Geographic Atrophy: A Comprehensive Guide for Eye Care Professionals

Defocus Media Podcast Network

Geographic Atrophy, a late-stage form of age-related macular degeneration (AMD), has become an increasingly prevalent topic in retinal care, particularly as advancements in diagnostic technologies and treatments evolve. While wet AMD has long been a primary focus in optometric and ophthalmologic practice, Geographic Atrophy’s rapid progression and significant impact on vision warrant attention and awareness. In this article, featuring insights from expert guests Dr. James Fanelli and Dr. Roya Attar, we will explore the nature of Geographic Atrophy, its diagnosis, patient education, and current treatment options, offering eye care professionals actionable insights to serve their patients better.

In Partnership with Heidelberg Engineering

Key Talking Points

Understanding Geographic Atrophy

Early Identification and Diagnosis For Geographic Atrophy

Risk Factors and Patient History

Current Treatment Options For Geographic Atrophy

The Role of Patient Education

Looking to the Future: Emerging Therapies

Key Takeaways for Eye Care Professionals

Understanding Geographic Atrophy

Geographic Atrophy refers to the irreversible degeneration of retinal pigment epithelial (RPE) cells and the photoreceptors they support, leading to permanent vision loss. Geographic Atrophy is a form of “dry” AMD, though it’s often distinguished from early dry AMD due to its severity. As Dr. Chris Lievens mentioned in a recent discussion, Geographic Atrophy was historically grouped into the broader category of dry AMD, leading many clinicians to underestimate its destructive potential. The reality is Geographic Atrophy can cause severe vision impairment, even if it doesn’t progress to the “wet” or neovascular form of AMD.

“One of the most alarming aspects of Geographic Atrophy is its rapid progression and the devastating visual loss it can cause,” notes Dr. James Fanelli, a seasoned practitioner specializing in retinal diseases. “Patients may start with minimal symptoms, but once the disease reaches the fovea, their vision is significantly compromised.”

Early Identification and Diagnosis For Geographic Atrophy

Identifying Geographic Atrophy early is critical for preventing its progression and protecting patients’ vision. Clinical diagnosis usually begins with a thorough fundus examination, complemented by advanced imaging techniques such as Optical Coherence Tomography (OCT) and fundus autofluorescence (FAF).

Dr. Fanelli emphasizes the importance of recognizing Geographic Atrophy in its early stages: “In the early stages, you may notice subtle changes such as small areas of RPE atrophy. These areas, best visualized in vivo using a slit lamp, will appear as depigmented patches, with choroidal structures becoming more visible.”

While OCT is a widely used tool, Heidelberg Engineering’s fundus autofluorescence (FAF) technology plays a pivotal role in detecting Geographic Atrophy. FAF allows for the visualization of lipofuscin, a byproduct of the RPE’s metabolic processes. Areas of hyperautofluorescence indicate stressed RPE cells that are still functional but are likely to atrophy over time, while areas of hypoautofluorescence indicate regions where the RPE has already degenerated.

“As eye care professionals, it’s crucial to employ FAF as part of our diagnostic protocol for Geographic Atrophy patients,” adds Dr. Roya Attar, Associate Professor at the University of Mississippi Medical Center. “FAF not only helps us assess the extent of RPE atrophy but also serves as a powerful patient education tool. Patients can visually see the progression of their disease, which often leads to better adherence to follow-up care.”

Risk Factors and Patient History

As with most retinal diseases, early detection is not only dependent on imaging but also on a thorough patient history. Key risk factors for Geographic Atrophy include:

• Age: The likelihood of developing Geographic Atrophy increases significantly after the age of 60.
• Genetics: A family history of AMD increases the risk of Geographic Atrophy.
• Smoking: Smoking is a well-established modifiable risk factor for both wet and dry forms of AMD, including Geographic Atrophy.
• Vascular Conditions: Conditions such as hypertension and diabetes are associated with an increased risk of Geographic Atrophy progression.

