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As optometrists, how do we look at geographic atrophy differently? Join us for an engaging and informative discussion with Dr. Jennifer Lyerly and Dr. Mile Brujic, renowned optometry experts, as they explore the evolving challenges and innovative treatments of geographic atrophy.
Dr. Brujic brings invaluable insights from his extensive, multi-location practice, emphasizing the need for early detection and advanced imaging in modern eye care. Dr. Lyerly adeptly leads the dialogue, focusing on the significant impact of this condition and the crucial role of optometrists in its management. Discover and learn about the latest advancements in eye care and optometrists’ increasingly vital role in early intervention and management of geographic atrophy, a condition significantly reshaping our understanding of comprehensive eye care.
Editorially Independently Sponsored by Iveric Bio, An Astellas Company. Iveric Bio had no control over the content of this piece.
Key Objectives:
Optometry Practice Insights and The Growing Importance of Medical Optometry
Dr. Jennifer Lyerly:
Dr. Brujic, I see you’re joining us from your optometry office. Could you share a bit about your clinic and what a typical day is like for you as an optometrist?
Dr. Mile Brujic:
Sure. I’m a part-owner of a four-location practice in Northwest Ohio, with two partners and eight doctors in total. I mainly work out of one location but visit another office every other week to see patients, focusing more on specialty cases. I’ve been in private practice for 21 years, and it’s been an incredible journey witnessing the evolution of optometry and anticipating its future directions.
Dr. Jennifer Lyerly:
As a private practice owner, I imagine medical optometry is a significant part of your work. Have you noticed increased demand for medical care in your role as an optometrist?
Dr. Mile Brujic:
Absolutely, Jenn. Since 2002, I’ve been fascinated by aspects of optometry where we can make a real impact, either through direct treatment or by quickly identifying subspecialties that benefit patients. This scope has expanded greatly, especially in the last five years. The practice of optometry has transformed rapidly, with many new developments that weren’t available even to those who graduated five years ago. Comprehensive care remains crucial, balancing optical and contact lens services with the broader medical care of patients. So, yes, medical optometry has become an increasingly vital part of our practice.
Rethinking Macular Degeneration: From Mild to Severe
Dr. Jennifer Lyerly:
Let’s discuss how we perceive macular degeneration, especially in our ongoing podcast series. Traditionally, we’ve viewed dry, non-exudative macular degeneration as a mild condition and wet macular degeneration as severe. However, we need to rethink this mindset. How would you explain to other optometrists that dry macular degeneration with geographic atrophy can be quite severe?
Dr. Mile Brujic:
The deeper our understanding, the more we realize that when we observe clinical signs, they represent a process that has been ongoing for years in patients. We used to categorize macular degeneration into ‘mild’ and ‘severe’ based on symptoms like leaking or neovascularization. But this overlooks a significant category, which didn’t get much attention because there was little we could do about it – geographic atrophy. This condition represents long-term tissue destruction, leading to macular dysfunction and tissue death.
In the past year, I’ve had many people ask about preventing macular degeneration, concerned about their family history. I advise them that prevention is critical, focusing on no smoking, good UV protection, and increasing intake of lutein and zeaxanthin through foods like dark green vegetables, kale, corn, spinach, orange peppers, and egg yolks. Our practice also offers high-zeaxanthin supplements and macular pigment optical density testing.
The distinction between mild and severe macular degeneration, particularly the notion that dry is mild and wet is severe, is rapidly changing. This shift is due to our growing understanding of the pathophysiology and the emergence of new treatments for the condition’s dry and advanced forms.
Geographic Atrophy’s Impact and the Importance of Early Detection in Optometry
Dr. Jennifer Lyerly:
The recent studies about vision loss due to geographic atrophy have been quite surprising. Like many, I previously considered this a less critical type of vision loss. However, a recent study involving 1,900 patients with geographic atrophy found that 66.7% lost their driver’s licenses within two years of diagnosis. This indicates that these patients are experiencing significant functional vision loss, drastically changing their lives. Previously, we had no treatments for this condition, leaving us, the care providers, without options. Acknowledging this form of vision loss is rapidly progressive is important.
Dr. Mile Brujic:
Let’s step out of our clinical roles for a moment and consider the general public’s perspective. When asked which of the five senses they’d be most concerned about losing, sight is invariably the top answer in any study. This realization changes my personal approach. As clinicians, we can get so caught up in processes that we sometimes lose sight of the profound impact we have on our patients.
I often have to remind myself of this, as I’m very process-oriented. Entering an exam room, I try to keep in mind that we’re dealing with our patients’ most valuable sense. With that in mind, Jennifer, we must be constantly vigilant. It’s about having that extra level of alertness, always considering how we can detect even the slightest signs of geographic atrophy (GA) earlier. We should strive to establish care patterns for patients as soon as possible, especially with emerging technologies that can slow the progression of these conditions.
While we can’t stop these diseases entirely, we can slow them down and offer hope. The statistic you mentioned about the loss of driver’s licenses due to geographic atrophy (GA) is startling, yet not unexpected for us in the field. But now, we can potentially extend the period of functional vision for these patients.
Incorporating Advanced Imaging for Geographic Atrophy in Optometry Practices
Dr. Jennifer Lyerly:
Alright, we’re dealing with geographic atrophy, a condition that can lead to rapid, progressive, and devastating vision loss, significantly affecting our patients’ daily functional activities. There’s now an FDA-approved treatment that can slow down the progression of geographic atrophy (GA). What do you think doctors need to understand to fully integrate this mindset of care into their daily practice?
