Points of View: Geographic Atrophy

Sheppard, MD: Clinicians should refer patients to a retina specialist whenever there are posterior polar lesions that either threaten fixation or have shown progression from prior examinations.  These referrals should be made under reasonable guidelines to insure reasonable utilization of retinologists’ valuable clinic time, as well as the inevitable logistics difficulties elderly patients always face when confronted with yet another physician office visit.

Adyanthaya, MD: Most patients with an initial diagnosis of geographic atrophy should be referred to a retina specialist to see if they are candidates for treatment. On fundus examination, geographic atrophy appears as well-defined regions with greater visibility of the choroidal vasculature in the macula. Lesions may be small and multifocal early in the disease course and can spare the fovea. As these lesions progress, they can expand and coalesce over time. Spectral domain OCT is a valuable tool and now considered the gold standard to diagnose the condition. It may show areas of loss of outer retinal layers and the collapse of overlying layers in the region of the geographic atrophy. These often show an increased reflectance of the underlying choriocapillaris and choroid. The infrared photo of the macula that accompanies the B-scan OCT image is also useful to quickly diagnose and monitor progression of geographic atrophy lesions over time.

Rachon, OD, FAAO: Until 2023, we did not have any treatments for patients with geographic atrophy. We were not referring them as much because the retina specialist would just monitor them. But now with advancements in treatment, such as complement inhibitors, we are referring these patients a lot earlier to possibly prevent progression and prevent vision loss that can come from geographic atrophy. Someone who may have 20/400 vision in one eye due to geographic atrophy and very early geographic atrophy in the other eye might be a good candidate for the eye that has not progressed to 20/400 yet. In general, in the optometry and ophthalmology community, we are referring to retina specialists a lot earlier than we were.

Figure 1. Left: An infra-red image showing a small round area of geographic atrophy nasal to fovea (black circle). Right: A B-scan image of the same eye showing loss of retinal pigment epithelium and photoreceptors nasal to fovea corresponding to the area of geographic atrophy (red circle). Image courtesy of Rohit Adyanthaya, MD.