Although geographic atrophy (GA) is most often treated in a retina clinic, patients largely enter into specialized care after a referral, a paradigm that highlights the role of primary eye care providers in early detection and diagnosis. The available complement inhibitors—pegcetacoplan (Syfovre, Apellis) and avacincaptad pegol intravitreal solution (Izervay, Iveric Bio, an Astellas Company)—slow the progression of GA lesions but are not a cure. Therefore, it is imperative that the referring network has a fundamental understanding of this disease to refer patients as early as possible.
What Challenge Does the Referring Network Face?
The main challenges for referring providers are access to diagnostic imaging technologies and recognizing early GA without relying on imaging techniques. Even if treatment isn't immediately necessary, providing patients with early awareness of their condition is invaluable. Importantly, visual acuity does not necessarily correlate with the severity of GA.
Patients with advanced GA that has already encroached on the fovea may offer vague cues like “I’m having difficulties reading” or “My vision seems worse,” but might already be at a point where treatment is not as effective.
Because the currently available treatments are intended to slow lesion growth, it is crucial to detect extrafoveal lesions before they progress—and thereby preserve the remaining viable retina for visual function. It is possible, although challenging, to identify GA lesions without OCT or fundus autofluorescence imaging, but this requires a skillfully conducted 90-diopter slit-lamp exam. During this exam, areas of GA appear more hypopigmented with choroidal vessels throughout.
Educational Initiatives for the Referring Network
Patients don't require a comprehensive understanding of GA progression, treatment options, and safety concerns before their appointment with the retina specialist, as these are nuanced conversations. However, a referring provider’s GA knowledge should be sufficient to explain to the patient what they suspect is happening and to let them know that treatment options are available. Bridging the knowledge gap with the referring network involves actively engaging them, arranging meetings, and conducting seminars to educate about GA.
When engaging members of one’s referral network, it's essential to not only teach how to identify GA through imaging methods like OCT or autofluorescence, but also to clarify individual treatment preferences. A common source of confusion for referring providers is that they don’t completely understand how the retina specialists they refer to approach the treatment of GA. By openly communicating their preferences, specialists can help alleviate any misunderstandings. In my view, the underlying educational message should be: "When in doubt, send the patient over." Additionally, these interactions are an opportunity to establish a relationship between the referring community and retina specialist, which builds the foundation for collaborative patient care.
Creating a Collaborative Environment
A relationship between the community of referring providers and retina specialists that is built on mutual trust enables elevated patient care and easy lines of communication. For example, to determine if a visit is necessary, a referring doctor might send an OCT image to the retina specialist. Another way to collaborate is by alternating monitoring visits of patients who don’t need treatment yet. In this approach, the patient coordinates biannual visits with their general eye care provider and with the specialist. This strategy ensures ongoing connectivity between providers, facilitating discussions about treatments and updates without imposing excessive office visits. This consideration is particularly important for elderly patients who already consult multiple health care providers.
Conclusion
GA poses challenges for both retina specialists and referring care providers. Early detection is vital, yet referring providers may lack access to necessary diagnostic tools. Educational initiatives can bridge the knowledge gap, enhancing awareness and patient care. Establishing collaboration between specialists and referring doctors fosters effective communication and mutual trust which benefits patients. By addressing these challenges and promoting collaboration, the health care community can better serve individuals affected by GA and other retinal diseases.
