GA Case Compendium: Multimodal Imaging for Following Geo

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Case Presentation

A 61-year-old Hispanic female presented for an annual eye examination complaining of decreased vision bilaterally at both distance and near. She had no secondary complaints, and her past ocular history was unremarkable. Her medical history was positive for hypercholesterolemia and prediabetes, which were being controlled with metformin, aspirin, and atorvastatin. Her family ocular history was positive for age-related macular degeneration (AMD) in a sister and brother; both still had vision but were visually impaired. The patient’s BCVA measured 20/20 OD and OS. A slit-lamp biomiscrosopy revealed age-appropriate lenticular changes. Posterior segment evaluation showed diffuse small and medium-sized drusen throughout the vascular arcades OD>OS, sparing the macula (Figure 1).

Figure 1. Right (A) and left (B) fundus images highlight small/medium drusen throughout vascular arcades, sparing the macula in each eye.

The patient was informed that she had age-related deposits in her retinas, and that due to her positive family history of AMD, she was at a high risk of progressing to more advanced stages of the disease. She was educated regarding proper diet, exercise, management of cardiovascular health, and UV protection, and was told to take an AREDS supplement. Follow-up was scheduled for 1 year. The following year, the exam findings and visual acuity remained stable. Then, the patient was lost to follow-up for 7 years.

Seven years later, the patient returned for examination after she failed a DMV vision test and requested that we sign a form allowing her to drive. She stated that she was seen in Peru 3 months prior and was told there was “something wrong with her macula.” Her BCVA measured 20/30 OD (with variability in responses throughout refraction) and 20/20 OS. Fundoscopic examination showed enlargement of the previously documented drusen with a well-delineated area of tissue loss over the fovea consistent with subfoveal GA in the right eye, and GA surrounding the fovea but sparing the foveal center OS (Figure 2). OCT performed at this visit confirmed the presence of GA (Figures 3 and 4). The patient was re-educated on lifestyle modification and vitamin supplementation to delay the progression of the disease. At the time of this exam, therapeutic modalities were not yet approved for GA. The patient was given a home Amsler grid and asked to return to the clinic in 6 months for re-evaluation, or sooner if she noted a change on her grid.

Figure 2. A fundus photo of the right eye shows subfoveal GA and medium/large drusen (A). A fundus photo of the left eye shows GA surrounding the fovea but sparing the foveal center and medium/large drusen (B).

Figure 3. OCT of the right eye shows subfoveal GA with choroidal hypertransmission, attenuation of the neurosensory retina, and scattered drusen deposits.

Figure 4. OCT of the left eye shows extrafoveal GA with hypertransmission defect, reticular pseudodrusen, “gull-wing” formation, and subsidence of OPL/INL.

One year later, the patient returned reporting a significant change in her vision OD. Two months prior, she had started seeing horizontal lines inferiorly when watching TV. Her BCVA measured 20/100 OD and 20/25 OS. A retinal exam showed enlargement of the GA OD with multiple soft, large, confluent drusen (Figure 5); the left eye looked stable with GA surrounding the fovea, but sparing the foveal center with multiple soft, large, confluent drusen (Figure 6).

Figure 5. A fundus photo shows subfoveal GA OD (A). FAF of the same eye shows hypofluorescence in the area of the GA with foveal involvement and hyperfluorescence at the junctional zone (B). OCT of this eye reveals subfoveal GA with choroidal hypertransmission, drusen, and subsidence of the OPL/INL (C).

Figure 6. A fundus photo shows extrafoveal GA OS (A). FAF of the same eye illustrates hypofluorescence in the area of the GA but sparing the fovea, and hyperfluorescence at the junctional zone (B). OCT of this eye shows extrafoveal GA, subsidence of OPL/INL, choroidal hypertransmission, and drusen (C).

One year later, the patient returned and reported that due to COVID, she had not been using AREDS vitamins and had neglected her health. She stated that her “good eye” was not as good anymore and that she was having trouble reading and sewing. Her vision now measured CF@5 FT OD and 20/25- OS. Significant progression in GA was noted OD, with extrafoveal GA OS; however, the area of GA was growing and encroaching upon the fovea OS (not shown). Thus, the patient was referred to the retina specialist for possible intervention with intravitreal complement inhibitors.

Conclusion

Over the course of 14 years, this patient’s BCVA declined from 20/20 at inception to CF @5FT OD. Despite stable visual acuity of 20/25- OS, the lesion size had continued to grow (but spared the macula) and the patient was experiencing functional vision decline. Of note, a patient’s visual acuity is often not a good representation of functional status. It is our hope that with new intravitreal therapy, the GA in the left eye will not encroach upon her fovea, and her functional vision and visual acuity will remain stable.

This case demonstrates several important lessons regarding GA, including:

The need to educate patients on lifestyle modification, maintaining good cardiovascular health, UV protection, AREDS supplementation, and smoking cessation to modify the course of the disease.
Use multimodal imaging to supplement the examination and track the progression of the disease.
Visual acuity is not a good representation of functional vision status.
Refer early for best overall outcomes.

Julie Rodman, OD, MSc, FAAO

- Professor of Optometry, Nova Southeastern University, Davie, Florida

- Chief, Broward Eye Care Institute, Fort Lauderdale, Florida

- rjulie@nova.edu

- Financial Disclosures: Consultant (Apellis, Astellas, iCare, LKC Technologies, Regeneron, Visionix)

ABOUT THIS SERIES

Newly available treatment options for geographic atrophy (GA) have the potential to change the prognosis for long-term eye health. However, their newness also raises important practical questions, including about who should be referred and when. The Geographic Atrophy Clinical Case Compendium was developed, with guidance from Carolyn E. Majcher, OD, FAAO, FORS, and Julie Rodman, OD, MSc, FAAO, to demonstrate real-world patient encounters and the impact of treatment on the clinical course.

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