Damon Dierker, OD, FAAO, the director of optometric services at Eye Surgeons of Indiana, and Ankur Shah, MD, FASRS, a retina specialist at Retina Partners Midwest at the Midwest Eye Institute in Indianapolis, discuss effective shared-care models currently in use. These models include routine monitoring, co-management of comorbid dry age-related macular degeneration (AMD), and patient education regarding disease progression.
Patient Expectations for GA Treatment
Treatments that use complement inhibitors slow the progression of geographic atrophy (GA). Some patients with a history of wet AMD may mistakenly believe these injections will improve their vision, as previous injections for wet AMD may have done so. Dr. Shah states that it’s important for patients to understand that these injections do not completely stop disease progression, reverse preexisting damage, or enhance vision.
The goal of GA treatment is stability. Providers should emphasize that until about three years ago, no treatment was available for GA, but now there are options to slow disease progression. It requires a long-term commitment to regular injections, as stopping after just one to three injections is unlikely to provide long-term benefits.
The Role of Primary Eye Care in Co-Management
The collaborative relationship is a team effort, not a simple "handoff." Dr. Shah confirms that patients should absolutely continue to see their primary eye care provider (optometrist or general ophthalmologist). While the retina specialist monitors for conversion to wet AMD with imaging at every visit, they typically do not dilate the patient at every appointment.
Patients with GA are often older and have other ocular diseases such as cataracts, glaucoma/glaucoma suspect status, and severe dry eye, which require attention that the retina specialist may not fully focus on. The primary eye care provider is responsible for:
- Monitoring optic nerve changes
- Managing ocular surface disease
- Performing refractive corrections to optimize vision
- Making referrals for low vision services
The Importance of Multimodal Imaging in Diagnosis
Dr. Dierker shared a patient case in which multimodal imaging was crucial for diagnosis.
Case Review
A 77-year-old male patient visited the clinic with blurred vision in both eyes. He was told he might be in the early stages of AMD, and his last eye exam was a year prior. His ocular history included cataract surgery in 2019. His best corrected vision was 20/25, and his initial OCT results were significant but failed to highlight the extent of the retina changes (see Figure 1).
Figure 1. Patient’s initial OCT OD/OS
However, multimodal imaging (Figure 2), including fundus autofluorescence, revealed multiple large parafoveal and juxtafoveal lesions with hyperautofluorescent borders, confirming progressive GA as the source of the patient's blurry vision.
Figure 2. AF OD/OS
Dr. Dierker noted that if you do not "dig deeper" with imaging in a patient who reports blurry vision, you could miss progressing GA.
Addressing Misconceptions about Cataract Surgery and GA
A common misconception among patients is that their GA worsened after cataract surgery. It’s important for providers to explain that GA is a slowly progressive disease that began years earlier, and its progression might simply appear coincidental with the timing of the surgery. To minimize the risk of infection, it is advisable to avoid administering intravitreal injections, including complement inhibitors, for at least 1 week after surgery.
Patient Education Following Referral
A patient-centered approach is crucial in collaborative care. Primary eye care providers can add substantial value by continuously educating patients, emphasizing the importance of ongoing injections, and keeping patients motivated and confident in their treatment. Using imaging to show the slow progression rate compared to the expected natural history can help reinforce that the retina specialist's treatment is effective.
