BACKGROUND
Geographic atrophy (GA) secondary to age-related macular degeneration (AMD) is a leading cause of irreversible central vision loss, with prevalence increasing globally. Until 2023, no treatments existed for GA, but the recent FDA approval of intravitreal complement inhibitors (e.g., avacincaptad pegol and pegcetacoplan) has shifted the management landscape. Because these treatments only slow GA progression, early detection is critical to preserve vision. This paper presents consensus guidelines developed by an expert panel of eye care providers (ECPs) to standardize the identification, diagnosis, and management of GA.
METHODS
The panel consisted of 11 expert ECPs: three optometrists, four comprehensive ophthalmologists, and four retina specialists. A modified Delphi method was used: an initial online survey gathered information on unmet needs in GA care, followed by a synchronous virtual meeting to achieve consensus on topics including imaging modalities, referral strategies, and disease management. Survey responses were measured on a Likert scale, and the meeting facilitated discussion and agreement on best practices.
KEY RESULTS
There was unanimous agreement among all ECPs on several key points. First, there is currently no standardized process for GA identification and diagnosis, representing a significant unmet need. Second, early identification and proper diagnosis are paramount for optimal patient outcomes. Panelists agreed that anterior segment specialists should be able to identify GA to manage patient expectations after cataract surgery, as it may increase the risk of AMD progression.
Regarding imaging, the panel identified OCT as the preferred method for GA identification due to its ease of use and accessibility. Key OCT features include: drusen (≥63 µm to ≥125 µm), hyperreflective foci, drusen volume, reticular pseudodrusen (subretinal drusenoid deposits), incomplete RPE and Outer Retinal Atrophy (iRORA)—a precursor lesion defined by hypertransmission into the choroid with RPE attenuation/disruption and photoreceptor degeneration—and complete RPE and Outer Retinal Atrophy (cRORA), which defines GA as a region of hypertransmission ≥250 µm with RPE attenuation/disruption of ≥250 µm, overlying photoreceptor degeneration, and no RPE tear. Fundus autofluorescence (FAF) was considered less useful for early/intermediate AMD due to lower patient tolerance and limited additional information over OCT.
For management, a care algorithm was proposed: patients with early AMD should follow up every 12 months, those with intermediate AMD every 6 months (ideally with OCT). Nonurgent referral to a retina specialist is recommended for suspected GA in one or both eyes; urgent referral is needed for suspected neovascular AMD. Treatment personalization is emphasized: avacincaptad pegol is dosed at 2 mg monthly for up to 12 months, and pegcetacoplan at 15 mg every 25–60 days. Lesion characteristics (e.g., extrafoveal lesions progress faster than foveal) influence treatment decisions. Bilateral GA occurs in up to 65% of cases, and concomitant neovascular AMD may require combined therapy. Treatment discontinuation may be warranted for severe adverse events (e.g., endophthalmitis, ischemic optic neuropathy, retinal vasculitis) or central vision loss. Overall, the panel stressed that early intervention can reduce the rate of vision loss and improve quality of life.
CLINICAL IMPLICATIONS
These consensus guidelines provide a practical framework for all ECPs to improve GA detection and management. Key recommendations include routine OCT use for screening, standardized referral pathways, and individualized treatment plans. The panel emphasizes that with current GA therapies only slowing progression, early identification is crucial to maximize benefit. The guidelines also highlight the importance of multidisciplinary collaboration among optometrists, comprehensive ophthalmologists, and retina specialists to optimize patient care.