Dr. Mile Brujic:
Yes, there are a few key aspects we need to consider daily. First, Jen, we’ve integrated advanced imaging technologies into every examination. This allows us to perform a standard series of tests on every patient before we even enter the exam room. I recall when we had to wait for pupils to dilate to understand a patient’s vision limitations. Now, we still perform these essential professional steps, but having this advanced information beforehand is a game-changer.
Interestingly, with these technologies, we can compare a patient’s current state with their past images, whether from six months or a year ago. This includes fundus scans and OCTs, enabling us to monitor their eye health more effectively. We’ve shifted the paradigm, detecting conditions earlier and providing better patient guidance as we learn more about these diseases.
We need to be very aware of two things as clinicians. Firstly, detecting conditions like macular degeneration and specifically geographic atrophy early can significantly influence patient outcomes. Secondly, we must monitor these conditions closely and provide appropriate referral protocols. However, in focusing on disease, we mustn’t overlook updating glasses, optical prescriptions, and providing additional magnification as needed. Our role is to ensure patients remain as functional as possible, especially when working with retina specialists on new treatments.
Everything has shifted regarding expectations, and we must be more aware of early-stage geographic atrophy patients. Previously, we might have overlooked these cases due to a lack of treatment options, but now we can intervene earlier. Therefore, it’s crucial to detect these lesions as soon as possible.
Challenges and Breakthroughs in Detecting Macular Degeneration
Dr. Jennifer Lyerly:
Detecting small lesions can be quite challenging. I had a patient recently where, during a dilated exam, it’s difficult to discern the impact of smaller areas of drusen. However, our imaging capabilities, particularly magnification, are immensely helpful. We recently added fundus autofluorescence imaging, and it made a significant difference. What I initially thought was an area of soft drusen turned out to be geographic atrophy. It surprised me how hard it was to detect. Large geographic atrophy (GA) lesions are visible with imaging, but smaller ones can appear just like a patch of drusen and remain hidden until revealed by the FAF photo. Have you also found certain imaging systems particularly useful for detecting these early changes?
Dr. Mile Brujic:
Jenn, you’re right. Each time we get new information, it leads to changes in our clinical protocols. As I mentioned, every patient who shows signs of AMD undergoes standard imaging and autofluorescence immediately. Moreover, our software is so advanced that I can monitor patients as they are pretested. Our electronic medical records system tracks patient locations in the office, allowing me to see the images taken in real-time.
If I’m with a patient and notice drusen in another patient’s images, I immediately message the technician to order autofluorescence. Often, what appears to be confluent drusen could be something more significant, and fundus autofluorescence helps us see that geographic atrophy clearly.
Another point is that before I enter the exam room with macular degeneration patients, they also undergo a macular OCT. This is especially helpful when autofluorescence photos are challenging to capture, like in pseudophakic patients or those with their natural lens. Sometimes, the OCT reveals small areas of atrophy that aren’t obvious or look like larger drusen on a photo. So, you’ve brought up some excellent clinical insights, Jenn.
How IZERVAY Works: Understanding the Complement Pathway
Dr. Mile Brujic:
The complement pathway is a constant background process in our bodies, helping us defend against pathogens. For instance, if a pathogen invades, our immune system responds through several mechanisms. Cells might phagocytose the pathogen, and others might release proteins that act like tiny bombs, causing destruction. These protein bombs are known as complement proteins. They bind to foreign elements, causing cellular destruction by creating small defects in the cell, leading to leakage of its contents. They also create receptors on these cells, signaling other immune cells to attack.
This process makes sense when dealing with pathogens. However, problems arise when the complement cascade targets our own body cells, leading to autoimmune diseases. In the context of our discussion, this is where geographic atrophy comes into play. Complement molecules, instead of targeting pathogens, start attacking retinal cells, leading to tissue destruction and loss of viable retina. Early on, we see thinning in OCT scans, but as it progresses, the affected area expands significantly.
Newer medications, administered intraocularly, inhibit these complement cascades. Currently, there are two primary drugs: SYFOVRE, which inhibits the C3 and C3b complement molecules, and IZERVAY, which targets C5. Both have been shown to reduce the expansion of atrophy over time. Interestingly, with C5 inhibition (IZERVAY), studies show a substantial reduction in geographic atrophy (GA) lesion size within a year. This is promising as it influences the progression of the disease by inhibiting complement pathways. It also allows for future medication iterations by combining these molecules with other treatments.
The Role of Optometrists in Managing Geographic Atrophy
Dr. Jennifer Lyerly:
For those listening to this podcast and thinking, “Okay, this is interesting, but retina specialists are the ones giving these injections, so why should I focus so much on this?”
Dr. Mile Brujic:
That’s a crucial point, Jen. If an optometrist thinks they don’t need to be involved because they’re not administering the injections, they’re missing a key aspect of patient care. While it’s true that we, as optometrists, can’t give intraocular injections and that’s the realm of ophthalmologists or retinologists, our role is still vital.
In our office, our protocol is clear: if we see any signs of geographic atrophy, we refer the patient to a retina specialist, especially now with new medications available. We started this practice over a year ago to establish patient relationships with retina specialists, providing them with our records for a baseline assessment.
It’s crucial for these patients to be in the hands of a retina specialist who can make informed treatment decisions. We don’t want a patient with advancing geographic atrophy in our chair, especially when effective treatments are available. The conversation about treatment should be between the patient and the retina specialist.
Moreover, setting up a follow-up protocol in our office is essential. While the retina specialist handles the specific treatment, all other aspects of eye care still fall under our responsibility. We need to ensure these patients don’t feel isolated and understand when to see us for their primary eye care. It’s important to schedule their next visit with us before they leave for the retina specialist so they know the plan moving forward with their primary care provider.
