What is Geographic Atrophy? Making the Invisible, Visible đź‘€

Geographic atrophy is a term commonly used in the context of age-related macular degeneration. Age-related macular degeneration is a progressive eye condition affecting the macula, the central part of the retina responsible for acute, central vision. Geographic atrophy is an advanced form of Age-related macular degeneration where there is a gradual loss of retinal cells in specific areas, leading to the formation of distinct regions of atrophy.

In Partnership with Heidelberg Engineering

Hear more of the discussion about SPECTRALIS multimodal imaging in clinical practice.

On today’s podcast, Dr. Chris Lievens sits with two retinal experts, Drs. Jessica Haynes and Steven Ferrucci. They discuss geographic atrophy, covering the disease state, diagnosing with the Heidelberg Engineering SPECTRALIS OCT, and the importance of the doctor-patient relationship.

The Unseen Impact of Geographic Atrophy


Dr. Chris Lievens:

Today’s topic is Making the Invisible Visible. Joining me are two esteemed guests, Dr. Steve Ferrucci from the Sepulveda VA in California, and Dr. Jessica Haynes from the Charles Retina Institute in Memphis, Tennessee. Our primary focus today is geographic atrophy, a topic that has recently made significant headlines.

The importance of early diagnosis cannot be overstated, just like with many other conditions. Quality scans that accurately identify the layers of the retina affected are vitally important. The numbers are staggering: over a million people in the U.S. are losing their vision to this swiftly progressing condition. It can lead to an inability to drive in under two years and cause blindness in the better-seeing eye in approximately six years.

This issue is a matter of great concern. In collaboration with Heidelberg Engineering, we will initiate our discussion with quality images, then pivot to the critical details of patient analyses for identifying geographic atrophy.

Dr. Jessica Haynes:

Indeed, the rest of us are catching up. We’re all becoming acquainted with a new treatment for this condition. As you pointed out, this was a disease previously overlooked, with minimal discussion or lectures devoted to it. But now, treatment is available, and we’re being inundated with new information about this condition.

We’re uncovering aspects we previously knew nothing about. It’s indeed an exciting time in the world of dry age-related macular degeneration.

Dr. Steven Ferrucci:

I couldn’t agree more. When you mentioned ‘curveball,’ I thought you would steer the conversation toward the anterior segment or contact lenses. But Jessica is right.

Recently, the FDA approved a new medication, SYFOVRE™, by Appellis. By the end of this summer, another drug, Symora by Iberic, is expected to be FDA-approved — that’s the general consensus in the retinal world. These medications don’t reverse age-related macular degeneration but help slow its progression.

Once you get a geographic atrophy lesion, these lesions will grow over time and coalesce. If you have several smaller ones, they’ll merge into a larger one, causing more functional loss and eventually leading to decreased visual acuity. These intra-vitro agents can slow down the progression, hopefully allowing our patients to function better and more independently for a more extended period.

I believe, until now, we didn’t really concern ourselves with geographic atrophy because we couldn’t treat it. But now that we have a treatment, we need to start recognizing it, looking for it, and eventually figuring out which are the most suitable patients for treatment.

Dr. Chris Lievens:

We used to think dry age-related macular degeneration was the ‘better’ type, but that’s not entirely accurate. How did we become so confused? Was it because we didn’t have a treatment, so it was easier to overlook? Was it due to our lack of technology to differentiate one type from another? Or were we misdiagnosing these cases as wet because the patients’ conditions were deteriorating, even though we didn’t observe vessel growth? What was the reason?

Dr. Jessica Haynes:

I think a lot of that confusion comes from the fact that we didn’t have treatments for exudative age-related macular degeneration for a long time either.

Exudative age-related macular degeneration was the number one cause of vision loss in patients with macular degeneration for a long time. But as we developed treatment options for exudative age-related macular degeneration, patients’ outcomes improved, though not all see excellent results. We still have patients that we identify too late, who already have significant macular scarring. We still have patients who may lose vision over time, but we can treat these patients and ultimately achieve much better results than before. But I believe this is an outdated mindset from the time before we had anti-VEGF injections to treat exudative conditions.

Dr. Steve Ferrucci:

I often explain to my patients that we have dry and wet age-related macular degeneration, and I avoid categorizing them as good or bad. As you mentioned, we used to consider dry as good and wet as bad, but I’ve heard patients express a wish to have the wet version since there’s a treatment for it. However, the wet type can cause more serious vision loss more quickly.