"Looking at patient history is crucial in predicting how rapidly the disease will progress," Dr. Attar explains. "Patients with larger Geographic Atrophy lesions, or those who already have advanced AMD in the fellow eye, are at greater risk of rapid progression."

Current Treatment Options For Geographic Atrophy

Historically, dry AMD, including Geographic Atrophy, had limited treatment options, especially compared to the extensive therapies available for wet AMD. However, the landscape has shifted with the development of new therapies that specifically target Geographic Atrophy.

In 2023, two complement inhibitors received FDA approval for the treatment of Geographic Atrophy: Pegcetacoplan (Empaveli) and Avacincaptad Pegol (Izervay). Both medications target the complement cascade, a key component of the immune system that, when overactivated, can lead to tissue damage in diseases like Geographic Atrophy.

• Pegcetacoplan is administered via intravitreal injections every 25–60 days and has been shown to slow the progression of Geographic Atrophy by inhibiting C3, a key protein in the complement system.
• Avacincaptad Pegol targets C5, another component of the complement system, and is administered every 28 days via intravitreal injection.

While these treatments do not restore lost vision, they offer hope in slowing the progression of Geographic Atrophy, particularly in patients whose atrophy is nearing the fovea, where it can severely impair central vision.

“These treatments have finally given us tools to intervene in Geographic Atrophy,” says Dr. Fanelli. “However, it’s important to select the right candidates for treatment. Patients whose Geographic Atrophy is progressing towards the fovea are prime candidates, as we want to preserve their central vision for as long as possible.”

The Role of Patient Education

One of the most challenging aspects of managing Geographic Atrophy is patient education. Unlike wet AMD, where vision loss is often sudden and dramatic, Geographic Atrophy can progress slowly, leading patients to underestimate its severity. As eye care professionals, it’s essential to communicate the importance of regular monitoring and early treatment.

Dr. Attar highlights the importance of functional testing: “Visual acuity alone isn’t enough to assess the impact of Geographic Atrophy. Patients may still see 20/20, but their contrast sensitivity or reading speed could be declining. Functional tests like these help patients understand that even if their vision seems ‘fine,’ their disease is progressing.”

Using imaging, especially FAF, as a visual aid during consultations can help patients grasp the seriousness of their condition. “Patients often make more informed decisions when they can see the disease for themselves,” Dr. Attar explains.

Looking to the Future: Emerging Therapies

While the approval of complement inhibitors marks a significant step forward, the future of Geographic Atrophy treatment may include more diverse approaches, such as gene therapy and stem cell treatments. Clinical trials are underway to explore these therapies’ potential to not only halt geographical atrophy progression but also potentially restore lost vision.

“In the next decade, I believe we’ll see even more advancements in Geographic Atrophy treatment,” says Dr. Lievens. “As research into the complement system and other pathways continues, we may find earlier intervention strategies that offer better outcomes for our patients.”

Key Takeaways for Eye Care Professionals

1. Early Detection is Crucial: Use a combination of fundoscopy, OCT, and FAF to diagnose Geographic Atrophy in its early stages. FAF is particularly useful for visualizing hyperautofluorescent areas that indicate stressed, but still viable, RPE cells.
2. Patient Education is Key: Help patients understand the progressive nature of Geographic Atrophy by showing them their imaging results and conducting functional tests. This can increase adherence to treatment and follow-up appointments.
3. Complement Inhibitors are a Game-Changer: While these treatments won’t restore vision, they offer a way to slow the progression of Geographic Atrophy, particularly in patients whose atrophy is nearing the fovea.
4. Monitor Risk Factors: Older age, smoking, genetics, and vascular conditions all increase the risk of Geographic Atrophy. Be vigilant in monitoring patients with these risk factors for signs of progression.
5. The Future is Bright: Gene therapies, stem cell treatments, and additional complement inhibitors are all on the horizon, offering hope for more effective treatments for Geographic Atrophy in the near future.

As Dr. Fanelli wisely said, “We have the license to drive the healthcare bus.” Geographic Atrophy may be a formidable opponent, but with new technologies and treatments, optometrists are in a prime position to lead the way in preserving vision and improving patient outcomes.