From detection to decision-making: Navigating disease progression and treatment in geographic atrophy

Geographic atrophy (GA) remains one of the most challenging conditions to manage in retinal practice—a slowly progressive disease with significant implications for patients’ functional vision. Priya S. Vakharia, MD, FASRS, of Retina Vitreous Associates of Florida, moderated a recent Ophthalmology Times Case-Based Roundtable®, presenting 3 cases from her own practice to guide a discussion on detection, progression, treatment selection, and the practical realities of managing GA in a busy retina clinic.

Case 1: GA in the setting of bilateral wet age-related macular degeneration (AMD)

The first case centered on a patient with wet AMD in both eyes, treated with intravitreal aflibercept 8 mg (Eylea HD; Regeneron) every 4 months—a straightforward treat-and-follow regimen until GA began developing in the right eye. Vakharia described the central teaching point: the importance of actively looking for GA even in patients already being treated for neovascular disease.

“It’s really easy to just kind of treat and forget and just see her every 4 months,” Vakharia said. “But then we started noticing that they were having some GA in the right eye—and that’s a conversation you have to have.”

The management plan involved initiating pegcetacoplan ophthalmic solution 2% (Syfovre; Apellis Pharmaceuticals) in the right eye every 8 weeks, alternating with aflibercept 8 mg every 16 weeks. Vakharia acknowledged the added complexity of tracking 2 injection schedules but emphasized that it is manageable and clinically warranted. Attendees came away with a clearer understanding that GA can coexist with wet AMD and should not be overlooked in patients already receiving anti-VEGF therapy.

Case 2: Treating a functionally monocular patient

The second case presented a more emotionally and clinically weighty scenario: a patient with 20/20 vision in the right eye and 20/200 in the left, with extensive GA lesions in both eyes on fundus autofluorescence imaging. In the right eye, the fovea was barely spared. The patient also had a significant family history of AMD and coexisting glaucoma.

The patient declined injections in the left eye but agreed to treatment in the right. Vakharia chose avacincaptad pegol intravitreal solution (Izervay; Astellas) for the right eye, citing the lower reported risk of inflammation and retinal vasculitis compared with other complement inhibitors—an important consideration in a patient whose remaining functional vision could not be put at risk. Treatment was given every 6 to 8 weeks to help ease the overall treatment burden in a patient already managing multiple ocular conditions.

“Somehow miraculously in the right eye, barely sparing the fovea,” Vakharia said of the imaging. “She continues to do well 1 year later—which is awesome. We know that she’s going to progress, but for now, we’re calling this a win.”

Case 3: Early-stage disease with high-risk imaging features

The third case involved a patient presenting earlier in the disease course, with 20/50 vision in the right eye and 20/80 in the left. Fundus autofluorescence imaging revealed peri-lesional hyperautofluorescence and multifocality in the right eye, and peri-lesional hyperautofluorescence in the left—both recognized risk factors for accelerated GA progression.

Vakharia treated the worse-seeing left eye first with pegcetacoplan, describing her practice of using the first eye as a “test” to assess for any adverse reactions before proceeding to the fellow eye. She treated the right eye 1 month later and has maintained an every-8-week regimen since then. At 1 year, the patient has shown some progression in both eyes but remains overall stable.

“We really want to do whatever we can to help prevent progression in that right eye,” Vakharia said, highlighting how imaging biomarkers can guide not just treatment initiation but prioritization of which eye to treat first.

Emerging discussion: Same-day injection of anticomplement and anti-VEGF

One of the more notable discussions to emerge from the roundtable was whether anticomplement and anti-VEGF agents can be administered on the same day rather than alternating visits or scheduling separate appointments. Vakharia noted that this approach has the potential to meaningfully reduce treatment burden, but adoption is uneven across the country.

“A lot of people aren’t doing it because of fear of payer restrictions,” she said. “In some parts of the country they’re doing this, in some parts of the country they’re not because of payer concerns.” The group members discussed their respective experiences, reflecting the real-world variation that physicians encounter when navigating insurance and reimbursement landscapes.

The value of the Case-Based Roundtable format

When asked about the value of this type of educational forum, Vakharia pointed to the intimacy of the setting as its defining strength. With 8 to 10 clinicians gathered around a dinner table, the conversation is unconstrained by the structure of a formal lecture or the restrictions of an industry-sponsored program.

“Everybody feels like they can learn, everybody feels like they can ask questions,” she said. “It’s not an industry-sponsored talk, and so it’s really nice just for education and learning to be able to discuss disease state and treatments.”