplan (Syfovre, Apellis) and avacincaptad pegol (Izervay, Astellas), which we know from experience work best in earlier stages of GA. I remind patients while they might be asymptomatic while in my office, it’s important to begin considering these treatment options sooner rather than later to preserve their functional vision and quality of life for as long as possible. Being able to provide patients with the knowledge and tools for them to see the global picture of their disease is the most important thing.
Setting Treatment Expectations
As I discuss treatment options with my patients who are experiencing early-stage GA, I inform them once the disease enters the fovea, the utility of these complement inhibitors decreases significantly, and I don’t really recommend them at that point. My goal is to prevent their disease from reaching that point for as long as possible. Once these patients agree to begin treatment, I remind them while complement inhibitors slow GA progression, these treatments do not restore vision and require fixed intravitreal injections to help maintain efficacy. I also like to engage patients’ support system during this time. I find that once family and friends are engaged, these are the patients who are most able to continue treatment and make it a priority to keep up with their appointments. Ultimately, I like to give my patients hope and advocate for their success. I discuss our groundbreaking FDA-approved therapies and all the incredible work coming down the pipeline in the GA space that may offer even more treatment options. I reiterate that early-stage disease is the time to begin saving vision while there is still something to save.
