The retina in focus: Expert perspectives for confident clinical decision-making

CPD hours

Optometrists: This activity may be logged as self-directed learning for 90min of your required CPD hours (dependent upon your personal learning plan).

GPs: This activity may qualify as self-directed learning for 90min of your required CPD hours (educational activities).

Our highly anticipated 2026 webinar, The retina in focus: expert perspectives for confident clinical decision-making, brought together clinicians from across the country for a clinical deep dive into contemporary retinal care. The session was designed to elevate confidence in managing retinal disease, with three of Vision Eye Institute’s leading ophthalmologists each bringing a unique perspective to the evening.

Dr Christolyn Raj opened the webinar with a practical look at IOL performance in retinal pathology, exploring how careful patient selection and lens choice can help optimise visual outcomes for patients with coexisting retinal disease.

Dr Simon Chen then shared practical analogies to help demystify retinal disease for patients, demonstrating how turning unfamiliar clinical terms into simple mental pictures can ease patient anxiety and support more informed treatment decisions.

Finally, Dr Tiger Zhou gave a comprehensive update on the latest developments in intravitreal therapy for age-related macular degeneration (ARMD) management, covering emerging agents and trial data shaping the future of treatment for both wet and dry ARMD.

The session concluded with a live panel Q&A, featuring all three presenters alongside clinical optometrists and moderators, Kristina Iacovangelo and Cindy Trieu, who guided a rich discussion of real-world clinical scenarios and drew out valuable pearls to support comprehensive, multidisciplinary patient care.

We thank our sponsors, Vision Hospital Group and Bayer, for making complimentary registration possible, and we were pleased to also hear highlights from our Enterprise Supporter partner, Sight For All, on its vision and purpose.

Presentations

IOL performance in retinal pathology: How you can help optimise your patients’ vision
Dr Christolyn Raj
Weeds, wine stains and wrinkled tissue paper: Practical analogies to help your patient understand retinal disease
Dr Simon Chen
The latest developments in intravitreal therapy in ARMD management
Dr Tiger Zhou

Key takeaways

IOL performance in retinal pathology: How you can help optimise your patients’ vision

Dr Christolyn Raj

Premium IOLs and retinal pathology

Retinal pathology is not an absolute contraindication to premium IOLs. EDOF and trifocal lenses may be suitable for carefully selected, stable patients
Patient selection and expectations are critical. Consider retinal stability, visual needs and whether increased spectacle independence will meaningfully benefit the patient.

Managing expectations

Premium IOLs don’t guarantee spectacle independence. Patients may still need glasses for reading, night driving or specific tasks
Retinal disease may further affect contrast and colour perception. This is particularly important for patients whose work or hobbies rely heavily on fine colour or contrast discrimination
Visual simulators can help set expectations. The Eye Wise app allows patients to preview potential distance, intermediate and near vision.

Matching the IOL to the retinal condition

EDOF lenses may be suitable for stable epiretinal membrane and early AMD, with selected patients achieving good functional vision and greater spectacle independence
Diabetic retinopathy requires caution. Evidence for premium IOLs is limited, and monofocal lenses may be preferable. Retinal disease should be treated and stable before surgery
Selected retinal vein occlusion patients may be suitable, particularly those with branch or hemiretinal RVO and healthy remaining retina. Macular oedema should be controlled and ischaemia assessed
AMD requires careful selection and monitoring. Avoid premium IOLs with unstable disease, scarring, significant atrophy or fluid. Reticular pseudodrusen are an important red flag.

Assessing retinal health

OCT and OCT-A can help guide IOL selection by assessing macular status and retinal ischaemia
Ongoing retinal treatment remains essential. Cataract surgery does not change the chronic nature of retinal conditions, so treatment and monitoring must continue.

IOL choice should be individualised

Retinal pathology does not automatically rule out a premium IOL. But the lens choice should be based on retinal stability, the specific pathology, visual needs and the patient’s expectations.

Weeds, wine stains and wrinkled tissue paper: Practical analogies to help your patient understand retinal disease

Dr Simon Chen

Clinical terms are unfamiliar to patients. Analogies turn abstract concepts into mental pictures, reducing anxiety and helping patients understand and engage with treatment decisions.

