A Review of Current and Future Management of Geographic Atrophy

Abstract

Age-related macular degeneration (AMD) is a multifactorial disease and a leading cause of vision impairment in elderly people in Western society. Geographic atrophy (GA), the late stage of dry AMD, is typically defined as a round or oval area of atrophy of 175 µm or more. In GA patients, visual acuity (VA) can still be good if the macula is spared, but decreased if GA extends through the fovea causing a great impairment of quality of life. Because of a poor correlation between VA and GA lesions or progression, a multimodal imaging approach is necessary to better follow up GA patients. In the last years, the introduction in clinical practice of new non-invasive tools such as fundus autofluorescence, structural optical coherence tomography (OCT) and OCT angiography helped the ophthalmologists to better understand the natural course of GA patients. However, several pathways concerning the pathogenesis of the disease are not completely clarified yet and should be investigated further. Although no approved therapy exists for GA, healthy lifestyle and nutritional intervention with some specific supplementations (e.g., vitamins C and E, beta-carotene, high dietary folate) may help to prevent the onset and to delay the progression of the disease. At the same time, several drugs are under evaluation in clinical trials with interesting results. These drugs try to stop several pathways implicated in the pathogenesis of GA, but probably only a few of these will prove truly effective, confirming the preliminary results, and will be available in clinical practice.

Keywords: Age-related macular degeneration; Antiinflammatory drugs; Dry-AMD; Geographic atrophy; Management; Neuroprotection; Nutritional supplements; Stem cell-based therapy; Vasodilators.

Fig. 1

Multimodal imaging of a patient affected by geographic atrophy (GA). Multicolor imaging (a) and fundus autofluorescence (b) showing the area affected by GA. c Combined infrared reflectance and structural optical coherence tomography (OCT) horizontal B-scan passing through the fovea showing the loss of photoreceptors, ellipsoid zone and retinal pigment epithelium/Bruch’s complex with a backscattering effect in the area affected by GA. Choriocapillaris segmentation on 6 × 6 OCT-angiography (d), corresponding en-face OCT (e) and B-scan with flow (f) showing the loss of choriocapillaris flow in the area affected by GA