What technologies could aid in early detection and intervention in geographic atrophy?
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Remote monitoring
The availability of treatments for geographic atrophy will lead to significant changes in our field and in the eye care community overall.
Many patients will need to be screened, informed, selected for treatment and monitored in follow-up. Health services will have to be reorganized and expanded, and we will need effective, innovative strategies to meet the growing demand and numerous challenges of this new era of retina care. I believe that remote monitoring technologies will be key in enabling new care pathways for these patients. General ophthalmologists and optometrists could remain the first point of care, where screening is performed, and retina specialists at the other end could remotely review the images of patients who potentially qualify for treatment.
New forms of home monitoring could also be implemented. Most of the algorithms that we currently use do not have the ability to predict geographic atrophy (GA) progression because they are based on fluid detection. However, because there is a different signal from the retina in the presence of atrophic lesions, in the future we could develop algorithms that are able to predict these changes. GA progresses slowly, and patients with GA will never need the daily monitoring that is recommended for neovascular age-related macular degeneration with the current home monitoring platforms. However, we could develop new protocols to detect the early signs of foveal involvement in specific patients and to predict the pace of lesion growth. This would allow us to act promptly with treatment, preventing further progression and potentially preserving vision. Remote monitoring technologies could also be beneficial for monitoring the effects of these new drugs, assessing if there is a reduction in GA lesion growth, which is what we expect from the treatment. Of course, we need more data and specific algorithms that measure the pace of growth of GA lesions, but hopefully in the future this might become a possibility.
Anat Loewenstein, MD, MHA, is chair of the department of ophthalmology and Sidney Fox Chair in Ophthalmology of the Sackler Faculty of Medicine at Tel Aviv University, Israel.
Artificial intelligence
So far, the lack of available treatments for geographic atrophy has limited our understanding of this condition.
Now that a first pharmacotherapy has been approved and others are in the pipeline, I expect that a lot will be discovered in future years about the natural history, diagnosis and management of geographic atrophy (GA). To refer GA patients for treatment, general ophthalmologists will need to become acquainted with diagnostic tools such as fundus biomicroscopy, fundus autofluorescence and OCT. As we gain new and increasingly complex data, the application of AI in the early screening and diagnosis of GA will become an invaluable support to our clinical decision-making, as it is already for diabetic retinopathy (DR). What was done in the past by human graders is done today by DR grading algorithms with equal or even superior accuracy. I can imagine screening campaigns in which an AI algorithm will be able to identify on color fundus photography, fundus autofluorescence or OCT who are the patients with GA and will also be able to determine the size and location of the lesion and monitor changes over time. These systems will also help us in our treatment decisions and in monitoring the effects of the new drugs and will shed light on how GA progresses under treatment as compared with the natural history of the disease. Eventually, we will be able to use AI to identify imaging biomarkers of disease progression and guide our decisions on whether to re-treat or not to re-treat a patient.
We are going to face a significant increase in patient volume in the years to come because GA affects a high number of people and can develop from both the wet and dry forms of age-related macular degeneration. One of the future applications of pharmacotherapies for GA will likely be in patients with choroidal neovascularization who eventually develop atrophy because this is part of the natural history of the disease. Therefore, administering anti-VEGFs as well as complement inhibitors to prevent GA lesion growth might become the standard in some patients.
Paolo Lanzetta, MD, is professor and chair of the department of ophthalmology at the University of Udine and founder and scientific director of the European Institute of Ocular Microsurgery in Udine and Milan, Italy.
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