This article was originally published in a sponsored newsletter.
Anti-complement injections have been a game changer for the treatment of geographic atrophy (GA) due to advanced dry age-related macular degeneration (AMD). As with any new treatment, patient selection, education, and safety are paramount to successful implementation of pegcetacoplan (Syfovre, Apellis) and avacincaptad pegol (Izervay, Astellas) in clinic.
While the decision to treat is multifactorial and varies within the retina community, letting patients make the final decision for their treatment is essential. To help my patients decide which option is right for them, I stress that these injections will slow progression of disease and preserve retinal function for as long as possible, but they are not a cure and do not stop progression. I also factor in each patient's support system, compliance, and motivation before providing my recommendations. For example, I do not treat patients with severe dementia or those who have poor systemic health. I often discuss treatment options with patients, give them literature to review, and bring them back in a month for potential treatment, at which point, we can address any additional questions. While this delay gives patients time to understand their options, it also provides my staff sufficient time to arrange for any pre-authorization required for treatment.
Educating our referral networks is a vital step in the treatment process with these therapies. Most anterior segment ophthalmologists and optometrists we work with every day have OCT or fundus photo capabilities in-office, and they can identify GA both in early stages and signs of progression. Because pegcetacoplan and avacincaptad pegol have only become available recently, it is important to discuss them with your referral network to reach a broad range of patients.
I often get the question, “When should I refer?” Earlier is better, but we should also remember that vision does not always correlate with the level of GA. I emphasize that patients with good vision benefit the most from early intervention; however, I also have many patients who are 20/20 with significant GA.
When treating patients with bilateral disease, I typically start with the worse-seeing eye. When patients tolerate treatment well, I inject both eyes at subsequent visits. I encourage patients to be vigilant for any changes in vision or pain in the post-injection period because, although they are rare, endophthalmitis and retinal vasculitis are potential complications. I also perform periodic dilated exams to rule out inflammation, retinal vasculitis, and optic neuropathy.
Finally, I do my best to optimize each patient’s experience, because these injections present a significant treatment burden. I avoid dilation at every visit and instead alternate injection-only visits with full examinations. I do an OCT at every visit to monitor for any evidence of wet macular degeneration. I treat with brimonidine before injections to decrease episodes of black-out vision post-injection and pain due to elevated intraocular pressure. After the injection is complete, I instill a drop of a topical NSAID to minimize discomfort.
