Progression of Geographic Atrophy Over Time

Nancy M. Holekamp, MD, FASRS: I have a question for the panel. When someone has intermediate age-related macular degeneration, I tell them that the disease progresses slowly, and I either follow them at 6 months or a year depending where they are on that spectrum of intermediate disease. When someone has wet macular degeneration, I tell them that their vision can change very suddenly, it could progress quickly, and that they need to be on treatment at the intervals that I’m recommending. However, when it comes to advanced GA [geographic atrophy], do we tell patients that it progresses slowly, or do we tell them that it progresses at a rate they will notice?

Jayanth Sridhar, MD: That’s a fascinating question. I know what you’re getting at because I think we all know that, for example, we talked about visual acuity—imperfect measure of function—but visual acuity in GA is often quote-unquote stable, stable, stable, and then it drops because of foveal involvement. For a patient functionally, it could be a very drastic, quick reduction, and we may have some predictability to when that happens. But we don’t know exactly when we meet them in person when that’s going to happen. I have that conversation with them and it’s hard when you don’t have treatment options to get into the weeds in terms of when exactly is that going to happen, and that would be my first question as a patient; When is that going to be? How do I prepare for that? How do I plan for that? To your question of control, what can I do? I tend to focus on things that a patient can control and say this may happen at some point, but we don’t know the lead time for when that will happen, but we have some trial data that guides us.

David R. Lally, MD: Excellent points. I will add that I typically tell them when I first see them that it’s a heterogeneous disease and we see all sorts of variability in terms of the progression of the disease over time. I tell patients I don’t know what speed train your disease is on until I have more follow-up imaging and I can monitor your disease over time. So, let’s take it one visit at a time, come back in 6 months, let’s re-image and I’ll try to inform you of what speed train you’re on. It’s important if patients are progressing quickly, that we give them a heads up or some alert that their visual acuity might precipitously drop in the next year or 2, like Jay is mentioning. We find often with these non-foveal GAs, that when that GA lesion does encroach into that fovea, that year the vision drops precipitously, and it’s a rough year for the patient. The patient’s vision is going along and then there’s that 1 year where it drops precipitously, and I tell patients I don’t know when that year is going to be, but as we get more imaging, and I’m watching how close it’s coming, I can give you an understanding of when that time may be, as best to my knowledge, so that you can prepare your life for what lies ahead.

Jayanth Sridhar, MD: One last point about what we talk with patients about when we meet them. We are all in different geographic areas—the Midwest, New England, the south—and yet we share many of these patients because these patients are active, they have lives, they travel, they have retirement plans, they’re doing things. It’s really important, and I think we all do this when we first see them, and we’re talking about an injection protocol and follow-up, what is that patient’s lifestyle like? Where do they live? How often are they going to be in town? Because let’s say you’re going to recommend monthly injections, are they going to be able to make those visits? Where are those visits going to take place? And pre-planning sometimes, we all do this, we pre-plan visits whether it’s a staff member or us with the patient because they have so many other things, medical or personal, because again, they tend to be very active.

Nancy M. Holekamp, MD, FASRS: They want to be active because they’re afraid they’re going to lose their vision at some point in the future. I just want to review some data from clinical trials. We’ve known as far back as the ARIES clinical trial when they looked at the GA population subgroups that patients lost a line of vision per year. This was reiterated when you look at the clinical trials that we now know represent natural history, that over a 1-year period of time they were losing 5 lines, 5 letters, of visual acuity in 1 year, and 10 letters of visual acuity in the second year. While we talk about how each individual patient will have a precipitous drop, on average when you look at large groups of our GA patients, it’s a relentless, progressive, decline in vision when you look at large groups of patients. For many of us we’ve been calling it slow because it’s not as fast as wet AMD, but it’s actually going at a progressive rate that if you’re affected with AMD, and you’re very active, it’s going to seem fast to our patients.

Eleonora M. Lad, MD, PhD: That was an outstanding conversation and discussion on what the GA patients are dealing with.

Transcript edited for clarity