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Join us for an insightful conversation with two leading experts in eye care, Dr. Jennifer Lyerly and Dr. Mark Dunbar, as they shed light on the often-overlooked topic of geographic atrophy. Historically, geographic atrophy presented challenges with limited treatment options, but recent scientific breakthroughs have brought newfound hope. With decades of experience and expertise, Dr. Dunbar, from the prestigious Bascom Palmer Eye Institute, shares his insights. Dr. Lyerly guides the discussion, exploring prevalence, detection challenges, early intervention, and the pivotal role of advanced imaging. Discover the evolving role of optometrists in managing geographic atrophy as we uncover the complexities of this condition.
Editorially Independently Sponsored by Iveric Bio, An Astellas Company. Iveric Bio had no control over the content of this piece.
Introducing Dr. Mark Dunbar’s Background
Dr. Jennifer Lyerly:
We are discussing a topic we all encounter in our clinical practice, but we may not have devoted much thought to how we, as doctors, handle it. In the past, there wasn’t much we could do about it. It doesn’t occupy as much brain space when you don’t have a treatment. We see it, but once we diagnose it, the conversation ends. Geographic atrophy is the focus now, with exciting breakthroughs in our science and clinical abilities. But our attention needs to shift towards better diagnosing and detecting it.
Let’s begin by introducing yourself. Could you tell us about your practice and how you became an expert in retinal care?
Dr. Mark Dunbar:
I wouldn’t call myself an expert, but I have a deep interest in the field of retina. I practice at the Baskin Palmer Eye Institute, part of the University of Miami’s Department of Ophthalmology.
I’ve been with them for over 35 years. I moved here in the mid to late ’80s. Some of you might remember Omni Eye Services. I was a resident at the Omni in Lexington. This was really the early days of co-management. My mentors, like Paula Jamie and others, had all trained at Bascom Palmer.
So, I had the opportunity to go there, and I thought I would spend a couple of years at Bascom Palmer and then move on. But before I knew it, 35 years had passed, and I’m still there. In my early years, I worked in the retina clinic with some of the giants in the field.
Although I’m known for my work in retina, I also provide primary eye care. I see a lot of glaucoma patients, diabetes cases, and cataracts. It’s quite typical for an optometric practice. Surprisingly, I’ve fitted a few contact lenses recently despite not having done so for over two decades. It’s been fun and exciting to revisit that aspect of my practice. But my true passion lies in retina, without a doubt.
The Prevalence and Detection Challenges of Geographic Atrophy
Dr. Jennifer Lyerly:
When we think about our average macular degeneration patient, the first thing that often comes to mind is those with wet age-related macular degeneration. If we look at prevalence data, it’s clear that only about 200,000 Americans are diagnosed with wet macular degeneration each year. So, in the grand scheme of macular degeneration, it’s a relatively small subset. Most of our patients have dry age-related macular degeneration and are expected to stay dry.
However, I found something surprising when reading up on this. Geographic atrophy can sneak up on you. Studies suggest that a million Americans have geographic atrophy, but that number is likely an underestimate because we haven’t been very successful at detecting the early stages of it.
I’m curious, how often do you come across cases of geographic atrophy in your practice?
Dr. Mark Dunbar:
When considering geographic atrophy, we often envision a patient with a central disciform scar. We’ve all witnessed the helplessness as patients develop that characteristic donut-shaped area of geographic atrophy, knowing that it will inevitably involve the fovea at some point.
That’s the image that usually comes to mind. However, the reality is quite different. While those cases certainly exist, I believe the majority are patients we aren’t actively looking for. When we code for macular degeneration, it’s typically categorized as either dry or wet. But when it comes to dry, we must ask ourselves, is it early or intermediate?
Now, if we look at the ICD-10 code for geographic atrophy, it’s specified as “central foveal involving geographic atrophy.” So, as we’ve been coding macular degeneration, we’ve essentially lumped geographic atrophy together with dry AMD. Here’s an interesting statistic from the Age-Related Eye Disease Study: the 10-year risk of developing vision loss from intermediate-level AMD is about 50%. We might not find that surprising.
However, the 10-year incidence of progressing to geographic atrophy is higher, also exceeding 50%. I remember looking at this statistic and thinking, “There’s no way. This must be a marketing ploy.” Pharmaceutical companies now have drugs related to geographic atrophy, and they want us to be aware of it. But is it truly more common?
Dr. Mark Dunbar:
I don’t think we’d be surprised to learn that the 10-year risk of developing wet macular degeneration is about 50%. I think that statistic makes sense, and we can accept it. However, the other statistic, the 10-year incidence of developing geographic atrophy, is actually higher. It’s over 50%.
I remember looking at that statistic and thinking, “There’s no way. This must be part of a marketing strategy, right?” With pharmaceutical companies now having drugs related to geographic atrophy, they want us to be aware of it. But is it truly more common than wet age-related macular degeneration?
