Patient selection and counseling for complement inhibitor therapy in geographic atrophy

In this episode, Joseph A. Anaya, MD, MBA, and Ashkan M. Abbey, MD, FASRS, FAAO, discuss how clinicians approach patient selection, counseling, and monitoring when initiating complement inhibitor therapy for geographic atrophy (GA). The conversation focuses on practical decision-making in routine retina practice, including identifying appropriate candidates, setting realistic expectations for treatment, and establishing monitoring strategies for safety and disease progression.

Abbey explains that one of the clearest candidates for treatment is a patient who has already lost central vision in the fellow eye due to a disciform scar or GA. In these cases, patients are often motivated to begin therapy to preserve remaining vision. He notes that conversations about treatment can occur across a range of lesion sizes and locations, including extrafoveal and subfoveal GA. Patients who report declining vision over time and have GA consistent with their symptoms are typically offered treatment after a discussion of the potential benefits and limitations.

When initiating therapy, Abbey describes a cautious approach, typically treating the worse-seeing eye first rather than performing bilateral injections at the initial visit. After observing the response for signs of inflammation or other complications, treatment may then be extended to both eyes if indicated.

The discussion also addresses the complexity of counseling patients with extrafoveal lesions who may not yet be symptomatic. Although these lesions often grow faster than subfoveal lesions, the absence of symptoms can make the treatment discussion more challenging. Abbey notes that longitudinal imaging, particularly autofluorescence demonstrating lesion growth over time, can help patients understand disease progression and inform decision-making.

Anaya and Abbey also discuss how clinicians frame treatment expectations for patients who perceive ongoing progression despite therapy. Abbey emphasizes that clinical trial data demonstrate a reduction in the rate of lesion growth compared with sham, rather than a halt in disease progression.

The episode also reviews monitoring strategies, including routine optical coherence tomography (OCT) imaging at each visit, periodic OCT angiography to assess for choroidal neovascularization, and patient education regarding symptoms that could indicate intraocular inflammation.

Ashkan M. Abbey, MD, FASRS, FAAO, is in practice at Texas Retina Associates in Dallas, Texas, and director of clinical research. He is a speaker and consultant for Apellis Pharmaceuticals, Inc and Astellas Pharma Inc.

Joseph A. Anaya, MD, MBA, is assistant professor of ophthalmology at Wilmer Eye Institute at Johns Hopkins University School of Medicine in Baltimore, Maryland. He has no relevant financial disclosures.