In my experience, the commonly used term “fast progressor” in the context of geographic atrophy (GA) lacks precision in clinical practice. We should instead think in terms of patients at higher risk for disease progression, not definitively measurable rates. Decision-making is based on risk stratification, not exact progression metrics, and that distinction helps guide treatment conversations.

Identifying Patients at a Higher Risk for Progression

While we cannot quantify progression rate with current tools, clinicians often rely on recognizable imaging findings and clinical features to identify patients at a higher risk of progression, including

  • bilateral disease;
  • extrafoveal involvement;
  • multifocal lesions; and
  • hyperautofluorescence on fundus autofluorescence (FAF) surrounding GA lesions.

These features increase concern for more rapid lesion growth and potential functional decline, which may guide earlier treatment discussions, even though they do not define a fixed trajectory for an individual patient.

Treatment Framing and Clinical Urgency

When speaking to patients about treatment, I reiterate that the goal is to protect their healthy retina tissue longer, potentially preserve their vision longer, and give them hope that they can continue their life independently with the vision they have for as long as possible. I remind patients that treatment will not improve their vision; it’s not going to turn back the clock. I let them know this is an ongoing treatment and, while it is a commitment, this is a worthwhile and potentially beneficial endeavor. Although it is not always imperative to begin treatment immediately, I encourage patients not to delay treatment by 6 to 12 months. Keeping patients motivated requires clear, repeated discussion about what treatment can realistically accomplish.

Management Strategy

Following a diagnosis of GA, I explain to patients that treatment requires ongoing injections and frequent visits, and we discuss any barriers that may prevent or challenge their access to treatment. Patients often need time to process their diagnosis before beginning treatment. My follow-up approach is a 3-month revisit for undecided patients and approximately 6-month follow-ups for those outright declining treatment.

I collect OCT images at every visit and FAF photos every 6 months. This imaging strategy helps identify high-risk features of disease, track structural progression, and monitor for conversion to wet AMD, particularly in treated patients. Additional management considerations I suggest to high-risk patients include the continued use of AREDS vitamins and a discussion of clinical trial options when appropriate.

Expectations and
Visualization of Risk

The expectation versus the reality of GA treatment can remain challenging for some patients to accept. When identifying higher-risk patients, I find it helpful to revisit treatment goals at follow-up visits every 3 to 6 months. I reinforce that visual stability and an absence of adverse events equals success. Use of patients’ FAF images is my preferred communication tool because it helps visually demonstrate atrophy and disease extent. Not only does this method improve understanding for patients and family members, but it also makes the risk of progression more tangible than an abstract discussion.

Final Clinical Pearls

In my experience, a core issue surrounding GA is that so much is missed. Often, GA is misdiagnosed or labeled as early AMD. Recently, a patient referred to me was diagnosed as having early AMD when they really had wet AMD OU and GA in both eyes. My diagnostic recommendations for identifying GA are to use OCT to evaluate the full macula, including above and below the foveal avascular zone; identify complete retinal pigment epithelium and outer retina atrophy (cRORA) and atrophic changes; and incorporate FAF photos frequently.

I encourage clinicians to avoid relying on one method of examination. Conduct a careful evaluation, spend time studying patient imaging, and ask patients questions about their vision. Find out if they have symptoms even if they have good vision, including difficulty with dim lighting, reading, and driving. A color photo is not adequate on its own. My biggest pearl is that active detection is essential; clinicians can miss GA if they are not specifically looking for it.