The fact is, the Age-Related Eye Disease Study focused on intermediate age-related macular degeneration. They were looking at whether nutritional supplements make a difference. So, this study covered any form of geographic atrophy, including small patches of geographic atrophy, extrafoveal geographic atrophy, or parafoveal geographic atrophy. Patients underwent imaging and photography. We’re not just talking about the central disciform lesions but any form of geographic atrophy. So when we realize it’s over 50%, that’s significant.
The problem is, we haven’t been actively looking for it or recognizing it in our practice. When we’ve been dealing with macular degeneration, our focus has been on dry or wet age-related macular generation. We haven’t been asking, “Does this patient have geographic atrophy?” It’s only been on our radar for the last six, eight, or nine months, and I’ve seen more geographic atrophy cases than I ever thought possible.
The Expanding Role of Optometrists in Managing Geographic Atrophy
Dr. Jennifer Lyerly:
There aren’t enough ophthalmologists to meet our aging population’s increasing eye care needs. This includes conditions like glaucoma, cataracts, and macular degeneration.
As a result, you, as optometrists, will play a more critical role than ever in providing advanced eye care. By 2030, one in five Americans will be 65 or older. Geographic atrophy is strongly age-related. When you examine the studies, you’ll find that one in 29 people over 75 have geographic atrophy and one in four people over 90 are affected.
As our patients continue to live longer, and as we, as optometrists, care for older and older Americans, we will encounter geographic atrophy at an increasingly high rate. It’s now essential that we become proficient at detecting and, when possible, treating it.
Early Detection and Biomarkers for Geographic Atrophy with Advanced Imaging
Dr. Mark Dunbar:
Your numbers are spot on. I believe that over the age of 70, age-related macular degeneration affects one in three individuals. It’s a significant issue. And when you think about it, 10,000 people turn 65 every day. I was actually watching the Today Show this morning, and they featured the “smuckers over 100” segment. There were ten people they talked about, some were 105, and a couple even reached 110. Patients are indeed living longer.
Regarding geographic atrophy, it’s even more pronounced among those over 80 or 85. About 20 percent of geographic atrophy cases occur in people in their 90s. So, we will encounter it in the younger age groups as well, but it’s certainly more prevalent among the elderly population. And, as you pointed out, managing elderly patients with various eye conditions, including glaucoma, macular degeneration, cataracts, and diabetes, requires a collective effort.
Optometry plays a crucial role on the front lines of diagnosing and managing these diseases. I commend companies like Iveric Bio, An Astellas Company. They actively engage with optometry, educating about age-related macular degeneration and diabetes. While we may not be the ones deciding which drug a patient receives or performing eye injections, we are the ones who diagnose and ensure that patients are referred to retinal specialists at the appropriate time.
It all starts with education and recognizing these diseases. When it comes to geographic atrophy, a condition we haven’t been actively looking for, there’s a significant need for education. How do we detect it? How do we recognize it? We must shift from monitoring the conversion from dry to wet age-related macular degeneration to actively seeking out geographic atrophy. If we can identify it earlier and get patients to retinal specialists, we aim to prevent vision loss and avoid seeing patients with 20/200 vision and central vision loss. We want to intervene earlier and potentially save their vision.
Dr. Jennifer Lyerly:
Let’s delve into the early detection of geographic atrophy and discuss some biomarkers for identifying the initial stages of the disease. Early intervention is crucial to reap long-term benefits, given the available treatments. We’re aware that genetics play a role in macular degeneration, particularly the CFH and ARMS2 alleles. Do you perform genetic testing for your patients or recommend it?
Dr. Mark Dunbar:
I do not. The American Academy of Ophthalmology advises against genetic testing. A Canadian company called Arctic DX pioneered genetic testing, with the idea that recognizing high-risk genetic markers could lead to closer monitoring and recommending specific nutritional supplements. However, the data on whether this makes a difference was somewhat flawed. Age-related macular degeneration is a complex condition influenced by genetics, environmental factors, and oxidative stress. It’s a combination of variables that predispose patients to age-related macular degeneration. The point is we don’t have a different treatment for these patients. We’d make the same recommendations to our elderly patients regardless, such as avoiding smoking and consuming a diet rich in green leafy vegetables and fish.
Even for individuals without age-related macular degeneration, not even early age-related macular degeneration, the Age-Related Eye Disease Study showed that taking a nutritional supplement didn’t make a difference. So, recommending genetic testing becomes challenging because there’s no clear benefit. And, on the other hand, some patients have taken tests like 23andMe and come in saying they have a genetic risk.
Dr. Jennifer Lyerly:
I was going to mention that. I’ve seen many patients who have taken such tests and believe they have a genetic risk.
Dr. Mark Dunbar:
Exactly. Many patients say, “I have the genetic risk; do I have macular degeneration? What should I do?” We perform an eye exam, and if they don’t have any AMD or drusen, we’re left with a dilemma. We lack data to guide us. Should we recommend a nutritional supplement for someone with a genetic profile but no age-related macular degeneration?
