Geographic atrophy: Treating a chronic disease chronically

Geographic atrophy (GA) is a chronic and progressive disease, and it has to be managed that way, according to Veeral S. Sheth, MD, MBA, FACS, FASRS, partner and director of clinical trials at University Retina and clinical assistant professor at the University of Illinois at Chicago. “The way we look at these chronic diseases is we’ve got to manage them chronically,” he said.

Sheth noted the label for avacincaptad pegol (Izervay; Astellas), which the FDA updated in February 2025 to remove the limit on treatment duration, allows for that conversation with patients. The original label had what he called a 12-month cap, an artificial treatment constraint. Without the question of whether treatment must stop at month 12, he can tell patients from day 1 that this will be a long-term journey. He added that the gap between treated and untreated continues to separate the longer patients are treated.

Defining functional benefit

Some patients say early on that they are seeing a little better, but most report that their vision is about the same, Sheth said. He tells patients that if they are still driving and doing what they want in their daily lives, “that to me is the victory.” He sets up that framing at the start and returns to it throughout treatment.

As clinicians gain experience, Sheth said they are introducing treatment earlier rather than waiting until vision is significantly affected. He cited driving as an example of the independence patients want to maintain. He said that as more data have been collected, including from the original GATHER1 (NCT02686658) and GATHER2 (NCT04435366) trials, “we’re starting to see that more and more of these patients are able to prolong that independence.”

A common question from colleagues newer to prescribing the drug is when to start. Patients who have lost some vision, such as 20/30 or 20/40, and perceive the impact are easier conversations. Harder are patients referred with GA who do not perceive a significant impact. For them, he reviews fundus autofluorescence (FAF) images showing thinning in the retina. “Once the vision is lost, we can’t bring it back,” he said. When a lesion is near the fovea, he encourages colleagues to talk with patients earlier, because it will grow and may move into the fovea.

He also talks with colleagues about how to counsel patients on day 1 and reinforce that conversation as the months go on. Coming in every month or every 2 months “wears on patients,” Sheth said.

Opportunities to improve outcomes

Sheth described a patient whose worse eye was 20/60 to 20/70 and better-seeing eye was 20/30. While starting treatment in the worse eye, he told the patient in that initial conversation that they would need to start talking about treating the better-seeing eye, because staying at 20/20 to 20/30 makes driving less of an issue. He said the opportunity is having those conversations earlier rather than waiting for perceived vision loss. He also pointed to emerging long-term data on slowing lesion growth and what that means for patients in the real world.

As someone involved in clinical trials, Sheth said these should be framed as first-generation treatments, with others likely to follow. “If we can slow disease down today, preserve as much tissue today, preserve as much vision today, that’s only going to benefit patients in the long run,” he said.