In this episode of Ready, Set, Retina, Daniel Epshtein, OD, FAAO, discusses geographic atrophy (GA) with Steven Ferrucci, OD, FAAO, who is the Chief of Optometry at Sepulveda Veterans Affairs (VA) in North Hills, CA, and a professor at Marshall B. Ketchum University’s Southern California College of Optometry.
A case of geographic atrophy
Dr. Ferrucci presented the case of an 85-year-old man who was diagnosed 2 years ago with GA. The patient was prescribed AREDS 2 vitamin supplements twice per day and had a follow-up schedule of every 6 to 9 months. At one follow-up, the patient felt that his vision was worsening, with 20/50 vision bilaterally.
The OCT scans revealed significant progressive GA. While color photos are often used to identify GA, Dr. Ferrucci and Dr. Epshtein both noted a preference for leveraging OCT technology in managing this disease. Some of the latest OCT units can automatically measure the size of lesions. While not as ubiquitous, another useful tool for imaging GA is fundus autofluorescence (FAF).
When viewing OCT B-scans, GA will often appear as a choroidal hypertransmission defect (also called a waterfall defect or barcode defect), a brighter region of the scan due to the absence or attenuation of the retinal pigment epithelium (RPE) allowing for greater transmission of light through to the choroid.1
OCT imaging taken a year apart illustrated GA progression in both eyes; however, vision in the left eye remained consistent, while there was a decrease in the vision of the right eye. This patient, Dr. Ferrucci noted, would be an excellent candidate for the new treatments available to potentially slow the progression of geographic atrophy.
Newly approved treatments for GA
SYFOVRE (pegcetacoplan injection) 15mg/0.1mL and IZERVAY (avacincaptad pegol intravitreal solution) 2mg are treatments aiming to possibly slow or halt the progression of GA secondary to age-related macular degeneration (AMD), which both received FDA approval in 2023.2,3
SYFOVRE (Apellis Pharmaceuticals) was approved in February of 2023 to be injected once every 25 to 60 days. The therapy has been shown to increase its efficacy over time, specifically demonstrated with the GALE extension study data up to 36 months. It could slow or halt the progression of GA lesions by blocking C3, a protein in the complement pathway.4
IZERVAY (Iveric Bio, An Astellas Company) was granted FDA approval in August 2023. This medication is meant to be injected every month for up to 12 months and reduce GA progression by inhibiting C5 and limiting inflammation and resultant retinal cell death and photoreceptor loss.5,6
GA lesions tend to appear outside the fovea in the earlier stages of the disease and then migrate towards the fovea with a notable increase in lesion size. While neither pegcetacoplan nor avacincaptad pegol can reverse GA, they are able to possibly slow its progression to allow patients the ability to retain some level of their vision over an extended period of time.
When to refer a geographic atrophy patient
Dr. Ferrucci says that he would see a newly diagnosed patient every 3 to 6 months after the initial visit to observe any growth in the lesion(s). If the lesion(s) has grown, then it’s time to consider referrals for consultations. Conversely, if the lesion(s) remain stable, Dr. Ferrucci might elect to observe and monitor the patient on subsequent visits.
Of note, the proximity of the lesion to the fovea is another critical factor to consider when contemplating the next steps in managing GA patients. Once the lesion encroaches on the foveal space, the patient may experience significant visual impairment.
It is advisable to refer patients to a retinal specialist immediately upon identifying lesion progression, especially when foveal encroachment is observed. Further, if a patient has GA in one eye and then initiates development in the fellow eye, this is also a case of greater concern.
Pearls for monitoring GA patients
Monitoring vision can also help indicate when it is time for a patient to receive a referral, but the anatomy may demonstrate more disease activity than the vision. Oftentimes, patients’ vision can remain intact until the lesion reaches the fovea.
If the lesion begins to infiltrate the foveal space, Dr. Ferrucci recommends taking proactive measures while the patient still has intact vision. With the advancement of treatment for GA, there are diagnostic methods for earlier detection which can raise awareness of GA’s importance to manage and treat the disease.
Drs. Epshtein and Ferrucci agree that they can monitor GA cases more closely with the latest technological advances coupled with the advent of treatment options for patients that were not previously available until last year.
Conclusion
Since the approval of SYFOVRE and IZERVAY, it’s critical for eyecare providers to take advantage of the diagnostic treatment modalities available to proactively identify GA.
The take-home message is that earlier detection and treatment of this progressive disease can offer your patients a measure of hope to retain some level of their vision.
