My Step-by-Step Geographic Atrophy Referral Protocol w/ Downloadable Referral Form

As a retina specialist, one of the most important partnerships I have is with optometrists. Together, we are often the first line in recognizing and monitoring patients at risk for geographic atrophy (GA) and ensuring that they get timely care. With new therapies finally available, the way we think about referrals and co-management has changed.

As a retina specialist who co-manages closely with my optometric colleagues, I would like to share what has optimized our approach to collaborative care, along with key considerations when it comes to determining when to make that initial referral for patients with intermediate age-related macular degeneration (AMD) or GA.

Key clinical findings that warrant referral

When evaluating patients, I tend to divide findings into two categories: high-risk intermediate AMD and established GA. Both groups benefit from referral, though for different reasons.

Intermediate AMD patients at high risk include those with:

Large hollow pigment epithelial detachments
A high number and volume of drusen
Reticular pseudodrusen (subretinal deposits above the retinal pigment epithelium [RPE], often in a reticular pattern along the arcades, seen clearly on OCT)

These patients have a very high risk of developing GA. In addition, smoking history remains a critical risk factor. Even if patients quit, their risk remains elevated, so counseling and referral are essential.

Geographic atrophy patients should also be referred, as delaying referral risks missing the window to preserve vision and independence.

Diagnostic tools for identifying GA

For many of the optometrists we collaborate with, we have found that there are critical diagnostic tools and investments that have enhanced the ability to detect GA early on.

Specifically, it is imperative to never skip a baseline FAF and OCT in patients with AMD, as these tools are indispensable and sensitive for early detection, as shown below:

Fundus autofluorescence (FAF): Provides a topographic overview of the macula. Specifically, dark areas tend to be highly suspicious of GA.
Optical coherence tomography (OCT): Offers direct visualization of photoreceptor and RPE integrity. Areas of outer retinal atrophy or bright underlying signals in the choroid below the retina indicate precursor lesions or GA.

Taking a proactive approach to referral

In my opinion, for the patients described above, it is never too early to refer to a retina specialist. If a retina specialist feels the patient doesn’t need close monitoring, they can easily send them back, but at least the patient is now “plugged in.” This serves to alleviate patient nervousness for future visits as well as reiterating the collaborative nature of care between providers.

Not every patient will be treated right away—particularly those with advanced lesions and severe vision loss—but specialists will want to monitor closely. For example, we may not treat an eye with count-fingers vision, but we’ll watch the fellow eye with intermediate AMD carefully, in conjunction with the optometrist.

For high-risk intermediate AMD, we generally schedule annual visits, both with our practice and the referring OD's practice, to co-monitor for changes in both structure and function as it relates to the retina and vision.

Download the Geographic Atrophy Referral Form here!

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Geographic Atrophy Referral Form

Use this referral form template to ensure timely diagnosis and co-management emphasizing collaboration between optometrists and retina specialists.

The geographic atrophy co-management triad

Historically, patients with GA often did not grasp the importance of follow-up because no treatment existed. We have not had a treatment until the last few years, but now that treatments are available that can preserve vision and protect healthy retinal cells, referring sooner rather than later is paramount.

Emphasize that GA is irreversible and progressive; this framing increases patient motivation to follow through with seeing a retina specialist to determine the best timing and course for treatment.

Therefore, counseling is a key part of the referral process. Co-management works best when the ophthalmologist, optometrist, and patient form a triad with aligned messaging. Patients need to hear consistent messaging multiple times to truly absorb it. By mirroring each other’s counseling, we help ensure patients stay motivated and engaged.

One challenge is when patients hear conflicting information from different providers. To ensure consistent messaging regarding treatment goals, timelines, process, and outcomes, we actively encourage the optometrists we work with to connect with us on an individual basis or through continuing education (CE) events so we can align on "scripts" and "best practices" as it relates to patient counseling and education specific to our approach.

