This article was originally published in a sponsored newsletter.

Visual outcomes are improved when age-related macular degeneration (AMD) is proactively managed by primary eye care practitioners. This includes early AMD diagnosis and education so patients can understand their risks of progression and the effects of their lifestyle, as well as supplementation options to slow disease advancement and to preserve vision.

While timely AMD intervention slows disease progression, it does not halt it altogether. Unfortunately, some patients will still progress to advanced wet AMD or geographic atrophy (GA). Yet even advanced disease has best visual outcomes with proactive management.

As primary eye care providers, optometrists’ responsibilities in diagnosing and managing GA involve early detection, monitoring, patient education, consulting a retina specialist when complement cascade inhibition therapy is warranted and referring to a low vision specialist when needed.

Once AMD of any stage is diagnosed, patients should be well educated about the disease and monitored regularly in office with dilated examination and imaging. While this may include color fundus photography, even more helpful in GA are OCT, fundus autofluorescence (FAF) and en face or infrared imaging. If progression is noted over time, these patients should be seen more frequently and educated as to why that is recommended.

Early markers of GA can be found uniquely on OCT with the presence of hypertransmission defects and incomplete retinal pigment epithelium (RPE) and outer retina atrophy (iRORA), which are precursor findings to complete RPE and outer retina atrophy (cRORA). The latter defines GA and is the condition associated with complement cascade inhibition therapy studies.^1,2 However, FAF, en face and infrared imaging are the easiest ways to show patients the status of their GA and to compare progression with serial testing.

Patients with these early signs of nascent GA should be told what GA is, how it can affect their vision and how it progresses. This thorough education helps patients understand the totality of their condition and make informed decisions about their immediate and future care. This is also the time to start the discussion about newly available GA treatments. Then, when cRORA occurs, it is time to consult a retina specialist. Remember that these drugs do not improve or stop GA; they only slow the growth of GA lesions. However, earlier intervention provides more time to preserve central vision.

As with any treatment, always discuss the risks, benefits, alternative options and limitations of what you are recommending. Having a co-managing retina specialist is helpful during these conversations because there is not a standard of care yet established for patients with GA. It is a case-by-case and individualized decision based on retina health, ability to commit to monthly or every-other-month treatments for the long-term, cost, medical insurance coverage and the patient’s willingness to receive intravitreal injections. Referral to a low vision specialist should be done whenever a patient’s best corrected visual acuity is not enough for their individualized needs.

With my patients, I discuss that the goal for complement cascade inhibition is to slow the growth of their current GA lesions to preserve their vision for as long as possible. While there are no alternative treatment options yet, there is a large body of research in various stages for potential therapeutics in the future. Preserving central vision today is important for what is to come because there are few options now or on the horizon for those with obliterated macular function due to GA. Proactive management and vision loss preservation from AMD is the best way to provide the best visual outcomes and quality of life with GA right now.

1. Regillo CD, Nijm LM, Shechtman DL, et al. Considerations for the identification and management of geographic atrophy: recommendations from an expert panel. Clin Ophthalmol. 2024 Feb;18:325–335. doi:10.2147/OPTH.S445755
2. Sadda SR, Guymer R, Holz FG, et al. Consensus definition for atrophy associated with age-related macular degeneration on OCT: Classification of Atrophy Report 3. Ophthalmology. 2018 Apr;125(4):537–548. doi:10.1016/j.ophtha.2017.09.028

AMANDA S. LEGGE, OD practices primary eye care with special interest in retinal diseases, at Wyomissing Optometric Center in Wyomissing, PA. She is a VisionUSA doctor who provides free eye care to the working poor who are screened and referred by the Salvation Army, and she participates in the national InfantSEE program, sponsored by the American Optometric Association, offering free vision and eye health screenings to 6-12 month old infants. Dr. Legge is also is an active member of the Muhlenberg Lions Club and serves many other roles in her community.