GA Case Compendium: Rapid Loss of Vision Associated With

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Case Presentation

A 72-year-old white man was referred by his local optometrist for an evaluation of age-related macular degeneration (AMD) in the right and left eyes. The patient reported having difficulties reading small print and said he thinks he is seeing distortion in the left eye, which he described as wavy lines. The patient denied flashes, floaters, pain, or redness in either eye. Relevant medical history included diagnoses of systemic hypertension, arthritis, and thyroid disease. Family medical history was positive for macular degeneration (mother and father), stroke (father), and thyroid disease (mother). As for past ocular history, the patient’s status was post phacoemulsification with PCIOL implantation OU 2 years prior, and there was a history of posterior vitreous detachment OU. Presenting VA was 20/20 J1 OD and 20/20 J2 OS. Imaging captured at this initial visit, in March 2022, confirmed a diagnosis of geographic atrophy (GA) with hyperautofluorescence OS (Figures 1 and 2).

The patient was instructed to continue taking AREDS2 vitamins. In addition, the patient was educated on the need to monitor vision with an Amsler Grid and to call the office with any new distortion or changes. The patient subsequently returned to his primary care optometrist for a dilated fundus examination and routine care. One year and 4 months later the patient returned to our clinic with worsening distortion and vision changes in both eyes (OS>OD). The patient relayed that he wanted to learn more about the new treatments available for AMD that his primary care optometrist informed him of. VA at the time of this visit, in July 2023, was 20/20 J3 OD and 20/300 at distance and 20/400 at near OS. Imaging captured at this follow-up visit confirmed worsening of the GA OU (Figures 3 and 4). Unfortunately, the patient’s insurance was not covering GA treatment at this time, and so he was instructed to follow up in 6 months with hopes that his insurance would be able to cover treatment.

At another follow-up exam 6 months later, in January 2024, presenting VA was 20/30 J7 OD and CF @7 feet at distance and 20/400 at near OS. Imaging showed evidence of progression of the GA (Figure 5 and 6). At the time of this visit, we learned that the patient’s insurance was now covering both available treatments for geographic atrophy, and so we reviewed risks and benefits of starting treatment. The patient subsequently started treatment for GA in the right eye in March 2024. He will continue with AREDS2 supplements and Amsler grid monitoring.

At the time of the last follow-up with this patient, in June 2024, four total intravitreal injections of avacincaptad pegol intravitreal solution (Izervay, Astellas) had been administered in the right eye. There was minimal non-central GA lesion growth noted in the treated eye, yet vision remained stable at 20/20. The left eye was not treated due to central atrophy and limited visual prognosis; VA remained stable at CF @8 feet. Nevertheless, the patient was happy with the results of the injection and only complained of burning and tired eyes on the day of the injection but stated that by the next day his right eye feels back to normal.

Summary/Clinical Take-Home

This case demonstrates several notable learning points about GA. First is the deterioration of VA in the left eye in a relatively short timeframe, from 20/20 in March 2022 to 20/300 at distance in July 2023, and finally to CF @7 feet just 6 months after that. Related is the discordance between VA findings in the two eyes, as the patient maintained relatively good vision in the right eye. These facts demonstrate that GA progression is highly individualized and unique to each eye, and that progression of GA can be highly detrimental to functional vision in a relatively short time span. It is well known that VA change is not correlated with risk of GA lesion progression, and so the decision to act should be based on detecting early warning signs discovered during the clinical examination and based on multimodal imaging.

A second notable feature of this case is the difference in progression between the two eyes. Although GA was evident in each eye at the initial visit (Figures 1 and 2), the presence of hyperautofluorescence in the left eye suggested a worse prognosis. Indeed, over the course of this patient’s journey, serial imaging was useful for confirming progression of the lesions in each eye.

A third lesson from this case, and one that was unfortunate for the patient, is that the newness of complement inhibition therapy means that insurance coverage for treatment is not universal. There is no telling if initiation of therapy in July 2023, when treatment was first considered, would have helped preserve functional vision in the left eye. However, it may have slowed lesion growth enough to do so. Moreover, this scenario highlights the important role of optometrists in following GA patients over time. This patient diligently followed our advice to return in 6 months, at which time insurance coverage was available, and we could begin discussions about the risks and benefits of starting therapy in the right eye.

Mary Beth Yackey, OD

- Optometrist, Cincinnati Eye Institute/Eye Care Partners

- dr.marybethyackey@gmail.com

- Financial disclosure: Consultant (Notal Vision, Optos, Regeneron, Reliance Ophthalmic Equipment, Topcon); Consultant/Speaker (Apellis, Astellas)

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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