Geeta Lalwani, MD:

Hi, my name is Geeta Lalwani and we're going to be discussing geographic atrophy in practice. Carl's going to be discussing a case for us.

Carl Danzig, MD:

Thank you, Geeta. This is a really fascinating case of a 71-year-old female, history of smoking. She lives far away, four hours away. She has poor vision in her left eye because she had wet AMD that was never treated. She has a fibrotic scar. Her right eye is 20 / 40. Her left eye is count fingers. The image quality here is poor due to cataract. She comes in here this October 2022. We can see the atrophy between the nerve and the fovea. You can see the ONFOS image. Then after cataract surgery in August 2023, at this point, we have two products that are FDA approved. She underwent cataract surgery the month before. She's 20 / 30 and count fingers in the left eye. We see the autofluorescent image here. It's beautiful. She has extrafoveal lesions. They're multifocal with this hyperautofluorescence around those lesions. And here's the OCT, but we see that hypertransmission marching towards the fovea.

What happened was we started treating her with ACP in November 2023. She had an injection November in December, comes back in January 2024. In her right eye, she developed a subfoveal neovascular membrane. We can see the foveal edema. We see the membrane under the fovea. Her vision dropped from 20 / 30, 20 / 40. We injected bevacizumab on this visit. Remember, this is a monocular patient. What are we going to do? I paused treatment of avastincaptid pagel and we focus on making sure that she didn't have a bad outcome. So in February 2024, one month after she got her second injection, bevacizumab anatomically, it almost looks like there's nothing there. March 2024, vision remained 20 / 40 and we re-injected avastincaptopego at this point. So we had had a two-month hiatus. We treated bevacizumab twice, avastin-captipago on this visit, and we would alternate monthly. Remember, she's monocular.

She lives far away. We were able to do one month avastin captipegol. The next month, bevacizumab, and her vision improved back to baseline 20 / 30. So I think this is a beautiful case of a patient who is monocular and I was afraid that it could have a worse outcome, but in the end, she did really well.

Geeta Lalwani, MD:

Carl, that's a great case and really highlights barriers of access to care. This woman clearly had already lost one eye due to a very treatable condition. It's heartbreaking to see that, but you were able to adequately explain to her what was going to happen in terms of progression. I'm curious, so how did you explain wet AMD versus dry AMD?

Carl Danzig, MD:

I explained to her that her vision is poor in the left eye because she had wet AMD that was never treated. And when it's not treated, this is what we get, subfoveal fibrosis. And it's because this network of blood vessels are breaking through the bottom of the retina like a weed and they're sprouting and then they're bleeding and then they scar down. And we don't want that to happen in the right eye. But we also need to make sure that with the dry AMD is a constant bombardment of the fovea. We have this Swiss cheese. Those holes are getting larger.

Geeta Lalwani, MD:

Sure. You can clearly see on your images how those extrafoveal lesions are kind of coalescing into one ring on the nasal side of her and marching towards a fovea. So what about you do, Moo, in terms of treating patients who develop wet AMD? How do you manage them? In Carl's case, he put her on a fixed treatment regimen given that she was monocular and coming from a very long distance to really and preserve her vision and make sure that she didn't fall through the cracks. So I commend you. What do you do?

Murtaza Adam, MD:

We know that fixed treatment monthly or every other month, depending on the drug that you choose from wet AMD is going to lead to excellent outcomes. So a great decision on your end to do that. I generally will try to treat and extend my patients with regard to the anti - VEGF therapy if they do start developing neovascular AMD in the midst of receiving complement inhibition. And so when I see a patient, they have new onset wet AMD, I do what exactly Carl did, which is to switch gears and treat anti - VEGF and then make sure that CNV is quiet and controlled. Fortunately in these cases, when CNV develops secondary to anti-complement therapy, they tend to be minimally leaking. They tend to respond well. And in my experience, you can extend the timeline between injections pretty rapidly and then interplay or intersperse the anti-complement therapy in between once you feel comfortable with that.

And some patients, they do so well, I'll switch to PRN treatment if we can.

Geeta Lalwani, MD:

Sure. It's something what I do since we're seeing these patients quite frequently to be able to monitor them, but it also takes good education for patients to understand what to look out for. Less worrisome with complement therapies that is so safe, but anti - VEGF and having breakthroughs is really a big deal in these patients.