Dilation – the keyhole and the door: Examining an undilated retina is like peering through a keyhole into a room – you get a glimpse, but only by opening the door (i.e. dilating) is the full picture revealed
Dilation – the car and the mechanic: Refusing dilation is like refusing to let a mechanic open the bonnet to diagnose a noisy engine – you can’t properly assess what’s wrong without full access
Ageing vitreous – the egg: The vitreous is like an egg – firm/semi-boiled when young, becoming runnier and waterier with age. In older patients, the thinner/watery vitreous flows through retinal tears more readily, so detachment tends to progress faster than with the thicker, more viscous vitreous seen in younger patients
Chronic floaters – the pebble in the shoe: Floaters are usually a mild, tolerable annoyance, like a pebble in your shoe on a short walk. But they become a chronic, quality-of-life-affecting irritation when endured long-term
Myopia and retinal thinning – the balloon: A longer (myopic) eyeball stretches the retina over a larger surface area, thinning it – like a balloon’s walls thinning and becoming more fragile as it’s inflated
Gas bubble surgery – the splint: After macular hole/retinal detachment surgery, a buoyant gas bubble (positioned via face-down posturing) holds the retina in place against the macula while it heals, like a splint stabilising a broken bone
Retinal vein occlusion – home plumbing: Blood vessels are like water pipes. A blockage raises pressure until the pipe cracks and leaks (haemorrhage, exudates and macular oedema). Even after the blockage clears, the damaged pipe can still leak – explaining why chronic macular oedema often requires ongoing anti-VEGF treatment
Epiretinal membranes – tissue paper: The retina is thin and delicate like tissue paper. Scar tissue contracts and wrinkles it. Like tissue paper scrunched and released, some wrinkling persists even after the membrane is surgically peeled, though usually improved
ARMD – the carpet: Metabolic waste (drusen) builds up under the retina like debris under a carpet, causing bumps. Over time, this wear and tear can degrade the ‘carpet’, leading to geographic atrophy (threadbare, patchy areas)
Wet ARMD – burst pipe under the floorboards: As the structures beneath the retina weaken, abnormal blood vessels can grow and leak fluid or blood causing swelling and haemorrhage – like a burst pipe leaking beneath floorboards, allowing water to build up and damage the timber
Treating wet ARMD – garden lawn and weeds: Abnormal vessels are like weeds and anti-VEGF injections are like weed killer – effective at clearing them, but treatment must be reapplied
AREDS2 (Age-Related Eye Disease Study 2) supplements – sunscreen: Like sunscreen, AREDS2 antioxidants protect against further damage (slowing progression in intermediate AMD) but don’t reverse damage already done
Combined cataract and retinal surgery – F1 pit stop: Combining a vitrectomy with cataract surgery (phacovitrectomy) in one sitting is like an F1 pit stop handling multiple tasks at once
Choosing an intraocular lens – choosing a car: There’s no single ‘best’ lens, just as there’s no single best car. The right choice depends on individual lifestyle, needs and the trade-offs.

The latest developments in intravitreal therapy in ARMD management

Dr Tiger Zhou

Anti-VEGF therapy for wet AMRD

Mechanism and agents

Anti-VEGF drugs (bevacizumab, aflibercept, faricimab/Vabysmo, brolucizumab/Beovu, Eylea HD) are monoclonal antibodies that block VEGFR-1/2, reducing new vessel growth and leakage
Faricimab additionally targets angiopoietin-2. Aflibercept also inhibits placental growth factor, hence contraindicated in pregnancy

PULSAR trial (Eylea 8mg vs 2mg)

Compared 2mg 8-weekly vs 8mg 12-weekly vs 8mg 16-weekly dosing
Visual acuity outcomes were equivalent across all three arms
8mg dried the retina faster, with more patients fluid-free at 16 weeks
Injection burden was reduced: 8 injections/48 weeks (2mg) vs 6.1 (12-weekly) vs 5.2 (16-weekly), with ~78% of patients maintaining their extended interval
Safety was equivalent across arms despite the larger 8mg injection volume (70μL vs 50μL) – no difference in IOP spikes or inflammation
3-year extension data: patients switched from 2mg to 8mg caught up in outcomes; benefits and safety profile held over time, with some patients extending to 24-weekly dosing.

TENAYA/LUCERNE trials (Vabysmo/faricimab)

665 treatment-naive patients assigned to 8/12/16-weekly dosing based on a treat-and-extend protocol driven by disease activity – importantly, not randomised, so the 16-weekly group had milder disease at baseline
Take-home: patients with mild disease can be safely extended to 16-weekly dosing
Possible signal for higher (but not statistically significant) rate of low-grade inflammatory events vs aflibercept

Why treat retinal fluid?

Recent meta-analyses: >40% of anti-VEGF-treated eyes retain some fluid at 1–2 years. Median time to resolution is 10–12 weeks, with 17% never fully resolving
Longer duration of intraretinal fluid exposure is linked to worse visual outcomes, but fluid presence itself was paradoxically linked to better outcomes – likely reflects milder disease rather than a causal benefit of fluid

Emerging therapies for dry AMRD (geographic atrophy)

Pegcetacoplan (Syfovre) – OAKS/DERBY trials

Complement C3 inhibitor, monthly or bimonthly injection, ~1,250 patients over 2 years
Slowed GA progression by ~18% – effect statistically significant in OAKS but not DERBY at 1 year, maintained at 2 years
Safety concern: rare but serious cases of occlusive vasculitis, some resulting in severe vision loss. Also a risk of conversion to wet AMD.

