While there is no established treatment currently available for dry age- related macular degeneration (AMD), we now have treatments in Australia for geographic atrophy (GA). Optometrists, as primary eye health providers, play a crucial role in the diagnosis of patients with these two diseases, providing them with education, support, and ongoing monitoring under shared care relationships with ophthalmology.

To prepare this CPD article, optometrist Tina Huynh interviewed Associate Professor Anthony Kwan, an academic retinal specialist from the Queensland Eye Institute in Brisbane, about recognising AMD and early GA on imaging, when and how to refer for complement inhibitor treatment, and how to explain benefits, risks, cost, and long-term commitment to patients.

WRITERS Associ ate Professor Anthony Kwan and Tina Huynh

DIAGNOSING DRY AGE-RELATED MACULAR DEGENERATION IN PRACTICE Q. In an optometry practice with a retinal camera and optical coherence tomography (OCT), what are the key features that assist in the diagnosis of dry age-related macular degeneration (AMD)?

On colour fundus photos, dry AMD starts with drusen and subtle pigment changes at the macula – small yellow deposits and areas of mottling under the retina before any obvious scar appears. Larger, soft, confluent drusen and clusters, especially with retinal pigment epithelium (RPE) hyper- and hypopigmentation, signal intermediate disease and a higher risk of progression to late AMD, including GA.

On OCT, look for elevation and thickening of the RPE from drusen, disruption of the ellipsoid zone, and any early outer retinal and RPE thinning that suggests nascent atrophy. Reticular pseudodrusen (subretinal drusenoid deposits) are important risk markers, as they are associated with faster progression to advanced AMD, including GA. autofluorescence (FAF), where available, acts like a ‘heat map’ – areas of mixed increased and decreased autofluorescence around drusen or early atrophy often mark zones where GA will later expand.

Fundus

One way to explain this to patients: “Dry AMD is a bit like rust developing under

Early GA often

LEARNING OBJECTIVES On completion of this CPD activity, participants should: 1. Be able to identify key clinical and imaging signs of dry AMD and GA and know when ophthalmology referral is indicated, 2. Understand how intravitreal complement inhibitors work, who benefits most, and what trial data show, 3. Be able to clearly set expectations, support adherence, and involve patients in shared decisions, and 4. Implement a shared care model for monitoring, co-managing risk factors, coordinating referrals, and supporting vision rehabilitation when needed.

AREDS2 Low Zinc Target

Pegcetacoplan (Syfovre) Complement C3 inhibitor. Intravitreal; monthly or every other month in trials and on label. OAKS and DERBY phase 3 plus GALE extension. ~16–21% at 12 months; ~19–22% at 24 months vs sham, higher in non-subfoveal GA and with longer follow up. FDA-approved 2023; TGA registered in Australia for the second eye GA secondary to AMD.

Table 1. Key features of the two agents (Note: there is no head-to-head study between the molecules, this is for illustrative purposes only).

Administration (TGA) in Australia for GA secondary to AMD. These agents do not restore lost tissue or, on average, improve visual acuity, but they consistently slow the rate of GA lesion enlargement compared with sham injections in Phase 3 trials.

IDEAL CANDIDATES AND MECHANISM OF COMPLEMENT INHIBITORS Q. In an ideal world, who would be the best candidate for complement inhibitors to slow the progression of GA, and what is the mechanism of action?

One way to explain this to patients: “None of today’s treatments can ‘re-grow’ the damaged cells, but they can slow the disease marching further into your central vision”, or, if using the lawn analogy, “they can stop a bare patch of grass spreading to destroy the whole lawn –

Complement inhibitors target an overactive component of innate immunity, the complement cascade, which plays a major

In OAKS and DERBY, monthly or every- other-month pegcetacoplan reduced GA growth by roughly 16–21% at 12 months and

about 19–22% at 24 months versus sham, with greater effects in non-subfoveal lesions and over longer follow up. and GATHER2, monthly avacincaptad pegol reduced GA expansion by around 18–35% at 12 months, depending on lesion location and analysis, with benefits sustained over two years. Extension and emerging real-world data suggest that benefit accrues over time, at the cost of ongoing regular intravitreal injections. It is important to remember that there is currently no head-to-head trial between the two molecules. Additionally, the main trials of the two molecules have different inclusion and exclusion criteria, hence their data cannot be compared directly, but for the convenience of an overview, please see Table 1.

