Geeta Lalwani, MD:

Hi there. We're going to get back to the cases and I'm going to present another case. This is an 87-year-old white female who presented to my clinic in 2019. She had intermediate dry AMD in the right eye and advanced AMD with GA in the left eye. When she initially presented, she had very good vision, as you'll see in a couple minutes here, but she developed wet AMD in the right eye, which we started treating and we were able to get to a long interval. She does not use AREDS vitamins. She prefers to put her whole concoction of vitamins together herself with diet control. She's a non-smoker, but she's a very, very active post-retiree. She lives independently with her spouse and despite being 87, they travel around the world, very involved with her church as well as playing music. So here you see her in March 2019, you can see that area of geographic atrophy on the spectral domain image superior temporally in the left eye.

And as you would expect, she has very good vision. However, when she presented five years later, March 2024, you can see her on the fundus autofluorescence the extent of the geographic atrophy. Not only though is it a large area, you can see the ring of hyperautofluorescence all the way around it indicating to me a very aggressive GA pattern. So we discussed this situation and despite having very good vision, she was well aware of gaps in her vision missing off to the side. And after discussion, we decided to proceed with ACP in both eyes on the same day. She had previously been receiving injections for anti-VEGF, so she was comfortable with the concept of injections. When you see here in May 2025, about a year later, she had developed persistent recurring wet AMD that left her with a subretinal fibrotic scar and dropped her vision down to 20 / 400.

So we made a decision together that we no longer wanted to treat. However, we continued to treat the left eye. You can see here the image still with that large area of hyperautofluorescence, but she's been able to maintain her vision. On the OCT below, you see the hyperautofluorescence just temporal to the fovea, but she maintained her vision at 20 / 30. April 2026, again, about a year later, you can see the progression of the geographic atrophy in the right eye almost entirely encompassing the foveal area. In her left eye, she continues to have a small subfoveal island and maintain good vision at 20 / 40. So we've continued to treat her and while she realizes her vision is progressing, it's been two years of maintaining good central vision. So tell me about what do you think about patients like this? It's a blessing to see that we've been able to maintain her vision, but clearly you see the progression of geographic atrophy.

Carl Danzig, MD:

So you really manage this case as optimally as one could possibly do. I mean, she had wet AMD in the right eye and she has these atrophic lesions in both eyes in 2024. And you see the biomarkers that show a risk of more rapid progression. So it was extrafoveal bilaterality and that ring of hyper autofluorescence. And I liken that's like a brush fire where you see where the edge of it is where it's expanding and that's where it's going to be burning up the retina.

Murtaza Adam, MD:

She's held onto 20 / 40 vision, but I imagine that she's noticing some really significant functional decline. She has a really aggressive case and it's unfortunate she had that large gap between visits. What was it that kept her from coming back?

Geeta Lalwani, MD:

I think that she had been traveling and didn't present, but she's also, as you can imagine, a little bit reluctant about treatment. She doesn't want to take the ARIDS vitamins. She prefers to come up with this situation together. It's not unlike quite a few of patients in the area where I live where they're highly educated and we're just not comfortable. And so once we did decide, I think she was all in and we moved forward.

Murtaza Adam, MD:

In terms of treatment interval, given her aggressive case, do you have a preference for treating monthly or every other month?

Geeta Lalwani, MD:

That's a good question. So I treat most of my patients roughly every six weeks. So I split the difference and it allows for the effect of life. And so sometimes it's a little bit shorter, sometimes a little bit later, but it's a great question. What do you guys do?

Carl Danzig, MD:

So I always start monthly and I try to maintain monthly as long as possible because if they can't tolerate monthly, then I'll go to six weeks. Sure. So if you start off six or eight weeks, it's hard to go back to more frequent injections. So I always start monthly and move on from there.

Geeta Lalwani, MD:

How about you, Moo?

Murtaza Adam, MD:

If you look at the GATHER2 trial and the extension data that we have monthly and every other month didn't seem to have a big delta in terms of dose dependency. And so I feel comfortable treating every six to eight weeks. Theoretically it would make sense that the more drug you use, the more frequent you treat, you'd have more treatment effect. But we also saw on the pexetic hopin trials, there was not a two to one ratio of efficacy when you do monthly versus every other month. It was a pretty small delta. And I think treatment fatigue is real. Carl, your point is well taken. When patients get treated every month, it's hard to maintain. So I think every six to eight weeks is what most retina specialists do because it balances that need for treatment with flexibility of their quality of life.