Avacincaptad pegol (Izervay) – GATHER1/GATHER2 trials

RNA aptamer targeting complement C5
GATHER1 raised injection-volume concerns (up to 200μL, near the full anterior chamber volume) given drug viscosity
Slowed GA progression by ~19–30% across the two trials
Similar rare adverse events: conversion to wet AMD, plus injection-related risks (endophthalmitis, lens dislocation).

Availability and cost

In Australia, aflibercept 8mg and faricimab are the current mainstay agents for wet AMD
Pegcetacoplan and avacincaptad pegol are not PBS-listed and cost ~$3,500 per 8-weekly dose, limiting uptake despite clinical interest.

If you have any concerns about your patients, refer to your local ophthalmologist or hospital ophthalmology service.

Resources

Q&As

Below are the questions attendees asked on the night, answered by our presenters.

The EDOF IOLs might be OK for the early AMD patients but what happens when the AMD worsens?

The answer is assessing your patient carefully and trying to prognosticate their pathway harder to do than our patients may think. At this stage, premium IOLs have been used cautiously for patients with early AMD or AMD precursor changes (Beckman classification), or in cases of intermediate AMD that you have been following for some time and remain stable. The risk of these patients losing vision suddenly is lower, so considering these IOLs – if this helps the patient with their ADLs without compromising their vision – could be useful.

I advise patients with early AMD to move more quickly towards IOLs, because they will only get older (hopefully) and their maculae will become more delicate. Is this correct advice?

If there is a visually significant cataract and macular disease, then absolutely. We know we can improve vision post-cataract surgery. Then the IOL choice becomes important. If we aren’t sure if the macular condition is stable, then a monofocal IOL is still the best choice. If it is stable and the patient is open to newer IOLs, then this should be offered to them.

Are there any considerations of IOL choice for a patient post retinal detachment surgery, e.g. buckles, vitrectomy?

It depends on whether the patient’s macula was detached or not. If the macula was detached, then macular function will be impaired, and they would generally only be suitable for a monofocal/toric IOL – not an EDOF/multifocal IOL. If the macula was not involved and is healthy, then they could potentially have any IOL.

Do you check the vision post IOL in macula patients with a contrast chart?

In general, patients have their BCVA checked with a contrast chart pre- and post-operatively.

What happens if these retinal conditions develop 20 years after implantation? With increasing lifespan, these lenses need to be suitable for 30 years or more.

A great point, and an important part of a fully informed consent process. Ideally, patients should be advised that if they have a multifocal/EDOF lens and later develop macular pathology, then their vision may be partly compromised by that lens choice. We need to inform our patients well at the outset. Any patient can develop retinal pathology with time – this is medicine, and unfortunately we don’t have a crystal ball. But we do have the ability and tools to detect early or precursor changes to retinal disease (from general medical history/family history/OCT imaging etc). If we, or our patients, have concerns, a monofocal IOL is the best choice. The newer IOLs need to be used with care, as with any new technology. But we shouldn’t avoid offering them as an option to our patients because they may develop pathology down the track – we should avoid them in patients who have a higher risk of this.

Any comments on the Crystalens and the Trulign Toric accommodating monofocal IOLs?

Accommodating-type IOLs are, in general, considered somewhat inferior to the existing EDOFs on the market. In their maiden use approximately 10–15 years ago, they were an exciting option, but have largely fallen out of favour, with EDOFs and trifocals replacing them.

For patients who just had cataract ops, how long should they wait before they can restart their dry eye treatments, such as hot compress or IPL?

It’s recommended waiting 2 weeks before restarting hot compresses/IPL.

In fairly advanced cataract, how reliable are OCT scans in assessing pathology and deciding on IOL types?

OCT signals are often significantly attenuated in advanced cataract. Depending on the degree of signal attenuation, sometimes it is not possible to make a judgement on the state of the macula. Any other sources of information, such as previous scans or a scan of the other eye, can be helpful. If in doubt, I would explain the situation to the patient and often lean towards monofocal solutions. These patients are often very happy just to have their vision back and are not fussy about wearing glasses.

If an EDOF/multifocal IOL is inserted and then significant retinal issues develop later, where do you stand in this case?

The issue with the use of premium IOLs in this subset of patients is that, to offer patients some spectacle independence, you need to choose your patient carefully, be well aware of how much vision loss is caused by the macular condition, and be able to prognosticate their progress at the outset. If the latter cannot be done, then don’t use these IOLs.

