Geographic Atrophy: Diagnosis & Management for Eye Doctors | 2026 Update
Geographic atrophy (GA) represents a significant challenge in age-related macular degeneration (AMD) management, and increasingly, careful screening and timely intervention are becoming crucial for preserving vision. While treatments for the “wet” form of AMD have been available for decades, only recently have therapies emerged to slow the progression of GA, the more common, dry form of the disease. This shift necessitates a heightened awareness among all eye care professionals to identify patients who may benefit from these modern options.
GA is characterized by the slow, progressive loss of central vision due to the degeneration of the retinal pigment epithelium and underlying photoreceptors. Unlike the sudden vision loss often associated with wet AMD, GA progresses gradually, often going unnoticed by patients in its early stages. This insidious nature underscores the importance of routine eye examinations, particularly for individuals with risk factors for AMD, such as age over 65 and a history of smoking. Recent discussions among specialists highlight the evolving landscape of GA management and the need for comprehensive approaches.
Understanding the Diagnostic Landscape
Diagnosing GA requires a careful examination of the macula, the central part of the retina responsible for sharp, detailed vision. While fundus examination can reveal drusen and pigmentary changes suggestive of early AMD, identifying GA often requires more advanced imaging techniques. Fundus autofluorescence (FAF) imaging is particularly valuable, as it highlights areas of reduced autofluorescence corresponding to areas of retinal pigment epithelium loss. Spectral-domain optical coherence tomography (SD-OCT) provides detailed cross-sectional images of the retina, revealing changes in the outer retinal layers, including loss of the retinal pigment epithelium, ellipsoid zone atrophy, and photoreceptor loss. Advances in OCT technology, such as home-based devices, are also emerging, potentially expanding access to early detection.
Although, access to these advanced imaging modalities isn’t universal. For practices without SD-OCT, a high index of suspicion and timely referral to a retina specialist are essential when GA is suspected. Patients with confluent drusen and significant areas of hypo- and hyperpigmentation are at higher risk, as are those with reticular pseudodrusen, best diagnosed using SD-OCT. The presence of these features should prompt further investigation.
New Treatment Options and Their Implications
The approval of Syfovre (pegcetacoplan injection, Apellis) and Izervay (avacincaptad pegol intravitreal solution, Astellas) marks a turning point in GA management. These complement inhibitor therapies, administered via intravitreal injection, can delay the progression of the disease by 15% to 30%. While this may seem modest, it can translate to a significant preservation of vision over time, potentially delaying the onset of driving difficulties and legal blindness. The average loss of retina and pigment epithelium in untreated GA is just under 2 mm2 per year, and slowing this rate can have a substantial impact on a patient’s quality of life. Recent research emphasizes the clinical relevance of monitoring the ellipsoid zone as an endpoint in GA trials, further refining our understanding of treatment response.
It’s important to note that these therapies are not without potential risks. Like anti-VEGF injections used for wet AMD, intravitreal injections carry a small risk of infection and retinal detachment. A unique complication associated with complement inhibition is the potential development of wet AMD with choroidal neovascularization. Long-term monitoring is crucial to detect and manage any adverse events.
GA and the Broader AMD Picture
GA often occurs bilaterally, but it is typically asymmetric, meaning one eye is affected more severely than the other. Patients with significant vision loss in one eye are often highly motivated to treat their better eye to preserve functional vision. The severity of GA tends to increase with age, with most cases presenting after age 65. Fortunately, Medicare currently covers intravitreal complement inhibition therapy for confirmed GA, making it accessible to many eligible patients.
Interestingly, GA shares similarities with primary open-angle glaucoma (POAG) in terms of its slow, progressive nature and the irreversible loss of retinal cells. Just as with POAG, early detection and intervention are critical to maximizing the potential benefit of treatment. Comprehensive eye care professionals must prioritize regular screening for both conditions, educating patients about their risks and the importance of adherence to treatment plans.
What’s Next in GA Management?
The field of GA research is rapidly evolving. Ongoing clinical trials are investigating novel therapeutic approaches, including gene therapy and stem cell therapy. Researchers are also working to identify biomarkers that can predict which patients are most likely to respond to treatment. Efforts are underway to develop more sensitive and accurate diagnostic tools for early detection of GA. The development of artificial intelligence-powered diagnostic tools, like the Scanly home OCT device, could play a significant role in expanding access to early detection and monitoring.
The emergence of effective treatments for GA represents a major advance in AMD management. However, realizing the full potential of these therapies requires a concerted effort to raise awareness among eye care professionals, improve diagnostic capabilities, and ensure timely access to treatment for all eligible patients. The key takeaway is that proactive screening and early intervention are now essential components of comprehensive AMD care.
Richard L. Lindstrom, MD, can be reached at [email protected].