Patient Characteristics in Geographic Atrophy

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David Lally, MD describes individual phenotypic features in geographic atrophy and determining patient response to treatment.

David Lally, MD: For my patients with geographic atrophy, traditionally I would see those patients in my office every 6 months. When they would come to my office every 6 months, they would undergo certain visual assessments. I always check their visual acuity, I check their eye pressure, I do a dilated eye exam to look at the eye and look at the geographic atrophy. I also like to get imaging, and standard imaging would be to get a picture of the center of the retina, called an optical coherence tomography (OCT) picture. That OCT picture is almost like an optical biopsy of the retinal tissue, where I can see on a very microscopic level, what the health of the retina is looking like. I like to follow that picture over the years. That gives me understanding of what type of progression rate the patient is showing with their geographic atrophy.

I also many times like to get another imaging picture called a fundus photograph, which is just a photograph of the back of the eye. That's another way that I can follow the change in the size of the atrophy over time. The final picture I like to get often would be called a fundus autofluorescence picture, which is similar to the fundus photography picture, although it uses a different technique to look at the geographic atrophy in a different manner. And that also is a third way that I can assess how the geographic atrophy is expanding over time. With those three different types of imaging modalities, it gives me the best understanding of the patient and counseling the patient in terms of how that atrophy is progressing over time.

Historically speaking, we have not had any treatments where I could offer any treatment but that has changed in the year 2023 with our two new FDA-approved treatments. Depending on how the characteristics of their geographic atrophy appear, and by that I mean, is the geographic atrophy lesion located in the fovea? Is it located outside the fovea? Is it located outside the fovea, but close to the foveal center? Is it one lesion of geographic atrophy or is it many lesions I'm seeing appear in the macula. Depending on that appearance, I may or may not have a discussion with the patient about the option of treatment with our new FDA-approved treatments.

The other thing I want to look at is the progression rate of the atrophy over time. Some patients, their atrophy lesions can expand and progress very slowly over time. In those patients, I may be less hesitant to want to discuss treatment with our FDA-approved therapies. On the other hand, many patients will show me signs of progression over time at a moderate or significant rate, where I'm observing the atrophic lesions expanding over time. In those cases that I see moderate to significant progression rates, I will be likely to counsel patients on the option of starting one of these two therapies in an attempt to slow down that progression rate.

The other thing I look at is the visual acuity of the patient. If the patient has very advanced geographic atrophy with very large subfoveal geographic atrophy lesions in both eyes, and their visual acuity is poor, they can only see the E on the chart, and that perhaps they're an older patient in their 80s or 90s. The idea of starting and initiating these FDA approved therapies to slow progression when they're already close to the end of the progression. They're close to the end of the road. That treatment burden of coming in for frequent injections monthly or every other month, does not, in my opinion, have great benefit for that individual patient.

With that being said, I don’t use visual acuity as a make or break if I will counsel the patients for these treatment options. Certainly I have patients that have 2200 vision with large atrophic lesions that have been progressing over the years, those patients are still noting progressive, continuous vision loss. For these patients. I know they're not at the end of the road yet. I know that over the next few years, their disease is going to continue to progress. And these can be motivated patients who are looking for some treatment that can impact the progression rate of their disease. And in those cases, I will discuss the treatment options with our FDA-approved therapies.

I think the important take home message is there's a wide variety of different phenotypes of this disease that we see. There's different age ranges of patients that we see. There's different motivating factors within patients that we see. Some patients are noting unrelenting vision changes. Other patients do not notice changes in their vision, even though I'm detecting the atrophy lesions grow on my imaging. I think it's really a case-by-case decision in my practice on what I see the value of these therapies for and the counseling is really individualized for my individual patients.

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