Geeta Lalwani, MD:

All right, let's get to the next case. I'm going to share this one. This is an 81-year-old female, very active, very social. She's retired with her husband and she presents to my clinic in 2022. She had previously been diagnosed with macular degeneration and she was taking AREDS vitamins. She was a former smoker, but had quit. So you can see here, so in a pinch, they sometimes use, as Moo, you alluded to, using the spectral domain image to look at GA. Unfortunately, here in the slide doesn't show up as well as it does live, but you can see here the presence of some extrafoveal GA lesions in both eyes, but you can see on the OCT below, you really don't see any kind of hypertransmission show up as you would expect. She had very good vision. She came back to my clinic about three years later.

She had moved to Arizona and then moved back because her grandkids were born. And here on the fundus autofluorescence, you see multiple areas of geographic atrophy in both eyes. They're both extrafoveal, but you still see some hyperfluorescence around these smaller areas of GA, but they're really quite numerous, almost too numerous to count. On the left eye, you see a little bit of hypertransmion in fairly close proximity to the fovea, but as you would expect, she still has very good vision. So this being 2025, we started to discuss complement inhibition, but she was really reluctant. She just had a fear of the medication, not the injection. I take a great amount of time to explain to patients who've never had an injection before that injections really are not painful. You would think that's what hurt, but she really was very reluctant about the medication in general.

So when I have those patients, I bring them back a little more frequently. Instead of coming back in six months, I bring them back in three to four months and it's a little clue to myself to say, "Hey, this patient is somebody I would like to treat, but I haven't been able to get through to them." And so I call it whispering in their ear. I give them a little bit information each time, including the vision loss, but I can also then show them these pictures. I find fun is auto fluorescent's a fantastic teaching tool for patients because it's very obvious as you see her now in April 2026, about a year later and clearly those areas of geographic atrophy have increased. They are still not fovea involving. Her vision still is good, but she's begun to understand that her vision is going to decline if we do nothing.

So I was able to finally convince her and we were able to start ACP in her right eye. I don't know what you guys do, but when I have a patient who in this case, I though bilateral treatment would be ideal for her, but I start in one eye, not so much as a risk when I use ACP of inflammation or any kind of side effect, but more so that they can understand the process and then come back to receive bilateral treatment. So what would you guys do in this situation? How do you talk to patients who are reluctant about treatment?

Carl Danzig, MD:

So the first thing I love about your case is that it's so easy to miss the GA if you are in a rapidly moving clinic, lots of patients, and you're just looking through the OCT with one raster through the fovea, you are going to miss us. And you illustrate so nicely that when we look a little deeper, we want to look for the GA. If we don't look for it, we're not going to find it. Okay? So you did a great job. Now I always start with one eye just because I think it's hard for a patient to have two eyes treated on the first visit, especially if they've never had a treatment before. In this situation, I'd ask her which one to choose first, but I agree with you. If I have a patient that is reluctant, I bring them back a little sooner.

I always give them the brochures. I also talk about driving vision. I said, "This is an independent patient, very independent. She loves life. She's driving around. I mean, she lives in Boulder. There's a lot to do and she needs to see to do it." So I also talk about driving vision. It's been in manuscripts. We have a great poster here at ARVO by Margaret Chang about driving vision with ACP and the GATHER trials. But in general, the biggest hurdle we have is not which drug to choose. It's getting treatment period because there's apathy and treatment across the spectrum in ophthalmology in some cases. And then patients are fearful too.

Geeta Lalwani, MD:

Sure. I think you bring up a very good point about driving vision. There's plenty of evidence that's been shown you really can reduce the risk of losing driving vision within a very short period. So I think that's a very good point. I think the other thing that worked well is that I had her bring her husband in. I think having a second set of ears in these patients really important because it's a complex topic to understand that we're not improving vision. We are maintaining vision. What else would you have done, say Moo, in this case, in terms of treatment? Would you have started her even earlier had it been available?

Murtaza Adam, MD:

I think it's a challenge to navigate the consultation, the initial consultation with these patients because it's a lot. The moment a patient hears macular degeneration, they just think in their heads over and over again, "I'm going to go blind. I'm going to go blind." And a lot of what you say goes in one ear and out the other. There are a lot of data on health comprehension for patients. About 40 to 80% of what you say in the first visit is lost. And it takes three to seven visits for the average patient to really understand and repeat what you have taught them. And so I think you did a great job of repeating the message over and over again. And the best part about your case is that you use the images to tell the story. In the end, we can describe what GA is all we want, but the picture showing those potholes of areas of cell loss really I think convinced the patient, educated the patient that if I keep doing what I'm doing, things are going to get worse.

I always tell my patients, you have two options. You can sit on your hands or we can do something about it. And most of the time people choose to do something.

Geeta Lalwani, MD:

Sure. So talk to me, Carl, about multimodal imaging. I use it often at baseline when I see these patients, but I don't actually use it throughout the whole treatment. What do you do?

Carl Danzig, MD:

So every time a patient comes to my office, they have an OCT and we do the whole macular cube or posterior pole and we look through everything. I also do autofluorescent photos in all my dry AMD patients, even before they have GA, just because I want to document early changes. I get the FAF images, those fundus autofluorescent photo images every six months. If they're on treatment every six months, if they're not on treatment, still every six months. And I go over it and I look. I feel that the color photo, it's easy to miss GA. And so many referring doctors are using a wide field color image sometimes in lieu of even dilating a patient. And then you're missing the autofluorescent. I do tell them that on the Optos, there is autofluorescent imaging capability also. So please do that if you're not dilating patient and look at the image.