On today’s episode of Ready, Set, Retina, John W. Kitchens, MD, shares a case of rapid geographic atrophy (GA) progression with Daniel Epshtein, OD, FAAO, to analyze how well-treated wet age-related macular degeneration patients can still be susceptible to losing their vision—and quickly.
Dr. Kitchens is a vitreoretinal surgeon with Retina Associates of Kentucky in Lexington.
The conversion conundrum
It’s easy to fall into the trap of thinking that age-related macular degeneration (AMD) starts dry and then fully converts to wet. However, even once neovascularization occurs, some dry macular degeneration will remain.
Practically, this means that even if you administer the perfect wet AMD treatment regimen, your patients adhere to it fully, and they see improvements in their vision, there’s no guarantee that they’ll be able to keep it.
As Dr. Kitchens explains, there are some patients who initially respond well to wet AMD treatments but still lose their vision. The cause of these changes? As the following case study demonstrates, GA can progress incredibly quickly.
Rapid GA progression case report
A 78-year-old male patient presented to the clinic in the fall of 2023, having been diagnosed with dry AMD OU. The patient’s initial visual acuity (VA) was 20/50 OU. Although the optical coherence tomography (OCT) scans highlighted some areas of concern—including epiretinal membranes OU, lumpy retinal pigment epithelia (RPE), and suspicious intraretinal defects—the patient was asymptomatic.
Dr. Kitchens’ team decided the patient’s presentation warranted close observation, and a 3-month follow-up appointment was scheduled, at which no major changes were observed. As a result, another observational follow-up was arranged, this time 6 months later.
Figure 1: Initial presentation (left) and 3-month follow-up (right).
Figure 1: Courtesy of John W. Kitchens, MD.
However, before this, the patient contacted the practice, having experienced decreased vision in both eyes. Although the imaging of the left eye seemed similar to its 3-month appearance, the right eye had active choroidal neovascularization (CNV), increasing intraretinal fluid, and a disruption of the outer retina.
Figure 2: Note the active CNV, increasing intraretinal fluid, and a disruption of the outer retina in the right eye on the third visit.
Figure 2: Courtesy of John W. Kitchens, MD.
Wet AMD management
The patient was put on aflibercept 8mg OD. Although there are many capable anti-vascular endothelial growth factor (VEGF) agents available, Dr. Kitchens finds the next-generation agents, namely aflibercept and faricimab, work better than other options—with aflibercept in particular resulting in better anatomy.
Here, using a higher dose offered extended durability, with the patient being extended to 8 weeks. Despite initially responding well, at the start of 2025, while still under treatment in his right eye, the patient began to experience conversion to exudative AMD in his left eye.
Because of this, Dr. Kitchens shifted the treatment regimen to bilateral administration and, 8 weeks after the first treatment, the patient’s intraretinal edema had resolved, and his RPE elevations had flattened out. However, even with these positive anatomical changes, the patient’s VA had dropped.
Figure 3: While being treated with aflibercept 8mg OD, the patient converted to exudative AMD OS, prompting a shift to bilateral administration.
Figure 3: Courtesy of John W. Kitchens, MD.
By comparing OCT scans across the patient’s various appointments and using the sub-RPE slab within the advanced RPE analysis, Dr. Kitchens confirmed the presence of subfoveal GA and quantified the density and progression of the atrophic changes over time.
This analysis showed that in less than a year, the patient had progressed from having only a marginal amount of subfoveal atrophy OD and focal atrophy OS to having large areas of dense subfoveal atrophy OU, with these changes corresponding to the decline in visual acuity to 20/150.
Figures 4a and 4b: The sub-RPE slab showing progression of subfoveal atrophy OD and focal atrophy OS (top, both sides, taken 7/24/24) to dense subfoveal atrophy OU (bottom, both sides, taken 6/30/25).
Figure 4a: Courtesy of John W. Kitchens, MD.
Figure 4b: Courtesy of John W. Kitchens, MD.
The sub-RPE slab is a useful tool Dr. Kitchens uses for patient education and explaining why changes to treatment regimens are warranted—in this case, administering complement system inhibitors to slow further GA progression.
Hindsight is 20/20
For Dr. Kitchens, as such a fast-progressing case, this is one that left him looking back to see whether a different approach could have preserved more of this patient’s vision. Although there has been longstanding discussion surrounding whether anti-VEGF therapies precipitate GA, dating back to the results of both the CATT and HARBOR studies,1,2 this isn’t a theory Dr. Kitchens has particularly bought into.
Additionally, he explains that it’s also hard to initiate both wet AMD and GA treatment at the same time—and the rapid onset and progression of GA in this patient obscured the need to have a conversation about GA therapy when the anti-VEGF modality was employed.
Though unfortunate, it’s likely that, at present, the outcome that this patient experienced was inevitable—but Dr. Kitchens notes that there was still preservation of vision and that, while not perfect, the outcome wasn’t bad.
This is especially true when compared to an untreated GA patient who, over 3 years, would have progressed to encompassing the entire circle. As he says, there are still benefits of 20/150 vision compared to 20/800 vision; and these shouldn’t be undersold.
Emerging data and significant studies
But there are new potential considerations on the horizon. Dr. Epshtein highlights emerging data from the Archway study showing that a multipronged approach using a sustained port delivery system (PDS), which enables patients to receive continuous anti-VEGF while also offering them the time needed for monthly GA injections, may result in less atrophy.3
Dr. Kitchens, who recently presented the 5-year data from this patient cohort, also agrees that this approach may have promise. “With the Archway study, patients who received PDS maintained their vision better—they lost around 7.5 letters on average rather than the 2.5 to 3.5 lines that they may have lost otherwise,” he explains. “The patients that actually dragged those numbers down the most were atrophy patients.
In the 5-year extension study, it looks like the patient cohort who may not have developed GA in the Archway study may have started to develop it, alongside those previously. But in every one of the patients who lost three or six lines, it was because of atrophy.”
In conclusion
Both eyecare professionals agree that, as a relentless and unpredictable condition that can progress at different rates at different times, the key to effectively managing GA is picking up atrophy before it progresses—and that means being aware that, even when you’re effectively controlling a patient’s wet AMD, you need to be on the lookout for GA.