So, how do we make that decision? I believe education is key. We inform them about the importance of regular eye exams and discuss nutritional supplements. I also told them that the Age-Related Eye Disease Study found no benefit for people without age-related macular degeneration, but they didn’t study individuals with this genetic risk. So, taking a supplement won’t hurt, although it might have an economic disincentive because they can be expensive.
Ultimately, we provide information and hope that we’ll have more guidance on managing these patients over time. I had another case where a patient, in his mid-50s, came in worried because his father had lost central vision due to macular degeneration and had received injections. He asked, “What should I do?” I didn’t recommend Arctic DX, but I informed him about direct-to-consumer genetic tests, although I’m currently blanking on the name. I told him he could find out if he had the genetic risk through genetic testing. Otherwise, we’d see him annually, advise him on diet, exercise, and other lifestyle factors.
This is an evolving area, and genetics are here to stay. I expect more patients and more companies to be involved in genetic testing in the future, which means we’ll be making these decisions more frequently.
Dr. Jennifer Lyerly:
I take a similar approach to you regarding recommending genetic testing. Since the AREDS study didn’t find a benefit for individuals without macular degeneration or even those in the early stages, I don’t specifically recommend it for them. The study did show a benefit for intermediate dry macular degeneration, right?
However, I do emphasize the importance of diet and lifestyle modifications. I encourage them to avoid smoking, consume green leafy vegetables, maintain good cardiovascular health, and exercise regularly. If someone is already taking a vitamin supplement, there’s no harm in choosing one with lutein. Lutein is not harmful to the body, so it ultimately comes down to each individual’s personal decision about vitamins. Our role is to present the information, as you rightly said.
Moving on to detection, especially for geographic atrophy, our best tool is imaging. Early macular degeneration changes can be quite challenging to spot with an undilated or even dilated eye exam. But when you have access to imaging and can use various filters, it can bring those changes to life, especially with red fluorescein angiography or OCT scans.
Leveraging Fundus Autofluorescence and OCT for Geographic Atrophy Detection
Dr. Mark Dunbar:
We heavily rely on OCT imaging, which is now common in optometry practices. Each device can highlight geographic atrophy differently, and it’s essential to be familiar with these nuances.
When analyzing OCT images, it’s crucial to examine various cross-sectional lines, including hyper-transmission defects in the central B-scan image and other retinal layers. Learning to recognize biomarkers becomes important. These biomarkers include hyper-reflective foci just above the RPE, reticular pseudodrusen, and hyper-reflective columns that penetrate the RPE on B-scans. These biomarkers could be predictive indicators, suggesting a higher risk of developing geographic atrophy.
As we become more familiar with age-related macular degeneration, we should elevate our diagnostic approach, going beyond merely detecting fluid and choroidal neovascular membranes. Instead, we should look for these predictive biomarkers. If you see them, consider more frequent follow-ups—perhaps twice a year—focusing on these areas, as they could indicate a higher risk not only for geographic atrophy but also for wet age-related macular degeneration.
Certain OCT devices offer specialized programs like sub-RPE sub-illumination analysis, which highlights the sub-RPE layer, assesses drusen volume, and aids in tracking geographic atrophy progression. We should invest time in understanding how to better use OCT to detect geographic atrophy, as it can be sensitive and highly accurate.
Now, let’s discuss fundus autofluorescence (FAF), which has been a benchmark for detecting geographic atrophy. In clinical trials, FAF was instrumental in evaluating the efficacy of drugs and slowing down geographic atrophy progression. Combining FAF and OCT is the ideal approach. FAF reveals hypo-reflective areas or patches, which may not always be apparent on fundus photos, especially when dry age-related macular degeneration is present with numerous drusen.
Most ODs have wide-field fundus cameras, such as Optos, EIDON, or CLARUS, that can capture fundus autofluorescence. It’s crucial to break out these tools and use them specifically for detecting geographic atrophy. It’s an area where we’ll see a lot of education and improvement in the coming years.
Treatment Approach and Preserving Vision
Dr. Jennifer Lyerly:
Your description of the treatment approach for geographic atrophy (GA) reminds me a lot of our mindset with glaucoma. While we can’t cure or reverse the damage, we must focus on preserving and protecting vision in patients at risk of losing it. Treatment for geographic atrophy aims to do just that. The key is to assess whether an individual is at risk of vision loss during their lifetime and determine if treatment is necessary to safeguard their vision.
Dr. Mark Dunbar:
Exactly, you’re right. If we consider the people featured on the Smuckers segment on the Today Show, they may live to be a hundred or even 105. We want them to enjoy a lifetime of good vision, whether it’s reading the New York Times or recognizing the faces of their grandchildren and great-grandchildren. It truly does take a collective effort. We all need to be vigilant in identifying these patients early, well before they reach the stage of central GA, as those are not the patients we’re aiming to treat.
