This article was originally published in a sponsored newsletter.
For years, we have lamented with patients about the insidious vision loss associated with geographic atrophy (GA). Prognoses were bleak and central vision loss was almost a foregone conclusion. But enter complement cascade inhibitors and our conversations have become significantly more optimistic. Initiating treatment with either avacincaptad pegol (Izervay; Astellas) or pegcetacoplan (Syfovre; Apellis), however, is not as straightforward as it is with neovascular AMD (nAMD). Given the slower and somewhat uncertain nature of progression, patient selection is paramount. I tend to observe patients with established central vision loss who are unlikely to benefit from treatment. The decision is significantly easier in patients with noncentral areas of GA, especially in cases of increased fundus autofluorescence and lipofuscin activity. In my real-world clinical experience, patients with vision-threatening GA have responded well to injections and the benefits outweigh the limited potential risks.
Retina specialists have become efficient when creating and implementing treatment plans, but we must remain cognizant of the entire patient. We should not just myopically treat the results of imaging. I often introduce treatment options at the initial visit, but I also ask patients to review materials on all their options and return within 2 to 4 months to initiate treatment if it is the best choice for them. I am considerably more vigilant with patients who have noncentral GA and have already lost vision in the fellow eye. In appropriate cases, initiating treatment earlier is certainly acceptable. Retina specialists have decades of experience injecting eyes and the risks thus far, coupled with the results of the clinical trials, should instill a level of optimism and hopefully mitigate any skepticism, both among patients and treating physicians.
Initial fears about increased clinic volume have largely been quelled. Payers have been receptive to both avacincaptad pegol and pegcetacoplan, as have patients, their families, and referring doctors. The long-term goal of eradicating GA or halting disease progression finally has a beacon of hope. We cannot falsely promise to stop vision loss, but the current complement cascade inhibitor treatments provide an option to maintain functional vision. I am happy to advocate for their use and have already witnessed multiple cases of delayed disease progression with treatment. Avacincaptad pegol and pegcetacoplan have added a valuable weapon to our arsenal in combatting vision loss related to AMD and GA.
