Geographic atrophy: Treatment decisions before foveal involvement

When should complement inhibition begin in geographic atrophy (GA): in a patient with extensive atrophy and 20/20 vision, or in one whose lesion has not reached the fovea? An Ophthalmology Times Clinical Forum roundtable, “From Detection to Decision-Making: Navigating Disease Progression and Treatment in Geographic Atrophy,” featured 2 cases from Travis Peck, MD, a vitreoretinal surgeon at Retina Consultants of Delmarva, which has offices in Delaware and Maryland. Peck described why he treated each patient and how their treatment plans evolved.

Extensive atrophy and conversion to wet age-related macular degeneration

The first patient was a 77-year-old woman whom Peck described as someone who “functions like she’s 60.” Referred by her primary eye doctor for macular degeneration, she had best-corrected visual acuity (VA) of 20/20 in both eyes and very mild symptoms. Fundus autofluorescence (FAF) showed extensive atrophy in a bull’s-eye pattern with peripapillary sparing, and optical coherence tomography (OCT) showed no real drusen.

Because the pattern was atypical, Peck looked for other causes. She had no medications that could explain it, and although he raised the possibility of an ABCA4 mutation, genetic testing was negative. The atrophy kept progressing in a circumferential pattern while she remained asymptomatic.

After further discussion, they decided to treat. Peck said he always starts with 1 eye in GA, typically the worse one, because “we’re not dealing with as time-sensitive of a process as with anti-VEGF, and we can spare 2 months to see how people react to it.”

After a few complement inhibitor injections, a routine visit showed a small pigment epithelial detachment and an area that looked like choroidal neovascularization. She did not come in because of a change in vision, and Peck had discussed the possibility of conversion beforehand. He switched her to anti-VEGF therapy with 3 loading doses every 4 weeks, and “she goes back to totally normal in that eye.”

Peck said he waits until the wet macular degeneration is stable on anti-VEGF therapy before restarting complement inhibition. To help patients understand, he tells them, “You have this new disease, wet age-related macular degeneration, now, but you still have your old geographic atrophy.”

For a patient with extensive atrophy and good vision, Peck said showing the FAF images is “probably the No. 1 most useful thing.” He added, “You having good vision is actually a reason to treat, because we can maintain that for longer.”

A small lesion in an active patient

The second case involved a 70-year-old man who is a caregiver for his spouse and an excellent golfer. At baseline in March 2025, his VA was 20/25 in the right eye and 20/20 in the left. He had difficulty seeing the golf ball and did not drive at night. The right eye had early atrophic areas on OCT, the left eye had drusen and trace atrophic changes, and the fovea was uninvolved in both.

He had heard about complement inhibitors, which prompted the visit. Peck told him he was “just not severe enough yet,” and treatment was deferred in favor of Age-Related Eye Disease Study supplements, diet, and lifestyle measures.

Six months later, in September 2025, his VA was 20/30 in the right eye and 20/25 in the left. The right eye had a new GA lesion measuring 0.15 mm² in the superotemporal macula, more than 1500 µm from the fovea. The left eye had worsening atrophic changes but no GA. The patient was anxious about progression, and Peck started treatment every 8 weeks in the right eye.

At 1 year, in March 2026, the lesion measured 0.2 mm² with hyperautofluorescent borders. Peck acknowledged that most clinicians would not treat a lesion like this: “If I showed you this in isolation, probably zero people would treat it.” The patient repeatedly asks to start the left eye, but Peck has held off because that eye has no GA.

By August 2026, after 10 injections in the right eye with no interruptions, the lesion measured 0.24 mm² and remained about 1500 µm from the fovea. His VA was unchanged at 20/30 in the right eye and 20/25 in the left.

The lesion is still enlarging, and Peck said he tells patients, “This is the best thing we have to slow it down.” He said the treatment is “probably doing more for his outlook on his vision and life” than for his retinal pigment epithelium, because the patient now feels in control of his disease.

Peck said early treatment makes sense here because the patient has “a long way to get to the fovea,” and “if we can change that from 10 years from now to 20 years from now, you know that’s a huge difference to him.”

Peck said he would avoid rigid thresholds for lesion size or proximity to the fovea. “Each case is really different,” he said, and the right approach is “really a patient-specific approach.”