On this episode of Ready, Set, Retina, Daniel Epshtein, OD, FAAO, is joined by Michael Ammar, MD, to review a case report of neovascular age-related macular degeneration (nAMD) following geographic atrophy (GA) treatment.
Dr. Ammar is a vitreoretinal surgeon and the chief of the ophthalmology department at Scripps Memorial Hospital, La Jolla, as well as the co-director of clinical research at Retina Consultants San Diego.
Case report
Presentation
An 85-year-old Caucasian female patient was referred to the clinic for GA OU with best-corrected visual acuity (BCVA) of 20/400 OD and 20/30 OS. She reported deteriorating vision OD > OS over the past year.
Baseline imaging
Overall, the fundus images showed clear areas of GA, and on fundus autofluorescence (FAF), there were hypoautofluorescent areas of atrophy with hyperautofluorescence surrounding the periphery of the lesions, which has been shown to be a risk factor for continued growth of the atrophic lesions.1
Figures 1 and 2: Fundus and FAF imaging OD at baseline, respectively; the fundus imaging shows central areas of atrophy and scattered drusen in the macula, and the FAF shows hypoautofluorescent areas of GA with a rim of hyperautofluorescence.
Figure 1: Courtesy of Michael Ammar, MD.
Figure 2: Courtesy of Michael Ammar, MD.
Figures 3 and 4: Fundus and FAF imaging OS at baseline, respectively; similar to the right eye, the fundus imaging shows central areas of atrophy and scattered drusen in the macula, and the FAF shows hypoautofluorescent areas of GA with a rim of hyperautofluorescence.
Figure 3: Courtesy of Michael Ammar, MD.
Figure 4: Courtesy of Michael Ammar, MD.
Figures 5 and 6: Optical coherence tomography (OCT) imaging OD and OS, respectively, showing areas of outer retinal loss and retinal pigment epithelium (RPE) atrophy, which correspond to the areas of GA shown on fundus imaging.
Figure 5: Courtesy of Michael Ammar, MD.
Figure 6: Courtesy of Michael Ammar, MD.
1-year follow-up
Complement inhibitors for GA were not available at the time of the initial appointment, so she was scheduled for a follow-up in 6 to 12 months. At the 1-year follow-up, the patient’s vision had deteriorated from 20/400 to counting fingers (CF) OD and 20/30 to 20/80 OS.
Figures 7 and 8: FAF and OCT imaging OD, respectively; FAF demonstrated significant lesion growth, and OCT highlighted further outer retinal loss and RPE atrophy.
Figure 7: Courtesy of Michael Ammar, MD.
Figure 8: Courtesy of Michael Ammar, MD.
Figures 9 and 10: FAF and OCT imaging OS, respectively; FAF indicated significant lesion growth and the development of multifocal lesions, and OCT showed further outer retinal loss and RPE atrophy.
Figure 9: Courtesy of Michael Ammar, MD.
Figure 10: Courtesy of Michael Ammar, MD.
By the time of this appointment, complement inhibitor therapies were available, so Dr. Ammar discussed the risks and benefits of these interventions with the patient. She agreed to start SYFOVRE (pegcetacoplan injection, Apellis Pharmaceuticals) in the right eye at every-other-month (EOM) dosing.
If she responded well to treatment, they would consider starting SYFOVRE in her left eye as well. Dr. Ammar noted that he prefers to start with the worse-seeing eye in the rare event that the patient experiences adverse events that impact visual acuity.
Follow-up 1 year later
At this time, the patient had been receiving SYFOVRE injections EOM for 1 year OU, and her BCVA had reduced from 20/80 to 20/100 OS.
Figure 11: FAF imaging OS after 1 year of SYFOVRE injections; there has been some lesion growth, however, the speed of progression seems to have slowed with treatment compared to the prior year with no treatment.
Figure 11: Courtesy of Michael Ammar, MD.
Figure 12: OCT imaging OS showing intraretinal fluid, and the patient appeared to be developing choroidal neovascularization (CNV) and wet AMD in addition to the existing GA.
Figure 12: Courtesy of Michael Ammar, MD.
Dr. Ammar noted that CNV and wet AMD are potential complications of complement inhibitors,2 and that he prefers to see patients within 2 weeks if they convert to wet AMD in order to quickly initiate anti-vascular endothelial growth factor (VEGF) therapy to prevent the development of hemorrhage that may drastically reduce VA.
Treating patients with complement inhibitor and anti-VEGF drugs concurrently
As the patient was receiving EOM complement inhibitor injections OU, Dr. Ammar typically chooses not to give patients anti-VEGF and complement inhibitor injections on the same day because they have to stay significantly longer at the clinic, and he finds it to be a lot of volume to inject into the eye in 1 day.
Usually, for patients requiring both anti-VEGF and complement inhibitor injections, Dr. Ammar will separate these treatments by at least 1 week. If they respond well to the medications, he will try to extend treatment intervals to 3 months between anti-VEGF injections, helping lower the treatment burden for patients.
In his experience, patients who convert to wet AMD as a complication of complement inhibitor injections don’t lose vision, in part, because they are seen so frequently that he can detect it early and initiate treatment before the neovascularization impacts their vision.
Figure 13: OCT imaging OS showing resolution of the intraretinal fluid, and the patient’s BCVA returned to baseline (20/80).
Figure 13: Courtesy of Michael Ammar, MD.
To learn more about monitoring patients receiving complement inhibitor injections for conversion to wet AMD, watch the full video!
Conclusion
Dr. Ammar explained that treating GA has some similarities to glaucoma, wherein it isn’t currently possible to stop disease progression; however, complement inhibitor injections can aid in preserving and protecting patients’ vision to improve their quality of life.