Patients with a BRVO or a fine ERM compare more favourably than AMD, as there is still a lot of ‘healthy retina’ remaining to offer good vision. Also, in these conditions the macula is not normal but is likely to remain stable. You really don’t want to be left with the situation you describe, which is inserting such an IOL in a patient when you aren’t sure where the pathology may take you – for instance, AMD not assessed adequately, reticular pseudodrusen missed initially or an ERM with macular traction. This is usually where this scenario may occur. Premium IOLs shouldn’t be used to ‘see if you can get away with it.’

Why do we get macular membranes? What is creating it?

The large majority are secondary to anomalous posterior vitreous detachments. A minority are secondary to other eye conditions, e.g. uveitis, trauma, macular oedema.

Would doing the cataract operation and vitrectomy surgery at the same time increase the risk of developing a retinal tear/detachment later on?

Answered live during the session at 01:18:21.

Knowing a cataract will develop post-vitrectomy, would you offer cataract surgery if the cataract has yet to develop?

If the patient is young (i.e., under 50) or has significant diabetic retinopathy or is a high myope, cataracts can sometimes take many years to develop. In older patients (over 50) who are not highly myopic and don’t have advanced diabetic retinopathy, cataracts generally develop within 1 to 2 years after vitrectomy surgery. So it’s reasonable to offer lens surgery at the same time as vitrectomy.

In this situation, if they don’t actually have a cataract, they would not be eligible for Medicare and health-fund-subsidised lens surgery, and they would have to pay out of pocket for the lens part of the surgery. If they have the vitrectomy and then later develop a cataract, Medicare and health fund rebates do apply.

In some countries, including parts of the UK, Japan and Europe, it’s routine for patients to have vitrectomy with lens surgery.

In the ‘old’ days there was thought to be a risk of CVA with anti-VEGF injections. Is that still a consideration?

It’s still there as a risk in all studies (all quote similar rates). But all mention it was not statistically significant and felt it was to do with the patient demographic – so generally not a major concern.

What factors would influence the decision to start a patient on Eylea vs. Lucentis, etc.?

It often depends on the treating ophthalmologist’s preference/experience with the particular medications. Some factors they might consider include:

Anatomical drying and durability – ranibizumab (Lucentis) generally requires the most frequent dosing to maintain a fluid-free macula. Aflibercept 2 mg (Eylea) established the standard for 8- to 12-week intervals. Faricimab (Vabysmo) and aflibercept 8 mg are increasingly preferred as first-line or early-switch options, extending treatment intervals to 12–16 weeks
Mechanism of action – faricimab inhibits both VEGF-A and angiopoietin-2 (Ang-2) to improve vascular stability and reduce inflammation, making it a strong candidate for switching eyes that show recalcitrant fluid on pure VEGF inhibitors
Aflibercept acts as a decoy receptor binding VEGF-A, VEGF-B and placental growth factor (PlGF), providing broader anti-angiogenic blockade than ranibizumab’s isolated VEGF-A inhibition
DRCR.net Protocol T established findings relevant to DME patient management (note cut off in original).

Do you consider higher than 8 mg Eylea in some cases if the adverse events are not significantly increased with higher doses?

Eylea is not available in higher doses, and you can only inject a certain volume of drug into the eye before you get IOP problems.

Cost of 8 mg compared to 2 mg?

The dispensed price for maximum quantity (DPMQ), which reflects the acquisition cost and the subsidy paid by the government:

Eylea 8 mg: DPMQ is $443.80
Eylea 2 mg: DPMQ is $304.55 to $315.15, depending on the specific restriction code used for initial or continuing treatment.

If prescribed privately without PBS eligibility, Eylea 8 mg costs approximately $934 per vial.

How was the slowing of dry AMD quantified?

Fundus autofluorescence, with measurement of the area of geographic atrophy (GA).

Does reduction of dry AMD lesion size correlate with improved visual acuity?

Good question. The studies do not demonstrate any difference in VA outcome, although the result may be different if a longer time period was observed, as some in the sham group may develop central-involving GA.

What is the advice for cataract surgery in a patient who has 6/12 vision in the right eye due to amblyopia and 6/6 in the left eye? Can they still use an EDOF?

Personally, I wouldn’t recommend an EDOF for a patient like that.

What are your thoughts on using EDOF IOLs in patients who have other conditions like glaucoma?

It depends on the degree of field loss and disease control. If the patient has well-controlled IOP on minimal drop therapy or SLT with no significant field loss, it’s appropriate to give them an EDOF.

How do you manage anisometropia in a high myope who had undergone cataract surgery for one eye before the second operation?

Very rarely would you embark on this without consenting the patient to bilateral surgery at the outset. Usually, we try to organise surgery for the following week.

Is BCVA at near measured in any of the AMD studies?

The BCVA measured is distance vision. For research standardisation and generalisation, most studies would aim to use the same outcomes.

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This article is for educational and informational purposes only and may not be directly applicable to your individual patients.

Date last reviewed: 2026-09-15 | Date for next review: 2028-09-15

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