Geographic atrophy therapy uptake reveals the disease-monitoring infrastructure gap

Reading the signal

Geographic atrophy is the late-stage form of dry age-related macular degeneration, characterised by atrophic lesions that expand slowly over years. Until 2023, no approved disease-modifying therapy existed. Pegcetacoplan (anti-C3) and avacincaptad pegol (anti-C5) entered the market on the basis of pivotal trial data demonstrating reduction in lesion-growth rate.

Real-world uptake to date has been more variable than the pivotal trial population shape would have suggested:

• Specialist-centre uptake has been substantially stronger than community-ophthalmology uptake
• Disease-monitoring infrastructure (OCT, OCT-A, fundus autofluorescence) is the operational determinant. Centres with comprehensive imaging capacity and lesion-progression assessment workflows have higher uptake; centres without lag
• Intravitreal-injection capacity is constrained in many markets, with the existing capacity already absorbed by anti-VEGF therapy for wet AMD and diabetic macular oedema
• The patient-and-clinician decision frame is genuinely difficult. The clinical benefit is measured in lesion-growth slowing, not in vision-acuity preservation, and translating that benefit into a patient-decision conversation has been operationally challenging

Commercial implications

For sponsors of geographic atrophy assets and adjacent retinal pipeline:

1. Disease-monitoring infrastructure is part of the commercial pathway. Sponsors that invest in monitoring-infrastructure support (clinic-level OCT capacity, fundus-imaging support) shorten their own commercial timeline
2. Intravitreal-injection capacity is a finite operational resource that has to be planned for. New entrants into the intravitreal-route market are competing with established anti-VEGF therapy for chair capacity, not just for prescriber attention
3. The lesion-growth-versus-vision-acuity benefit conversation is a commercial frame that has to be designed, not assumed. Patient-decision aids, clinician-communication tools, and the longitudinal-monitoring story are commercial deliverables

What we are watching

• Real-world uptake curves at 12, 24 and 36 months and the gradient by region and centre type
• Long-acting and reduced-frequency formulation development that would substantially relax the intravitreal-injection capacity constraint
• Adjacent retinal pipeline (next-generation complement inhibitors, alternative mechanisms for GA) and how they navigate the same operational environment