Staying up-to-date on GA

In order to provide the most accessible and accurate information to patients, it is critical to stay informed and educated on the latest research and advancements in GA diagnosis and treatment.

Some great educational resources for ODs that are looking to expand their knowledge of GA and treatments, or those who are looking to start managing retinal conditions, include:

Peer-reviewed reviews on GA and early OCT diagnosis are excellent
Patient-facing resources and podcasts are emerging and will be useful for co-management
Podcasts and videos

Top tips when it comes to patient education

The importance of patient education for those with GA is critical as it relates to their patient journey from diagnosis to potential treatment. Remember, this condition is sight-threatening, and many of these patients will experience visual changes that meaningfully impact their lives.

Additionally, many patients have never heard of GA. Therefore, it is vital to help them understand the disease by explaining in a way that allows them to visualize its progression and impact, while also offering compassion and providing hope.

To do this, utilize:

Educational handouts: Astellas has created an excellent resource showing GA lesions alongside simulated patient vision, including driving scene images that illustrate the progression of GA and subsequent vision loss.
Statistics: Inform the patient that GA can involve central vision within 18 months to 2.5 years after diagnosis—a very short timeframe in terms of maintaining independence. Sometimes, we find that this is helpful in allowing them to understand the urgency of referral and potential treatment.
Imaging: A picture is worth a thousand words. Show patients their own OCT or FAF images. If not available, use examples (from resources like the above link from Astellas) to illustrate where they are now and where the disease may go without treatment.

Resources on geographic atrophy

For ODs:

For patients:

Don't forget to check out the Geographic Atrophy Referral Form!

What makes a high-quality referral

We have had great success by keeping our referral process simple. Referrals don’t need to be complicated.

At minimum:

Contact the office and justify the reason for referral—whether high-risk for GA or GA progression—the retina specialist will know what to do from there
Supply the patient with contact information
Provide a working diagnosis
Share any relevant imaging if possible

However, a little extra detail goes a long way. If the patient is fearful about losing their ability to read or drive, note that. If you send imaging, it allows us to have a more informed conversation. When patients hear that “your doctor is very concerned and has provided us with a thorough history and images,” it increases trust and buy-in.

Building connections

Of course, at their core, referrals depend on established working relationships between optometrists and ophthalmologists. Retina specialists are often busy, and so it can be hard to get that communication initiated.

However, remember that we all as eyecare professionals share the mission of preventing vision loss, and we, as retina specialists, fully grasp the necessity and value of co-management with our optometric and ophthalmologic colleagues.

For building relationships:

Attend CE events hosted by retina practices, as these are an excellent venue to connect with specialists and colleagues. Our office regularly provides classes/workshops.
Reach out to fellow optometry mentors or peers who frequently refer and ask which retina specialists they have found most open to collaboration.
Contact directly with a retina specialist for advice—a simple text to discuss a case can start a strong working relationship.

The GA treatment landscape and optimizing patient outcomes

It's an exciting time. As a practicing retina specialist for the past 8 years, I didn't anticipate we would have two treatments available at this point, as there had been so many prior failures. After decades of research, there are two FDA-approved drugs for the treatment of geographic atrophy: Izervay and Syfovre. And while they don’t reverse GA or stop it completely, they do meaningfully slow disease progression.

Each has a different safety and efficacy profile, and treatment selection by the retina specialist can be based on many factors. Not every patient with GA is an ideal candidate for treatment—those with large central lesions and very poor vision may not benefit. But for most others, even with acuity as low as 20/200 or 20/400, treatment may be worthwhile.

Beyond these available treatments, multiple clinical trials are underway for potentially more effective therapies. There is more hope now than ever before that we will be able to better preserve and hopefully someday restore visual function in patients with advanced AMD.

In closing

My advice: cast a wide net. It’s better to refer a patient who turns out not to be a candidate than to miss one who is.

The future of GA management is bright. With optometrists on the front line, our ability to co-manage effectively will determine how many patients can maintain independence and quality of life.