Lakhanpal on the first-visit conversation in geographic atrophy

For patients with geographic atrophy (GA), the vision they have at diagnosis is likely the best vision they will have. According to R. Ross Lakhanpal, MD, FACS, retina specialist and vitreoretinal surgeon at The Retina Care Center in Baltimore, Maryland, an affiliate of PRISM Vision Group, that is the message clinicians need to deliver from the first visit.

Lakhanpal said his first goal with a newly diagnosed patient is to confirm the diagnosis and talk about GA in general. He tells patients that the 2 FDA-approved treatments—pegcetacoplan (Syfovre; Apellis Pharmaceuticals, Inc.) and avacincaptad pegol (Izervay; Iveric Bio, Inc., an Astellas company)—can slow GA growth but cannot stop it completely.

Setting expectations at diagnosis

Urgency depends on lesion location. For non-subfoveal GA a disc area or two from the fovea, he gives patients time to consider treatment and typically sees them again in 1 or 2 months. When the lesion is subfoveal or close to the fovea, he aims to see the patient in about a month. “I feel like I need to do my job, which is to stress the urgency,” he said.

The conversation also covers potential adverse events, including conversion to wet age-related macular degeneration (AMD) and, although extremely uncommon, vasculitis. He involves caregivers and focuses on what matters most to each patient, such as driving. He noted that studies have shown untreated patients lose the ability to drive after about 1.5 to 2 years.

Imaging as a teaching tool

Lakhanpal considered fundus autofluorescence (FAF) and optical coherence tomography (OCT) the 2 best imaging tests. OCT also confirms the patient does not have a wet macular process. He favors FAF because it shows both the areas already lost and, through hyperautofluorescence, the areas at greatest risk. Patients also find it easier to understand. He describes those stressed areas to patients as a brush fire that will eventually become dark unless the retinal tissue can be saved.

Visual acuity vs visual function

“Visual acuity does not equate to visual function,” Lakhanpal said, calling this the biggest misconception he encounters. A patient with 20/30 vision may have only a small island of vision, and may decline to count fingers or 20/400 within a year or 18 months. He encouraged referring physicians to send any patient with GA to a retina specialist.

Measuring long-term success

Lakhanpal pointed to long-term data for pegcetacoplan from the GALE extension study (NCT04770545). He also cited the GATHER2 open-label extension (NCT05536297) for avacincaptad pegol. “The longer a patient is on GA treatment, the more benefit there is,” he said. He also called for better, more standardized ways to measure how patients function in activities of daily living.

Lakhanpal compared GA with wet AMD, which had 3 drug options when he began practicing. It can now be treated to improve vision, with treatment every 4 months. He noted that several companies are investing in GA research, and he encourages patients to stay on treatment.