The archetypal candidate is an older adult with GA secondary to AMD, sufficiently preserved visual acuity to gain from preserving function, and lesions that threaten, but have not yet destroyed the fovea – especially extrafoveal or juxtafoveal GA where preserving central vision is most realistic. They must be motivated, able to attend monthly or every-other-month injections long-term, and willing to accept a higher risk of conversion to neovascular AMD and injection-related complications compared with observation alone. need to comprehend that these treatments will not improve their vision, unlike the anti-VEGF treatments for wet AMD.

Most crucially, they

A metaphor for the mechanism: “Think of complement as an over-sensitive security system. In GA, the alarm keeps going off, and the sprinklers soak healthy rooms along with the damaged ones. These drugs dial the system down, so it still works but doesn’t flood the whole floor every time.”

WHEN TO REFER AND WHAT TO INCLUDE Q. When should optometrists refer patients for consideration of complement inhibitor treatment, and what three important details should be included in the referral?

Updated RANZCO (Royal Australian and New Zealand College of Ophthalmologists) and Optometry Australia pathways encourage optometrists to identify patients with GA or nGA and discuss potential treatment options as therapies become available. is generally appropriate when you detect definite GA lesions (particularly extrafoveal or juxtafoveal) in a patient with meaningful functional vision, or when GA is progressing towards the fovea on serial imaging.

Clear clinical description and staging. Best-corrected visual acuity, AMD stage in each eye, GA location and approximate size (e.g. disc diameter or square millimetres if available), and symptoms such as scotomas or reading difficulty.

lies in losing vision more slowly – shifting the conversation from “Will I see better?” to “Will I see for longer?”.

One useful comparison for patients is between GA treatment and cholesterol tablets: “You do not feel better after each pill, but over the years, you are less likely to have a major event.” Functional assessments, such as microperimetry, suggest better preservation of retinal sensitivity near the GA border in treated eyes, reinforcing that treatment is protecting function, even when acuity is static.

“... most GA is first detected in optometry, often before symptoms are prominent” M ACU L A R D I SE A SE I SSU E

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A short phrase to use: “This treatment is about slowing the clock, not turning it back. At least, you potentially enjoy a longer period of driving ability, maintaining independence, enjoying your hobbies, and lastly, more time to prepare for changes in your vision.”

References available at mieducation.com.

EXPLAINING THE LONG-TERM TREATMENT COMMITMENT Q. What is your advice to optometrists when explaining the long-term treatment commitment associated with complement inhibitor therapy?

Patients need to understand from the outset that current regimens involve injections into the eye every month or every second month, and that most benefit appears to accrue with continuous, long-term treatment rather than short ‘bursts’. Clinical and qualitative data suggest that persistence is challenging; acceptability falls when injection frequency, travel burden, and perceived benefit feel out of balance.

It can be useful to liken the regimen to regular dialysis or insulin – an ongoing treatment that keeps a chronic disease from progressing as fast as it otherwise would. Encourage practical planning: discuss who can drive them, which time of day works best, and what contingency plans exist if a caregiver is unavailable, so adherence is woven into the routine rather than relying purely on motivation.

A phrasing you can use: “To get the most out of this treatment, we need to keep topping up the medication regularly – the same way that you keep topping up fuel in a car on a long trip. Missing the odd injection happens, but stopping altogether usually means the disease goes back to its natural faster speed.

Optometrists also coordinate low-vision and rehabilitation referrals, maintain general ocular care (refractive updates, cataract co- management, dry eye), and liaise with the patient’s general practitioner about systemic risk-factor control.

A way to frame this to colleagues and patients: “Think of GA care as a relay: the optometrist spots the problem early and hands the patient to the retinal specialist for treatment, but then keeps running alongside – checking the map, watching for new warning signs, and helping ensure the patient does not drop out of the race.”

This interview was conducted at the Queensland Eye Institute, Brisbane.

The sponsor of this article is Astellas. Astellas Australia had no direct input on the answers to the questions.

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managing-dry-age-related- macular-degeneration-a-fireside chat-with-associate professor- anthony-kwan.

Associate Professor Anthony Kwan MBChB (UK) MD (London) FRCOphth (UK) FRANZCO is a vitreoretinal surgeon, retinal specialist, and the Director of Vitreoretinal Service at the Queensland Eye Institute. He is a senior staff specialist and the former Head of Ophthalmology at Mater Hospital, Brisbane. Assoc Prof Kwan teaches medical students and ophthalmic trainees at the Mater Hospital, and is a training post inspector for the Royal Australian and New Zealand College of Ophthalmologists (RANZCO). He is on the advisory board of numerous pharmaceutical companies and is an active organiser for national and international ophthalmic meetings.

Tina Huynh BAppSci (Optom) (Hons 1st) GradCertOcThera is the Clinical Operations Coordinator at Queensland Eye Institute and a practising optometrist.