The treatment of geographic atrophy (GA), an advanced form of age-related macular degeneration (AMD), presents unique challenges in ophthalmology, particularly with the introduction of intravitreal injections. Appropriate patient selection, patient education, and safety protocols are essential for ensuring optimal care and maximizing patient outcomes.¹

Identifying the Right Candidates for Treatment

Candidates for GA intravitreal treatment can be categorized based on phenotype and imaging biomarkers.

From a phenotypic perspective, ideal candidates are at high risk of vision loss due to progressive atrophy, but still have functional vision. This category often includes patients with advanced subfoveal GA in one eye and a lesion encroaching on the fovea in the fellow eye.

Imaging biomarkers also play a critical role in identifying patients who may benefit from intravitreal treatment. The following high-risk characteristics in optical coherence tomography (OCT) and fundus autofluorescence (FAF) help determine eligibility:

OCT Features:²

• Hyperreflective foci: Small, hyperreflective deposits above the retinal pigment epithelium (RPE) indicate ongoing degeneration and a higher risk of GA expansion.
• Hyporeflective drusen cores: Hyporeflective spaces within drusen, drusenoid deposits, or both may increase the risk of progression to GA.
• RPE atrophy: Loss of RPE with choroidal hypertransmission signals faster progression.
• Ellipsoid zone disruption: Breakdown of photoreceptor integrity correlates with worsening GA.
• Reticular pseudodrusen: These markers are associated with an increased risk of atrophy development.
• Increased choroidal hypertransmission: This sign of underlying RPE loss can predict GA growth.
• Decreased choroidal thickness: Some evidence suggests that thinner choroids have a greater risk of progression to GA, though the mechanism remains unclear.

FAF Features:

• Hyperautofluorescent borders (“Ring of Fire”): Surrounding zones of increased FAF signal indicate metabolically stressed RPE, a precursor to GA expansion.
• Diffuse or band-like hyperautofluorescence: Patterns such as diffuse trickling or banded FAF are linked to more rapid progression.
• Focal loss of autofluorescence: This marker represents existing GA, but edges with adjacent hyperautofluorescence suggest active spread.
• Patchy FAF changes in the fellow eye: These changes are often a sign of bilateral involvement and progression.

Effective Patient Conversations

Patient engagement and education are key to managing GA and ensuring adherence to treatment. These discussions should:

• Set realistic expectations: Emphasize that treatment aims to slow progression rather than improve vision. Patients may struggle to grasp this concept initially, so providing educational materials and scheduling a follow-up visit before treatment initiation may improve understanding and workflow efficiency.
• Stress the importance of compliance: Adherence to the treatment schedule is essential for maximizing therapeutic benefits.

Mitigating Safety Concerns: Retinal Vasculitis, Endophthalmitis, and Inflammation

Safety remains a top priority when administering intravitreal injections, particularly due to the risks of retinal vasculitis and intraocular inflammation. Best practices include:

• Strict sterile techniques: Ensuring aseptic conditions during injections reduces the risk of infection and inflammatory responses. 
• Patient screening: Identifying a history of uveitis, autoimmune conditions, immunocompromising conditions, or prior adverse reactions to injections helps tailor treatment plans.
• Close monitoring: Postinjection follow-ups allow early detection of inflammation or vascular complications. Patients should be educated on symptoms such as sudden vision changes, pain, or increased floaters and advised to report them immediately.
• Training office staff: It is vital that staff promptly notify the physician of any patient complaints postinjection.

Conclusion

A well-coordinated approach—proper patient selection, patient education, and stringent safety measures—enhances the management of GA with intravitreal injections. By fostering a patient-centered environment, ophthalmology practices can improve treatment adherence and enhance the quality of life for those affected by this progressive disease.

References:

1. Bakri SJ, Bektas M, Sharp D, Luo R, Sarda SP, Khan S. Geographic atrophy: mechanism of disease, pathophysiology, and role of the complement system. J Manag Care Spec Pharm. 2023 May;29(5-a Suppl):S2–S11. doi:10.18553/jmcp.2023.29.5-a.s2
2. Vallino V, Berni A, Coletto A, et al. Structural OCT and OCT angiography biomarkers associated with the development and progression of geographic atrophy in AMD. Graefes Arch Clin Exp Ophthalmol. 2024 Nov;262(11):3421-3436. doi:10.1007/s00417-024-06497-8

Harit Bhatt, MD, MBA, FACS, FASRS is a board-certified ophthalmologist and vitreoretinal surgeon in Illinois.