This column is the second in a series on the comanagement relationship between optometrists and ophthalmologists when diagnosing and treating patients with geographic atrophy.

The management of geographic atrophy (GA) has changed significantly with the availability of complement inhibitor therapies.¹ As treatment options have developed, referral timing and patient preparation have become increasingly important. In many cases, the biggest barrier is not identifying GA but knowing when and how to initiate the referral process. Some referrals occur too late, after patients have experienced significant progression or functional decline. Others occur before patients fully understand the purpose of the referral or the potential treatment options. Effective referral strategies help address both challenges.

What Makes a Referral High Value?

A successful referral is not defined by the volume of clinic notes and imaging records sent to the retina specialist. Retina specialists will usually obtain their own imaging during the initial consultation, generally optical coherence tomography (OCT) and fundus autofluorescence (FAF). What can’t be reproduced as easily or efficiently is the historical context provided by the referring doctor. Symptom evolution, functional decline, and evidence of historical GA progression can be more valuable than extensive, low-quality image transfer. Increasing difficulty with reading, driving, or adapting to dim lighting can provide key insight for treatment discussions.²

Equally important is communicating the purpose of the referral clearly. Is the patient being referred to confirm the diagnosis, evaluate progression risk, or consider treatment initiation?

From the retina perspective, referrals are most effective when the patient arrives informed about their disease state and prepared for a meaningful discussion about long-term management and treatment options.

Preparing the Patient Before Referral

Preparing patients before referral may be one of the most valuable contributions the referring provider can make. Patients should understand why referral is occurring and what these therapies are designed to accomplish.

One way to frame the conversation is, “I’m concerned that your symptoms and imaging are showing signs of progression, and I think this is the right time to meet with a retina specialist while we still have an opportunity to be proactive.”

Setting expectations early may improve subsequent treatment discussions. Patients should understand that these treatments are designed to slow disease progression and preserve more healthy retina for longer, but cannot reverse prior damage or recover lost vision. Hence, earlier intervention can be beneficial in the long term.

Referral should not be presented as an emergency or catastrophic development, but rather as part of a proactive strategy to preserve vision and maintain independence.

In many cases, involving family members or caregivers early in the conversation can be extremely valuable. Long-term adherence often depends on transportation assistance, scheduling support, and positive encouragement outside the clinic.³ These considerations should factor into discussions regarding ongoing therapy.

The Continuing Role of the OD

Referral should not represent the end of the optometrist’s involvement in patient care. In many cases, the relationship between the patient and primary eye care provider remains essential after retinal treatment begins.

Optometrists continue to play a key role in reinforcing treatment expectations, monitoring functional concerns, optimizing refractive correction, managing ocular surface disease, and coordinating broader ocular care needs. Additional education and coaching may also improve long-term adherence and motivation for patients undergoing chronic injection therapy.

Offering patients the opportunity to reconnect after their retina consultation can reinforce comprehension and confidence. Patients often process treatment recommendations differently after the consultation and may benefit from additional discussion with a trusted provider already familiar with their goals and concerns from years of prior eye care.

Effective GA referral pathways depend on more than identifying disease. Earlier recognition, targeted and high-yield referral decisions, and coordinated longitudinal care all contribute to improved patient outcomes and a better overall experience. The most successful referrals do not end with a consultation. Rather, they establish the foundation for collaborative long-term management between the optometrist, retina specialist, patient, and family support system.

References

1. Liao DS, Grossi FV, El Mehdi D, et al. Complement C3 inhibitor pegcetacoplan for geographic atrophy secondary to age-related macular degeneration: a randomized phase 2 trial. Ophthalmology. 2020;127(2):186-195.
2. Fleckenstein M, Mitchell P, Freund KB, et al. The progression of geographic atrophy secondary to age-related macular degeneration. Prog Retin Eye Res. 2021;82:100910.
3. Obeid A, Gao X, Ali FS, et al. Loss to follow-up among patients with neovascular age-related macular degeneration who received intravitreal anti-vascular endothelial growth factor injections. JAMA Ophthalmol. 2018;136(11):1251-1259.
   

Damon Dierker, OD, FAAO, is the director of optometric services at Eye Surgeons of Indiana in Indianapolis.

Ankur M. Shah, MD, FASRS, is a fellowship-trained ophthalmologist and retina specialist at Retina Partners Midwest, PC at Midwest Eye Institute in Carmel, Indiana.

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