This column is the first in a series on the co-management relationship between optometrists and ophthalmologists when diagnosing and treating geographic atrophy.

A New Era in Geographic Atrophy Detection

Geographic atrophy (GA) has historically been managed with observation rather than intervention. Patients were typically followed at 6- to 12-month intervals, with limited therapeutic options beyond nutritional supplementation. Recent FDA approvals of complement inhibitor therapies have fundamentally altered this paradigm, shifting GA toward a disease state requiring earlier detection and proactive referral.^1-3 Geographic atrophy care functions optimally when detection, referral, and treatment operate as one continuous system.

In this evolving landscape, optometrists and general ophthalmologists play a critical role as the first point of detection. Identifying GA earlier—ideally before foveal involvement—may directly influence treatment eligibility, patient education, and long-term visual outcomes.

OCT: The Foundation of Early Detection

Optical coherence tomography (OCT) remains the most sensitive tool optometrists can use for identifying early outer retinal and retinal pigment epithelium (RPE) structural changes associated with GA. However, detection depends not only on obtaining scans but on how they are interpreted.

Rather than relying on static printouts, clinicians should dynamically review B-scans with attention to the outer retina. Early biomarkers include ellipsoid zone disruption and photoreceptor attenuation, which may precede clinically apparent atrophy, as well as hyperreflective foci and reticular pseudodrusen. Both imaging irregularities have been associated with increased risk of progression to GA.^4-6

Subtle RPE degeneration, including areas of attenuation or early collapse, may further indicate imminent transition toward nascent atrophy.^4,5 These findings reflect ongoing outer retinal and RPE dysfunction and represent actionable indicators of disease activity that should be used to refine monitoring intervals, patient counseling, and referral timing.

The Role of Multimodal Imaging

In clinical practice, optometrists can use fundus autofluorescence (AF) to document baseline GA, and then subsequently at serial intervals for evaluating changes in lesion size and growth over time. Hyperautofluorescent patterns surrounding atrophic lesions can be associated with the potential for faster lesion progression.⁷

En face OCT and infrared/SLO imaging are increasingly helpful for identifying early lesion location and extent and offer the convenience of additional imaging modalities on the same OCT machine without the need for an additional camera or filters. Optical coherence tomography angiography (OCT-A) complements evaluation by assessing for concurrent neovascular activity, often reducing the need for fluorescein angiography.⁸

Clinical Implications for Referral

The availability of treatment has lowered the threshold for referral. Patients with early or intermediate AMD and high-risk features for progression to GA should be monitored more closely and considered for earlier consultation with a retina specialist.

Equally important is preparing patients for what referral entails. Setting expectations that treatment slows progression but does not restore vision is critical to maintaining alignment across providers and improving initial patient buy-in and continued adherence.

Conclusion

Early detection of GA is no longer optional but rather foundational to modern retinal care. By refining imaging interpretation and incorporating multimodal strategies, primary eye care providers can identify at-risk patients earlier and facilitate timely collaboration with retina specialists.

References

1. Liao DS, Grossi FV, El Mehdi D, et al. Complement C3 inhibitor pegcetacoplan for geographic atrophy secondary to age-related macular degeneration: a randomized phase 2 trial. Ophthalmology. 2020;127(2):186-195.
2. Apellis Pharmaceuticals. Syfovre (pegcetacoplan) prescribing information. 2023.
3. Iveric Bio. Izervay (avacincaptad pegol) prescribing information. 2023.
4. Fleckenstein M, Mitchell P, Freund KB, et al. The progression of geographic atrophy secondary to age-related macular degeneration. Prog Retin Eye Res. 2021;82:100910.
5. Wu Z, Luu CD, Ayton LN, et al. Optical coherence tomography-defined changes preceding the development of drusen-associated atrophy in age-related macular degeneration. Ophthalmology. 2014;121(12):2415-2422.
6. Nassisi M, Fan W, Shi Y, et al. Quantity of intraretinal hyperreflective foci in patients with intermediate age-related macular degeneration correlates with progression to geographic atrophy. Am J Ophthalmol. 2018;195:44-52.
7. Holz FG, Bindewald-Wittich A, Fleckenstein M, et al. Progression of geographic atrophy and impact of fundus autofluorescence patterns in age-related macular degeneration. Am J Ophthalmol. 2007;143(3):463-472.
8. de Carlo TE, Romano A, Waheed NK, Duker JS. A review of optical coherence tomography angiography (OCTA). Ophthalmology. 2015;122(6):1228-1238.

Damon Dierker, OD, FAAO, is the director of optometric services at Eye Surgeons of Indiana in Indianapolis.

Ankur M. Shah, MD, FASRS, is a fellowship-trained ophthalmologist and retina specialist at Retina Partners Midwest, PC at Midwest Eye Institute in Carmel, Indiana.

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