So, it really depends on your perspective. When they ask, “Do I have the good or the bad kind?” I say that neither kind is good nor bad. They’re just different, and we must deal with what we have. Therefore, I hesitate to use such terminology with my patients, like “good” and “bad.” 

Dr. Chris Lievens:

So, when using Heidelberg Engineering SPECTRALIS OCT state-of-the-art OCT technology for either diagnosing or monitoring the progression of geographic atrophy, what types of things are you looking for? Could a poor-quality scan confound this disease state?

Dr. Jessica Haynes:

You can see traces of subretinal fluid in patients with exudative age-related macular degeneration that can’t be seen clinically and intraretinal fluid. In terms of identifying patients with geographic atrophy or perhaps patients more at risk of developing geographic atrophy, there are several markers on the OCT.

We’re talking a lot now about reticular pseudodrusen, which is actually a more subtle form of drusen. They’re not the large, soft drusen we know to increase the risk of developing advanced disease. These are tiny projections that sit on top of the RPE.

Looking for these things is important because patients with reticular pseudodrusen have an increased risk of developing geographic atrophy and tend to have worse visual function. So the patients who come in and say, “I can’t see to drive at night. I can’t read my phone. I can’t do all these things,” but still have 20/20 vision, they could have a variant of macular degeneration that’s more likely to advance. Therefore, having the quality scan needed to see these subtle changes is imperative.

Dr. Chris Lievens:

Let’s consider some facts about geographic atrophy that tend to catch people’s attention. Approximately 5 million people worldwide have this condition, with 1 million of those in the U.S. It’s responsible for 1 in 4 cases of legal blindness, and its prevalence quadruples every 10 years, starting at age 50.

Dr. Jessica Haynes:

Well, we know that age-related macular degeneration, in general, is underdiagnosed, and I’m certain that geographic atrophy within the age-related macular degeneration population is underdiagnosed too.

Unveiling the Real Speed of Geographic Atrophy Progression

Dr. Chris Lievens:

So, what is the approximate rate of progression of geographic atrophy? I’m under the impression that it’s rapid. Why is that?

Dr. Jessica Haynes:

The rate of progression is faster than we realized. We have told patients with dry age-related macular degeneration for so long that it’s a slow-moving condition. However, it speeds up as it progresses from early to intermediate to advanced stages. It may take a long time to go from no age-related macular degeneration to early or from early to intermediate, but once you reach geographic atrophy, it tends to move fast. We’re realizing this more and more, especially with clinical trials that are evaluating geographic atrophy. I believe the statistic now is that from the onset of the lesion, it’s about 2 to 2.5 years before you would actually have vision loss from that.

Dr. Steven Ferrucci:

Jessica is correct. Foveal involvement takes about 2.5 years or so from the first onset. So it progresses more quickly than I thought, and probably most of us. We now realize we can’t sit on it for as long as we initially believed. As these drugs begin to educate more, I think we’ll hear even more about these facts and figures and how quickly geographic atrophy can truly affect your vision.

The Art of Patient Communication in Retinal Diseases

Dr. Chris Lievens:

Let’s talk about communication skills. In your interactions with patients with retinal diseases, such as this one, how do you communicate to someone that there’s a likelihood of vision loss in a very short period of time? How do you deliver this message and ensure patients fully comprehend it? 

Do you show them your OCT images or your Spectralis images? Or do you try to describe it to them? How do you deliver this news to your patients?

Dr. Jessica Haynes:

One thing I consistently practice is validating their concerns, reinforcing the idea that they’re not imagining these problems. Too often, people are told, “You have 20/20 vision, you should be seeing fine.” Yet, their visual function can be quite poor, and acknowledging this can be deeply reassuring. It confirms that someone is listening, that someone understands what they’re experiencing. While I might not be able to solve all their issues, I can at least affirm that their condition explains the problems they’re facing.

Another critical point, which we sometimes forget to mention, but is crucial for patients to comprehend, is that they’re not going to go entirely blind from their condition. Many patients fear that if their vision has deteriorated this much in the last two years, then any day now, they’ll wake up to complete darkness. They’re often unaware that their condition doesn’t result in total vision loss. Remembering to emphasize this fact is straightforward, yet significantly important.

Dr. Steven Ferrucci:

I think Jessica hit the nail on the head. Showing them the images can be really powerful. The OCT scan images and fundus autofluorescence images really let them visualize what’s going on inside their eyes. I also make sure they understand what these images mean.

And the point about not going completely blind is very crucial. Many patients fear that they will wake up one day and not be able to see at all. So, reassuring them that while their central vision may be affected, they will not lose all their vision can be pretty comforting.

