GA Case Compendium: Patient Education, Advanced Technologies, and Timely Referrals Are Crucial in Geographic Atrophy

THIS CASE IS INTERACTIVE!
Strengthen your understanding of geographic atrophy by answering the challenge questions below.

Geographic atrophy (GA), an advanced form of dry age-related macular degeneration (AMD), is a significant cause of decline in visual function and quality of life. GA is on the rise with more than 1 million people in the United States living with the disease while 8 million have GA globally.^1,2 GA is irreversible, progresses faster than previously thought, and accounts for approximately 20% of legal blindness.^3,4 Patient education, early detection, and prompt referral for intervention with intravitreal complement inhibition pharmacotherapy are crucial in preserving sight in patients with GA.

CASE PRESENTATION

A 78-year-old Caucasian male presented for a comprehensive eye examination with a complaint of blurry vision while reading. His medical history was significant for hypertension, hyperlipidemia, heart disease, and colon cancer. He was taking medication for each condition and reported being a former smoker. He reported no ocular history or previous diagnosis of AMD. BCVA was 20/20 OD and 20/40 OS with NIPH. Multimodal imaging, including color fundus photography (CFP), fundus autofluorescence (FAF), and optical coherence tomography (OCT), confirmed a diagnosis of intermediate AMD OD and GA OS (Figures 1-3). The patient was referred for complement inhibition pharmacotherapy intervention.

Figure 1. Color fundus photography images revealed intermediate AMD OD (A) and an extrafoveal GA lesion OS (B; yellow arrow). 

Figure 2. Fundus autofluorescence showed stipple hyperautofluorescent lesions OD (A) and hypoautofluorescence of the lesions, indicating retinal pigment epithelium cell death OS (B; yellow arrow).

Figure 3. OCT revealed large drusenoid pigment epithelial detachments and visibility of Bruch membrane OD (A; yellow arrow). In the left eye (B), OCT showed hypertransmission defects and subsidence (sinking) of the inner nuclear layer and outer plexiform layer (red arrow) and hyporeflective wedges (blue arrow).

SUMMARY/CLINICAL TAKE-HOME

With increased prevalence of GA, it is increasingly important that optometrists educate patients about the risks, detect early signs, and promptly refer patients with GA for intervention with complement inhibition pharmacotherapy. 

Risk factors for GA includes older age, race (Caucasians), diet, smoking, and genetics, which is major contributor for both the development and progression of GA. Additional risk factors include hypertension, hyperlipidemia, diabetes, sunlight exposure, and reduced physical activity.⁵ It is important to encourage lifestyle changes that can slow down GA progression, which includes smoking cessation (including e-cigarettes or vaping), adopting a healthy diet, and managing weight.

Examining GA features using multimodal imaging techniques is essential to detect GA, measure and document its progression, and assess its risk for vision impairment. CFP can detect changes in lesion size overtime. FAF is considered the gold standard in measuring GA lesion size and disease activity, and OCT is now considered the gold-standard approach to detect and classify GA lesions. The Classification of Atrophy (CAM) consensus group defined GA using the terms incomplete retinal pigment epithelium (RPE) and outer retinal atrophy (iRORA) and complete RPE and outer retinal atrophy (cRORA).⁶ This OCT-based definition uses a combination of features, such as signal hypertransmission and the absence of structures in the external retina including the external limiting membrane (ELM), ellipsoid zone (EZ), and RPE.⁶ Near infrared reflectance (NIR) imaging for GA shows a hyperreflective signal, due to the loss of RPE cells, ⁷ while enhanced-depth imaging OCT can detect subfoveal choroidal thinning, which contributes to GA progression.⁸

With the availability of intravitreal complement inhibition pharmacotherapy, early intervention can stabilize vision and slow disease progression.

Key Points:

• GA, a leading cause of declining visual function and quality of life, is on the rise.
• Early detection and management are essential for improving patient outcomes.
• Intravitreal complement inhibition pharmacotherapies, such as pegcetacoplan (SYFOVRE, Apellis) and avacincaptad pegol (IZERVAY, Astellas), can slow GA progression.

References

1. Saundankar V, Borns M, Broderick K, et al. Annual prevalence of geographic atrophy and wet age-related macular degeneration among Medicare Advantage enrollees in a US health plan. J Manag Care Spec Pharm. 2025;31(1):88-94
2. Kalpana R, Farokh D, Arun U. Geographic atrophy: pathophysiology and current therapeutic strategies. Front Ophthalmol. 2023;3:1327883.
3. Fleckenstein M, Mitchell P, Freund KB, et al. The progression of geographic atrophy secondary to age-related macular degeneration. Ophthalmology. 2018;125(3):369-390.
4. Holz FG, Strauss EC, Schmitz-Valckenberg S, et al. Geographic atrophy: clinical features and potential therapeutic approaches. Ophthalmology. 2014;121(5):1079-1091.
5. Heesterbeek TJ, Lorés-Motta L, Hoyng CB, et al. Risk factors for progression of age-related macular degeneration. Ophthalmic Physiol Opt. 2020;40(2):140-170.
6. Sadda SR, Guymer R, Staurenghi G, et al. Consensus definition for atrophy associated with age-related macular degeneration on OCT: classification of atrophy report 3. Ophthalmology. 2018;125(4):537-548.
7. Souied E, Semoun O, Capuano V. Capturing geographic atrophy with multimodal imaging: Noninvasive technologies are redefining how we diagnose and monitor atrophic AMD. Retina Today. Available at: retinatoday.com/articles/2024-apr/capturing-geographic-atrophy-with-multimodal-imaging [accessed June 2025].
8. Lindner M, Bezatis A, Czauderna J, et al. Choroidal thickness in geographic atrophy secondary to age-related macular degeneration. Invest Ophthalmol Vis Sci. 2015;56:875-882.

Ready For Another Case?

• View All GA Compendium Cases »

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 Majcher, OD, FAAO, FORS, and Julie Rodman, OD, MSc, FAAO, and, to demonstrate real-world patient encounters and the impact of treatment on the clinical course.