The Wills Retina Report: Regillo and Garg on managing geographic atrophy—who, when, and how

Although retina specialists have had 2 FDA-approved treatment options for geographic atrophy (GA) since 2023, how to deploy them—and for whom—remains an evolving conversation. In this debut episode of The Wills Retina Report with Regillo and Garg from Modern Retina, cohosts Carl D. Regillo, MD, FACS, FASRS, and Sunir J. Garg, MD, FACS, FASRS, discuss how the management of patients with GA has changed over the past 3 years with the availability of pegcetacoplan (Syfovre; Apellis Pharmaceuticals) and avacincaptad pegol (ACP) (Izervay; Astellas Pharma). Both are partners at Mid Atlantic Retina and faculty at Wills Eye Hospital in Philadelphia, Pennsylvania, where Regillo serves as chief of the Retina Service and Garg as co-director of retina research; both hold professorships in ophthalmology at Sidney Kimmel Medical College at Thomas Jefferson University.

Who qualifies and what the lesion tells you

Garg opens with a question he still works through daily: Who to treat. His patients range from those who are asymptomatic with small peripheral lesions to those holding on to limited central vision, and he does not always have a clear algorithm. Regillo's framework centers on earlier disease and faster-growing lesions. Because these agents slow GA progression rather than reverse it, treating sooner—when there is more vision left to protect—makes the most clinical sense. Life expectancy factors in more explicitly than it would for wet age-related macular degeneration (AMD). "GA is slower growing," Regillo notes. "You don't have to jump into making a decision to treat on the spot, very much unlike wet AMD."

Garg asks whether Regillo uses imaging features at first encounter to guide treatment or brings patients back to assess progression over time. Regillo's answer: Both. For established patients with at least a year of follow-up, observed growth rate is the most reliable guide. For new patients, imaging features at first encounter serve as a surrogate—with reticular pseudodrusen, visible on near-infrared imaging, flagged as a key marker signaling both faster progression and elevated risk of choroidal neovascularization (CNV).

What happens once treatment begins

On dosing, both physicians favor intervals of every 8 weeks. Garg raises the safety consideration directly: The rate of secondary CNV is meaningfully lower at 8 weeks than at 4 weeks, even accounting for the reduced number of injections—a point Regillo affirms, noting that more frequent dosing also carries higher endophthalmitis risk. Both risks are attributed to the polyethylene glycol component shared by both drugs. Regillo adds that rates of intraocular inflammation (IOI) are modestly higher with pegcetacoplan than with ACP, and that the severe vasculitis-pattern IOI with retinal occlusion reported with pegcetacoplan has not been observed with ACP to date.

The two differ on which eye to treat first in bilateral disease. Regillo starts with the better-seeing eye. Garg takes the opposite approach with pegcetacoplan, treating the worse eye first at a reduced dose as a "test dose" to screen for inflammatory reaction before proceeding to the fellow eye. Regillo endorses this as reasonable for risk-averse clinicians.

When patients with GA develop CNV, Garg asks whether Regillo continues complement inhibitor therapy alongside anti-VEGF. Regillo's approach: Pause the GA treatment, prioritize anti-VEGF to control the wet AMD, then reassess—coordinating the 2 agents on separate days where feasible once the CNV is stable.

Both physicians close on the question patients ask most and that neither can fully answer: Is the treatment actually working? "We really don't have good software or ways to measure growth easily and to look for that change in growth over time," Garg says. Both anticipate that future imaging analytics will allow more precise growth prediction and individualized response tracking—tools that would benefit not only patient conversations but the design of future trials.

Carl D. Regillo, MD, FACS, FASRS

E: cregillo@midatlanticretina.com

Regillo receives consulting and research grant support from Apellis and Astellas.

Sunir J. Garg, MD, FACS, FASRS

E: sgarg@midatlanticretina.com