Communication is critical here. We must validate their concerns, explain what’s happening, and help them understand that while their vision may be affected, we’re here to support and guide them through this process.

Dr. Chris Lievens:

Thank you, Jessica and Steve, for those insights. Patient communication and understanding of the disease is a significant aspect of treatment. With advancing technologies and new treatments, we can better identify and slow the progression of diseases like geographic atrophy. It’s an exciting time in eye care, and we look forward to seeing how these advancements will improve our patients’ lives.

Dr. Chris Lievens:

What are some of the subtleties to look for when examining a high-quality image that signifies the onset of the disease and indicates its progression?

Dr. Jessica Haynes:

One thing to always remember when looking at an OCT is which tissue layers are affected by what diseases. When considering age-related macular degeneration, you need to focus specifically on the outer retinal layers: the RPE, photoreceptor lines, and look for drusen-type lesions or reticular pseudodrusen, as well as outer hypotransmission, which cascades down into the choroid. Most patients with age-related macular degeneration tend to have a thinner-than-average choroid, and studies suggest that patients with geographic atrophy who are at high risk of progression may have even thinner choroids. So, focusing on those outer retinal layers is crucial.

Dr. Chris Lievens:

Jessica, do you think patients with a naturally narrower choroid predispose them to geographic atrophy? Or is it the disease state that somehow causes the choroidal layer to change?

Dr. Jessica Haynes:

That’s a good question. We know we lose choroidal thickness to some degree over time. However, age-related macular degeneration is, to an extent, a choroidal vascular disease. Patients with age-related macular degeneration likely experience a faster loss of the choroidal capillaries, and it’s that ischemia that then leads to some of these cascades further down. It’s most likely not something present from birth but a condition that changes faster over time.

Emphasizing the Importance of Thorough Examination of OCT Scans

Dr. Steven Ferrucci:

I agree with Jessica’s comments about OCTs. But don’t rush when looking at the OCT. Some of us quickly look at the heat map — green is good, red is bad — but we need to dig a little deeper than that. Patients can have normal thickness but still experience issues. They could be losing the RPE layers and other layers, so you really have to spend a couple of minutes not just looking for edema or swelling. When considering geographic atrophy, you have to look at the RPE and various layers for these subtle signs and for the health of the retina and transmission defects. You need to spend a little more time as there are more things you need to look for.

Dr. Chris Livens:

What advice can you give our audience members as we wrap up this topic on Heidelberg Spectralis technology and geographic atrophy?

Dr. Jessica Haynes:

As Chris mentioned earlier, remember when you weren’t as skilled at interpreting these scans? When I was a resident, I would see these things and not recognize them, but now I do because of experience. Look at images online, attend lectures, and make a point that you want to understand this. It does take work, but as you get better, you see many things in these patients with age-related macular degeneration on the OCT scans that can help you understand what’s happening. You can identify why one particular patient is so symptomatic, and another isn’t, detect advanced stages of disease better, and ultimately serve your patients better.

Dr. Steven Ferrucci:

Jessica has made excellent points. The only thing I’d add is that when we didn’t have treatments for certain diseases, it might not have mattered if we recognized or diagnosed them because there was nothing we could do. But now that we have more treatments, it’s crucial to diagnose diseases like geographic atrophy better. With greater power comes greater responsibility. We now have the power to diagnose more conditions and get our patients better treatments. It’s our responsibility to use this power to take better care of our patients, recognize retinal diseases, and refer those who need treatment. In the long run, this approach will hopefully result in better vision for our patients for a longer period of time.

Overall, open and informative communication about geographic atrophy helps empower patients to take an active role in their ocular health, make more decisive, informed decisions, and better cope with the condition’s impact on their daily lives.

Christopher Lievens
Christopher Lievens
Chris Lievens is the Chief of Internal Clinics and Professor at Southern College of Optometry. Dr. Lievens has been employed in private practice, an ophthalmology referral center and he served in the United States Air Force. Dr. Lievens was the Chief of Aerospace Optometry at the Pentagon before joining SCO. Dr. Lievens is a fellow of the American Academy of Optometry and is a Region Chair of the Academy’s Admittance Committee. He is a distinguished fellow in the National Academies of Practice. Dr. Lievens is the co-creator of the fundus grading card and currently conducts research in glaucoma, dry eye, uveitis and contact lens care. Dr. Lievens has a Master’s degree in Healthcare Administration and is currently enrolled in a PhD program in Cambridge. Dr. Lievens is a member of the American Optometric Association, the British Contact Lens Association and the Association for Vision and Research in Ophthalmology.

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