Treatment of Both Eyes and Subfoveal Lesions in Geographic Atrophy

Nancy M. Holekamp, MD, FASRS: We often have patients who have bilateral GA [geographic atrophy]. Can you discuss treating both eyes? Would you treat 1 eye? Would that be the better eye or the worse eye? Also, comment on treating subfoveal lesions. In these clinical trials, subfoveal GA was included in the analysis. The results of a post hoc analysis at month 24 show that the subfoveal lesion slowing or reduction of the growth rate was about 34%. Both eyes, subfoveal lesions—how does that figure into your discussion?

Eleonora M. Lad, MD, PhD: That’s a very insightful question. I’ll probably use the wet AMD [age-related macular degeneration] approach that I currently use, and I’ll give the patient options. Most of them want to come to the office less frequently, so they offer bilateral injections. There are a few who are concerned and don’t love the anesthesia. They don’t love the way the eye feels for a day after they’re shot, so they choose to have 1 eye done at a time. I’ll take the disease into account. I’ll use our imaging tools, which David so nicely described. I like autofluorescence the best. I’ll hopefully have enough sufficient follow-up visits for these individuals to predict whether they’re fast progressors, intermediate, or slow, and I’ll try to give them a sense of how the 2 eyes will fare. Then we make a decision together about what works for them with their schedule, their comorbidities, and all the things that can happen in their lives outside their eye care.

I love the question about the subfoveal involvement. At 24 months, the results of DERBY and OAKS are similar for extrafoveal vs subfoveal lesions. That’s important information. Although GA affects the foveal center, the scotoma—the blind spot—can deepen around the area of the foveal. The patients by now, because the foveal became involved, are starting to use their eccentric fixation with a perifoveal area. We’d like to preserve this.

There’s still strong incentive to treat the subfoveal-involved patients. I have a conversation about all these things. I love imaging as a visual tool available to us as retina specialists. We’re unique in that regard. Oncologists have CT scans and MRIs, but we have retina images that are quick and high resolution. We’re fortunate in that regard.

Jayanth Sridhar, MD: Yeah, we’re super blessed. To your point, it’s going to be individualized, and there are going to be a lot of complex questions. Dave, you talked about how we like to think of this binary consultation. There’s geographic atrophy and wet age-related macular degeneration. Those are separate entities. Clinically there’s overlap in some of these patients. Some get treatment for wet age-related macular degeneration but lose vision because of atrophy, and some with atrophy can develop wet age-related macular degeneration. The real question, which wasn’t assessed in a study like this, but we’re going to have to confront, is what do we do with those patients? Whether it’s 2 separate eyes, 1 eye with wet age-related macular degeneration and 1 eye with atrophy, what do you do with that patient who has progressive atrophy while getting antiangiogenic treatment for wet AMD? That’s going to be an interesting question to answer in the next few years.

Nancy M. Holekamp, MD, FASRS: Clinical trials can’t answer every question, so we use them as guidelines for treatment. All of us in our practices have seen injections for wet [age-related] macular degeneration save vision, but we watch our patients lose vision to the GA. On an individual basis, I’ll have a discussion to treat the GA competently with the CNV [choroidal neovascularization], because it’s all about protecting and preserving vision.

Transcript edited for clarity