Optometrists have the most frequent contact with patients, can identify candidates for treatment, and are often the first to notice patients at risk. (Adobe Stock/Inside Creative House)
The recent approval of pegcetacoplan (Syfovre; Apellis) and pending review of intravitreal abasin captad pegol (Zimura; Iveric Bio) are changing the treatment paradigm for geographic atrophy (GA). Previously, there were no treatments to slow the growth of lesions. With so many options on the market, eye care must change to meet changing demands.
FAAO OD Steven Ferrucci shares his thoughts on how optometrists can lead the effort against geographic atrophy. From diagnosis to monitoring lesion growth, optometrists play an important role in disease management. Optometrists have the most frequent contact with patients, can identify candidates for treatment, and are often the first to notice patients at risk.
Q: What can optometrists do to identify patients at risk for GA?
A: Patients at risk for GA are generally very similar to those at risk for age-related macular degeneration (AMD). Obviously, it’s older patients, those with a family history of AMD or GA, those with a history of smoking, etc.
About. And then you start thinking about symptomology.
A comprehensive eye examination is performed to look for geographic atrophy, including dilation, optical coherence tomography (OCT), and other adjunctive examinations and photographs as appropriate. Some symptoms that patients report may tell us they have GA. They are usually symptoms of visual dysfunction such as scotoma, difficulty reading or disorienting while reading, impaired face recognition, and decreased darkness. Adaptive, reduced contrast sensitivity. Visual acuity may also be affected, but it tends to occur a little later in the disease, especially early in the disease, since these patients complain of pre-onset visual deficits, and thus visual acuity itself may be affected geographically. May not be a good measure of atrophy. They start complaining about their poor eyesight.
Q: Can you tell me how an optometrist can use images in GA diagnosis?
A: There are multiple imaging techniques that can be used to look for GAs. Perhaps the three most common are fundus photography, OCT, and fundus autofluorescence. Every optometrist I know has a fundus camera, so fundus photography is probably the most common. Lesions due to loss of RPE are clearly visible. [retinal pigment epithelium] But that’s probably not the best way to look for GA.
The best way is to use OCT. These days, most optometrists have his OCT, which is excellent. In my mind there are two ways to do it. One is to look at the normal cross-sectional images that we normally see and look for signs of so-called transmittance or transmission defects.Several [individuals] Also called waterfall defect. At this time, we see more light transmission from her OCT in areas with GA lesions due to loss of retinal layers and loss of her RPE. Therefore, more light transmission is seen under the lesion. Finding GA lesions is a very simple method. You can also look for lesions using frontal or near-infrared images. In my opinion it’s a good way to check for lesions. [whether] they are growing in size.
The last is fundus autofluorescence. This is less common and may not be used often in optometric practice, but it is also a good way to distinguish active from inactive lesions. But for me, OCT is the easiest way to look for lesions.
Q: What can optometrists do to improve collaboration with retinal specialists in the care of patients with GA?
A: Having open communication is important. Approved treatments for geographic atrophy will facilitate more collaborative management between optometrists and retinal specialists. If you see the same retinal specialist regularly, talk to that specialist. How do you see them using this in practice? What types of GA patients would they like to see?
We are confident that retinal specialists will be thrilled with the approval of pegcetacoplan. They would want to start treating these patients with GA. The majority of patients with GA are probably currently undergoing optometric care. Because there was no cure for this disease before. As such, there is no reason for these patients to be referred to a retinal specialist. However, now that treatments are established, it is important to diagnose GA and determine which patients are best candidates for referral to a retinal specialist and which patients are candidates for treatment.
I read an article about pegcetacoplan, and the headline said the drug slows lesion growth but has no positive effect on vision. That may be true, but it’s somewhat misleading and doesn’t tell the whole story. It is important to note that the goal is to slow progression of lesion size. And research has shown that it could be up to 36% in 2 years. The real goal is to prevent lesion growth, which reduces the number of visual symptoms patients have and, over time, promotes patient independence. The goal is not always to improve visual acuity, as many patients with geographic atrophy may not have lost visual acuity. Therefore, using visual acuity as an indicator of who should or should not be referred, or whether patients are benefiting from treatment, may not be the best approach. We have to think more about visual function than sight.
Q: Is approval of pegcetacoplan expected to change co-management of patients with GA, and how is it expected to change the treatment paradigm?
A: Yes. In the past, if we had a patient with geographic atrophy, there was nothing we could do. We observed their lesions grow larger and their visual function diminished. But now we have options for our patients. Therefore, when examining patients with advanced disease, who have already lost vision due to geographic atrophy in one eye and want to consider protecting the other eye, or who have vision loss due to geographic atrophy. If you have a family history, you may: It will be a red flag for us.
This will further facilitate communication between optometrists and ophthalmologists. Retinal specialists are already overwhelmed with the number of injections they do for wet AMD, diabetic retinopathy, and venous occlusion. Approval of pegcetacoplan will lead to more patients. Therefore, we can help patients manage these patients, see them between visits, talk to them, monitor GA, and see if symptoms progress faster. As retinal specialists get busier, it becomes even more important, opening up avenues for optometrists to help.
I have always had the impression that geographic atrophy is a relatively slow-growing disease. However, the results of some of their studies examining the natural history of GA point out that GA does not progress as slowly as many of us think. So while you might think you have plenty of time to observe these lesions before considering treatment, that may not be the case. I would encourage optometrists to start looking for GA patients and discuss what treatments are currently available. Again, think about the types of patients who might benefit from early treatment.
Q: Do you have any thoughts on the target date for Iberic’s Avacyncaptad pegol under future prescription drug licences?
A: It’s always good to have multiple treatment options. Time will tell which treatment options are the better treatment options, but having more tools for patients is great, which translates into better patient care overall.