This article was originally published in a sponsored newsletter.
In the last 2 years, we entered a new era with two FDA-approved treatments to slow the progression of geographic atrophy secondary to age-related macular degeneration. Previously, a large proportion of geographic atrophy patients were followed in optometrists’ offices and given limited opportunities for intervention, but now, many of these patients are referred to retina specialists to discuss and potentially initiate treatment with a complement inhibitor.
These medications represent an opportunity to reach more patients; however, managing clinical workflow is an important consideration as they are adopted. First, it is crucial to use a multifaceted approach throughout patient conversations about these treatments, starting with training your ophthalmic technicians and other members of the clinical team about the basics of treatment. These team members can be essential to initiating or continuing the conversation on treatment. Providing patient education materials to read at home with family members also can be an important adjunct to conversations in the office . Many patients may want to think about the initial conversation and then come back to initiate treatment within a few months, which can be a reasonable approach to staging the conversation and answering questions.
Considering the best candidates for treatment is also an integral part of incorporating these therapies into the clinic. Often, patients who have already lost a significant amount of visual function in one eye due to advanced subfoveal geographic atrophy lesions are committed to preserving vision in their fellow eye. Because the emphasis of treatment is on slowing geographic atrophy lesion growth rather than on visual acuity gains, these patients are often most able to appreciate the value of preventing further vision loss, compared with other patients. Both complement inhibitor agents have shown an increased treatment effect over time in the longer-term follow-up studies, so selecting patients who are able to commit to monthly or every-other-month injections for the long-term is key to maximizing treatment benefit.
Although some may view atrophy concurrent with neovascular age-related macular degeneration as different from other cases, these patients can also be good candidates for treatment because they may suffer further vision loss from their atrophy, even with adequate control of the neovascularization. These patients also may be more agreeable to regular intravitreal injections, given their ongoing neovascular age-related macular degeneration treatment. In these cases, injection visits can alternate between anti-VEGF and complement inhibitor agents. This routine is my preference, but it is not contraindicated to do both injections on the same day.
While additional reassuring safety data have been released since the approval of both medications, it can be reasonable to consider starting treatment in the worse-seeing eye if your primary concern about initiating treatment is the low–but nonzero–risk of retinal vasculitis or intraocular inflammation. If the patient tolerates the treatment well, additional treatments can proceed as planned in the better-seeing eye.
Initiating patient conversations, patient selection, safety considerations, and clinic workflow are all important factors as we continue in this new era of retinal disease care with promising treatments for geographic atrophy.
