Caesar Luo, MD, FASRS, FACS: What might be the biggest disrupter to our clinical flow is treatment for geographic atrophy and stem cell therapy/complement inhibition. We’re at the cusp of geographic atrophy. That conversation is going to be big over the next 6 months to a year. There’s going to be a flood of conversations with payers and managed care and utilization. It is going to be a completely new ball of wax. It will be interesting to hear what the other panelists think, but I’m expecting a deluge of new conversations and tricky situations to navigate.

Veeral Sheth, MD, MBA, FACS, FASRS: That’s a great point. One other thing I’ll bring up that might be a paradigm shifter is home imaging, like Home OCT [optical coherence tomography]. We haven’t talked about it. We’ve been talking about therapeutics, but diagnostics are equally important. If that means patients can be at home and we can monitor them there because we have to open up space for these patients with geographic atrophy who are going to be coming in. There’s a whole bunch of puzzle pieces that are moving around. Where are they going to end up? We’re still going to find out.

Caesar Luo, MD, FASRS, FACS: That’s a great point.

Jim Kenney, RPh, MBA: For our audience, could you describe what OCT is, Dr Sheth?

Veeral Sheth, MD, MBA, FACS, FASRS: OCT is how we scan the retina. It’s a pretty quick test. We’re able to tell a lot of information from that—in particular, what the anatomy of the macula looks like. Is there fluid? Is there macular degeneration? Is there diabetic retinopathy? As a baseline, that’s important. But also as we start to treat that patient and take them through their treatment journey, we’re going to be able to assess: how well are we treating them? How effectively are we treating them? In all this prior discussion, patients still have fluid. How do we know they have fluid? It’s not just the examination, but a lot of the time it’s the imaging that we’re doing. If we’re able to do that imaging remotely at this patient’s home and get reports, we’re going to be able to tell if a patient is going in the wrong direction, maybe sooner than we would have if we’re just bringing them in on a certain interval.

Caesar Luo, MD, FASRS, FACS: That’s a great point. Treatment burden should be broken down into treatment—the number of times I’m sticking that patient with the needle—and visits, how many times they’re coming in. Dr Coney, most of us do this treatment and extend regimen, and it’s the best of both worlds. You’re getting fewer shots and they’re coming into the office less. As-needed dosing didn’t work that well. For patients who did better on as-needed dosing, they still have to come in every month. For these sustained drug-delivery systems, like port-delivery systems or potentially gene therapy, are we going to feel comfortable seeing them every 3 months? Probably not without something like Home OCT available to say if there might be some early fluid that’s building up.

Joseph Coney, MD, FASRS, FACS: With these alternatives and other modalities of testing with artificial intelligence and Home OCT, we may be revisiting as-needed dosing. This is the best of both worlds if we have some type of feedback, and maybe immediate feedback, that patients can give. If they can just use their iPhone with an app, for example, and get feedback, they could say, “You know what? This is what I saw yesterday. This is what I’m seeing today. This is a smiley face. This is a sad face. I need to go in and be seen.” With this new technology, there may be ways where we revisit as-needed dosing to decrease the number of patient visits to maximize their therapy while increasing the durability of these agents.

Jim Kenney, RPh, MBA: The challenge from the health plan side is that there’s a phrase they like to use: “We don’t pay for convenience.” We need to be able to drive the message that it’s not just convenient when you have an extended-dosing interval or something like that. There’s sustained damage to the eye and vision when you’re not treating and the patient isn’t adherent to therapy. We have to get beyond that initial barrier because there have been a lot of drugs that are brought to market over the years that were strictly for convenience. You didn’t get better clinical results, as long as the patient was adherent with therapy. That’s an avenue that we’re going to have to focus some attention on to convince payers to open up access a little more for these therapies, and not simply view them as a convenience option rather than a true clinical advantage.

Joseph Coney, MD, FASRS, FACS: Jim, if we learned 1 thing during COVID-19, it’s that decreasing the number of patients in our office was really effective. Going forward, because of the overwhelming number of patients we’ll be seeing—particularly those with geographic atrophy—we need to find better ways to limit individuals from coming to the hospital. This isn’t just for patients. For the most part, our patients, at least older patients, need caregivers. Individuals are taking off time from work. That’s lost income and lost taxes. These are things that we may not see from a treatment standpoint, but there’s also a burden to the family. When these patients are receiving injections, it’s not just 1½ to 2 hours in the office; it’s half the day. If that’s a working population, that individual isn’t going back to work. We need to find better ways to limit the burden and to monitor them so they can have the better lifestyles that we all want for ourselves.

Transcript edited for clarity.