The atrophic form of age-related macular degeneration (AMD) is a particular interest of mine because it was the focus of my PhD thesis. Perhaps this is one reason for my early adoption of anticomplement therapy for the treatment of geographic atrophy (GA). The other is that there is currently nothing else to offer these patients. For more than 20 years, patients with exudative AMD (eAMD) and other retinovascular diseases have had excellent intravitreal treatment options; however, short of recommending lifestyle modifications and low vision evaluation, we have been entirely powerless against GA—an unrelenting and devastating chronic blinding condition. 

Thankfully, with the approvals of two anticomplement intravitreal injections for GA several years ago, we are no longer at the mercy of the disease. Although it is exciting to finally have “an arrow in our quiver,” there are myriad considerations before adopting such new therapies in the clinical setting. Outside of safety and efficacy, which are of utmost importance, we must also consider candidate selection as well as practice management issues, including accommodating for increases in patient and injection volume.

The labels for these drugs are lenient, which is both a blessing and a curse. They are approved for any patient with GA secondary to AMD, and unlike in the pivotal trials, there are no label restrictions with regards to baseline visual acuity, or size, location, or type of GA. Therefore, every single patient with GA secondary to AMD is a theoretical candidate for this intravitreal therapy—even those who are asymptomatic with 20/20 vision. In my practice, I make a concerted effort to educate all patients with GA about the natural course of their disease, the availability of these injections to mitigate their condition, and the potential benefits and risks. These can be long conversations that require additional “chair time,” so it is important to account for this time in the clinic schedule. Many patients choose to initiate these therapies, while others decide to continue with monitoring. From all the patient discussions I have had over the last 2 years, the status of the fellow eye appears to be the main determining factor as to whether therapy will be considered; that is, if one eye has lost vision due to disciform scarring from eAMD or subfoveal GA (functionally monocular), patients will most likely proceed to intravitreal injections in the better-seeing eye. Patients who are asymptomatic with good vision in both eyes (nonsubfoveal GA) tend to choose close observation. 

Population estimates predict that there are approximately as many patients with GA as with eAMD, and a potential influx of patients with GA who require long-term injections every 4 to 8 weeks could be crippling to some practices. Thankfully, we have dozens of doctors in my practice to accommodate an increasing clinic injection volume. The need to accommodate a larger number of patients receiving chronic intravitreal therapy may affect physician “threshold” or motivation for recommending anticomplement injections. Additional practice management considerations include added staff time for prior authorizations, billing, and appeals (which are rare in my experience). Even physical constraints have to be considered, such as the need for additional fridge space to store the injections.

All in all, I am thankful for the availability of these intravitreal treatments for patients with GA and I am looking forward to many more options coming down the pipeline—whether they are intravitreal, subretinal, suprachoroidal, or even systemic.

This editorial content was supported via unrestricted sponsorship.

Anton Kolomeyer, MD, PhD is a retina specialist at NJ Retina (PRISM Vision Group) and an adjunct assistant professor of ophthalmology at the Perelman School of Medicine, University of Pennsylvania.