Hawaiian Eye and Retina 2024: Key considerations for treating geographic atrophy

Glenn J. Jaffe, MD, recently spoke with Ophthalmology Times Group Editorial Director Sheryl Stevenson about the multifactorial complexities of treating patients with geographic atrophy in his talk from Hawaiian Eye and Retina 2024.

Video Transcript

Editor's note - This transcript has been edited for clarity.

Sheryl Stevenson: We're joined today by Dr. Glenn Jaffe, who is among the faculty at this year's Hawaiian Eye and Retina conference. Welcome to you. We're really excited to hear more about your talk regarding, 'How do I decide to treat patients with geographic atrophy?' Can you tell us a little bit about your talk, some of the key takeaways, today?

Glenn J. Jaffe, MD: Thanks very much, Sheryl. So the first question is, why is this even an important topic. We now have two approved therapies for geographic atrophy. We have pegcetacoplan [Syfovre; Apellis] and we have avacincaptad pegol [Izervay; Iveric Bio].

Geographic atrophy itself is a major problem [in]...United States and Europe. And the question is, how are you going to decide to use these new treatments. It's important because patients lose visual function over time with geographic atrophy and it's more than just the visual acuity. Somebody can read all the way down on the eye chart but because of the atrophy causing a scotoma or blind spot, they may not be able to drive, they may not be able to see somebody's face, they may not be able to read. And so obviously we want to prevent that from happening.

But the treatment decisions to decide how you're going to treat are actually a little bit complicated. It's multifactorial.

First, you have to make the diagnosis of geographic atrophy. You want to know how close is it to the center of the fovea, the geometry... In other words, is it surrounding the fovea, is it just on one side of it, the size of the lesion, whether it's unifocal, multifocal, how fast is it growing, what's the fellow eye doing.

There's social considerations. For instance, whether somebody can come in for their treatments, because the treatments need to be given very frequently. And for insurance purposes, insurance companies may be requiring you not only to measure the lesion size, but they may also be requiring you to measure the growth rate before you even start treating the patient so that you can make a decision. And then more recently, there have been some safety concerns. So I just want to highlight a couple of those things to summarize it.

We use the CAM [Classification of Atrophy Meetings] criteria to diagnose GA, which means that choroidal hypertransmission more than 250 microns associated with loss of the RPE [retinal pigment epithelium] or attenuation and loss of the outer retina. But to say whether it's geographic atrophy, I use an en face image to pick it up, either the color fundus photo, [an] autofluorescent image, the near infrared image and then I use those CAM criteria on OCT [optical coherence tomography] to confirm it. And I use OCT to measure the distance from the foveal center. And you can use the autofluorescent images to measure growth rate using a plug-in software RegionFinder with Heidelberg Eye Explorer software and that's a nice way to measure the growth rate.

And when we're trying to decide whether to actually treat the patient... Let's take an example of somebody who has lost one eye...that eye is not functioning, they have GA in the other eye that's near the foveal center, and you've determined that the growth rate is fairly rapid, that might be a very good patient to treat.

On the other hand, if somebody has a really good fellow eye and the eye in question has geographic atrophy that grows more slowly or that it's not as close to the fovea, you may elect to wait.

And you need to balance the potential risk, because as I think many of you know, there have been recent reports of inflammation, occlusive vasculitis, with pegcetacoplan. And although they don't occur frequently, in fact, none of them were identified during the trials, it was only after the trials were over and when it got into the clinics that these started to be identified. But nonetheless, you're going to need to balance some of those risks with the potential benefit of the treatment.

One thing that I just want to mention in closing is that when you talk to the patient, you can tell them about the goal, which is to slow down the growth rate of the lesion so that they can function for a longer period of time. But you also need to tell them that takes a lot of commitment, not just on their part, but it may be on their family's part as well, because it's not like neovascular AMD where you can treat on an as-needed basis or as a treat-and-extend. You have to treat either every month or every 2 months.

We don't have data on what happens if you stop the treatment. In fact, some of the data suggest that the treatment effect might start to diminish. So this is really a treatment for life, treating every month to 2 months with one of these agents and it's really important that the patient understands that.