This column is the third in a series on the comanagement relationship between optometrists and ophthalmologists when diagnosing and treating patients with geographic atrophy.
Most of the new geographic atrophy (GA) referrals in my retina clinic originate from optometrists within optometric or multispecialty ophthalmology practices. These GA patients arrive with varying levels of understanding—and expectations—regarding their disease status, prognosis, and treatment options. By the time patients reach the retina clinic, their expectations have often been shaped by conversations with their primary eyecare doctor, making consistency in how we describe GA and its treatment especially important.
The initial evaluation in my office always includes spectral domain optical coherence tomography (SD-OCT) and fundus autofluorescence (FAF) imaging, followed by a discussion with the patient to review the level of their age-related macular degeneration (AMD). Once we confirm the lack of active exudative AMD, we hone in on their GA.
After evaluating clinical factors including GA lesion location, size, rate of progression, symptoms, fellow-eye status, and medical comorbidities—as well as practical considerations such as transportation and caregiver support—we determine whether complement inhibitor therapy is appropriate.
Patient Consults
Treatment is generally not initiated at the initial consultation. Because GA is nonurgent and therapy requires an ongoing commitment to regular injections, we recommend patients take time to discuss with caregivers and review literature before returning for a follow-up visit anywhere from several weeks to a few months later.
During that time, we obtain insurance authorization for treatment if required. Even though many patients are initially hesitant and a bit apprehensive about ongoing injections, especially given the lack of vision improvement, it has been our experience that a very high proportion of patients inevitably decide to pursue therapy.
When patients decide not to pursue treatment, several factors commonly contribute. Unfortunately, some GA patients do not have full insurance coverage, and the financial barriers associated with ongoing injections every 4 to 8 weeks, sometimes bilaterally, can be burdensome. Even when treatment is medically appropriate, practical considerations such as transportation, caregiver availability, and work schedules can influence whether patients choose to proceed. Others feel that they have already lost substantial vision, leading to the inability to read and drive, and decide that the hassle of treatment is futile and not worthwhile.
Less commonly, treatment is recommended but patients are content with their level of visual function and decline treatment.
Beginning Treatment
Once treatment is initiated, the retina specialist’s primary focus remains on monitoring GA progression and early diagnosis of any potential conversion to wet AMD. Patients often settle into a cadence of regularly spaced injections. We obtain OCT at every visit, and additionally dilate patients and obtain FAF approximately twice yearly.
As we are focused on their retinal pathology, we emphasize to GA patients that they should continue nonretinal ophthalmic care with their primary eyecare provider. These patients often have concomitant ocular surface disease, refractive needs, glaucoma, or other conditions that continue to benefit from comprehensive eye care.
Successful GA management is not simply a series of injections. It is the result of coordinated longitudinal care between the retina specialist, primary eyecare provider, the patient, and often the patient’s family.
Remaining Adherent to Therapy
Complement inhibitor therapies have demonstrated increasing treatment effects over time, meaning the benefits on slowing disease progression gradually build over time relative to untreated patients. Accordingly, patients benefit from viewing treatment as a long-term commitment, and we emphasize the importance of remaining adherent to ongoing therapy.
As GA patients have often had longer-term relationships with their primary eyecare provider, they trust and value their recommendations and advice highly. When patients hear consistent messaging from both their retina specialist and primary eyecare provider, they often feel more confident in their treatment decision and better prepared for the long-term commitment that therapy requires.
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