Clinical Case Compendium: Setting Expectations and Patien

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Case Presentation

A 77-year-old white man presented to the clinic with decreased vision, right eye greater than left, over the last year. He assumed he had cataracts and wanted to discuss his options.

His medical history was notable for hypertension and dyslipidemia, both well controlled with medications, as well as coronary artery disease.
He was a previous smoker but had discontinued smoking in the last several years.
He also reported taking an AREDS2 supplement “off and on” since his exam with us 5 years ago.

The patient had been seen in clinic approximately 5 years ago. That appointment was notable for mild-to-moderate dry AMD OU, 1+ nuclear sclerotic cataracts OU, and large optic nerves OU. He was scheduled to come back for a follow-up examination in 6 months, including visual field testing, but missed his appointment and was lost to follow up. His BCVA was noted to be 20/25 OU at that visit.

Figure 1. Scattered drusen OD>OS with a small area of geographic atrophy (GA) between the macula and optic nerve head OD and an area of GA superior temporal to the macula OS.

Current examination revealed BCVA of CF at 3 ft (20/400 with eccentric viewing) OD and 20/50 OS. Dilated fundus examination revealed extensive GA OU, OD>OS, with macular sparing OS (Figure 2). OCT revealed extensive hypertransmission defects OU, again with apparent macular sparing OS (Figure 3).

Figure 2. Extensive geographic atrophy OU, with macular sparing OS.

Figure 3. OCT revealing hypertransmission defects OU, with apparent macular sparing OS (bottom).

A discussion was had with the patient regarding treatment options with the newly approved FDA agents for GA. The goal of hoping to preserve vision in the left eye for as long as possible was discussed, as well as a brief overview of the treatment. He was referred to our retinal specialist who agreed and initiated intravitreal pegcetacoplan (SYFOVRE, Apellis) OS. The patient has since received four to five injections over the last 9 months. While follow-up imaging is not available, correspondence with his treating retinal specialist revealed that the patient is tolerating the treatment well, and his acuity is currently stable at 20/50 OS.

Lastly, a referral to our low vision clinic was placed to see if any low vision aids may be beneficial at this time.

Summary/Clinical Take-Home

This patient was noted to have progression of his GA over the course of 5 years. At his initial visit, the GA was not noted, which is not uncommon in early or small lesions, especially before the advent of treatment. Unfortunately, the right eye progressed to a point that treatments would not be beneficial, as the lesion had invaded his macula and vision was already reduced. The left eye, however, revealed decent acuity with macular sparing. Thus, treatment was geared at slowing the progression of the GA lesion OS to delay further loss.

It should be emphasized that the goal is to slow down lesion growth, with the ultimate goal to provide longer time with usable vision.
It needs to be clearly explained that treatment does not reverse any damage already suffered, nor will it help with vision already lost.
It should be explained that this is a chronic disease that will require chronic therapy for an extended period of time.

After this initial discussion, if the patient appears motivated, a referral to a retinal specialist with any images or history that reveals progression over time is most helpful. A follow-up appointment with the patient is advised to deal with any other ocular issues that may arise, and to ensure the patient is compliant with treatment. Lastly, a referral to a low vision specialist can be very helpful to maximize the patient’s remaining vision.

ABOUT THIS SERIES

Newly available treatment options for geographic atrophy (GA) have the potential to change the prognosis for long-term eye health. However, their newness also raises important practical questions, including about who should be referred and when. The Geographic Atrophy Clinical Case Compendium was developed, with guidance from Carolyn E. Majcher, OD, FAAO, FORS, and Julie Rodman, OD, MSc, FAAO, to demonstrate real-world patient encounters and the impact of treatment on the clinical course.

View more Geographic Atrophy Case Compendium articles »

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