Ophthalmology Grew While Its Biggest Drug Fell 27%: The Money Moved to the Procedure

The two numbers that do not fit together

Pheonix Research values the global ophthalmology market at USD 68.40 billion in 2025, rising to USD 108.90 billion by 2033 — a compound annual growth rate of 5.98%, which reconciles to the year when computed from the two endpoints. Over the same window, the single largest revenue pool in retinal disease went into reverse: combined United States sales of the Eylea franchise reached USD 4.4 billion in 2025, down 27% on 2024 and 30.2% below the USD 6.3 billion peak of 2022.

Both are correct. A market growing at six percent contained a product line losing a quarter of its revenue in a single year, because the money did not leave ophthalmology. It moved from the molecule to the procedure.

The clearest demonstration is in geographic atrophy

Apellis reported SYFOVRE net product revenue of USD 586.9 million in 2025 against USD 611.8 million in 2024 — down 4.1% — while stating that total injections grew 17% year on year and that the product holds roughly 60% of the geographic atrophy market. Injections up 17% and revenue down 4.1% implies revenue per injection fell to about 82% of its prior level, a decline of roughly 18%.

Part of that gap is free goods rather than price. Apellis delivered approximately 102,000 SYFOVRE doses to physician offices in the fourth quarter of 2025, of which about 89,000 were commercial and about 13,000 were free goods — 12.7% of doses carrying no revenue. Volume growth in this category is partly a sampling programme, which is what a category looks like when the clinical case is accepted and the reimbursement case is still being argued.

That is the shape of ophthalmic drug economics in 2026: procedure volume rising, revenue per procedure falling, and the difference absorbed by competition on the interval and by channels that do not pay list price.

Why the molecule deflates: the interval is the product

Regeneron’s own attribution for the Eylea decline names two forces — continued competitive pressure and loss of market share to compounded alternatives. Roche’s Vabysmo is the first. Approved in 2022, it reached CHF 4.1 billion of sales in 2025, ranking as Roche’s third-largest drug by revenue, and reporting around the results put it near USD 5.3 billion.

Vabysmo did not win share by being cheaper. It won by being dosed less often. In a category where the patient experiences the therapy as an injection into the eye and the provider experiences it as a procedure slot, the dosing interval is the product. A competitor that extends the interval reduces injections per patient-year without reducing price per injection — so category revenue falls even as clinical care improves. That is not a pricing failure. It is a successful product being measured in the wrong units.

The second force, compounded copies, is a price floor problem rather than a volume problem. Once a compounded alternative sits at a fraction of the branded price, the branded product’s pricing power is capped regardless of its label, and the branded share is defended with rebates rather than with price.

Where the growth actually shows up

Alcon’s full-year 2025 results are the best available disaggregation of the non-drug side, and the pattern is unambiguous. Group net sales were USD 10,319 million, up 5% reported and 4% at constant currency. Inside that:

• Surgical net sales of USD 5,751 million, up 4%, of which implantables — intraocular lenses and the like — were USD 1,782 million against USD 1,775 million a year earlier. Essentially flat, and 31.0% of Surgical revenue.
• Consumables of USD 3,028 million, up 6% reported and 5% at constant currency, with growth attributed to cataract and vitreoretinal procedural growth as well as price increases.
• Equipment and other of USD 941 million, up 6% for the year and 21% reported, 18% at constant currency, in the fourth quarter, led by launches including the Unity platform.
• Vision Care of USD 4,568 million, up 6%: contact lenses USD 2,770 million, up 6%; ocular health USD 1,798 million, up 6%, with the fourth quarter up 14% reported and 12% at constant currency on Tryptyr and Systane.

The only line in that list that did not grow is the one installed inside the patient. Alcon attributes the fourth-quarter implantables increase of 4% to PanOptix Pro in the United States, offset by continued competitive pressure, particularly internationally. Everything consumed per procedure grew at five to six percent. Everything that creates a procedure — capital equipment — grew at the same rate with a much stronger exit quarter.

The read: consumables and equipment captured the growth; the implant did not

This is the structural fact that reconciles a 5.98% market CAGR with a 27% decline in the most famous product in the field. Three layers of the same market behave completely differently:

The molecule competes on dosing interval and is exposed to compounded substitutes. Revenue per injection falls even when injections rise.

The implant is a one-off purchase per eye, sold against a handful of global competitors with clinically similar outcomes, and its price is set by tender and by international competition rather than by outcome data. It grew 0.4% in a market growing 5%.

The procedure is where both volume and price held. Consumables grew on cataract and vitreoretinal procedural volumes and on price. Equipment grew on a capital replacement cycle. Neither can be compounded, neither can be dosed less often, and both are consumed every time a patient is treated.

That is why the value migrated. Ophthalmology is a procedure business with a drug franchise attached, and the market has spent five years pricing it as a drug business.

The next round of competition is also procedural

Look at what the companies are actually building. Apellis has a regulatory submission for a SYFOVRE prefilled syringe planned for the first half of 2026. Eylea HD exists to extend the interval. Neither is a new molecule; both are interventions on how the treatment is delivered.

A prefilled syringe does not improve the drug. It removes a preparation step, a transfer and a sterility risk in a room where a nurse compounds, and it removes a billing line. In a category where the drug’s price is under pressure, the defensible margin is in the delivery format and the consumable around it — which is precisely the part of the market that grew five percent while the molecule fell twenty-seven.

Dry eye is the category to watch, for a different reason

Ocular health at Alcon grew 6% for the year and accelerated to 12% at constant currency in the fourth quarter, led by Tryptyr and Systane. Dry eye is the one ophthalmic category with consumer repeat-purchase behaviour: a chronic condition, a large prevalent population, a product taken daily rather than administered quarterly, and a plausible over-the-counter pathway.

That combination makes it the closest thing in eye care to a consumer health franchise, and it is why the fastest growth in the fourth quarter came from the least surgical part of the franchise.

What the report’s own segmentation already says

The Pheonix Research ophthalmology report names retinal disorders treatment as its largest segment and minimally invasive ophthalmic surgery as its fastest growing, with AI-based eye diagnostics, advanced retinal therapies and minimally invasive surgical technologies as the key trend. That is the same conclusion reached from the other direction: the size sits in the molecule, the growth sits in the procedure, and the two have begun to diverge.

A note on the record itself: the report’s overview page still carries decode damage in its snapshot table — literal question-mark runs in place of non-breaking spaces, and “2026???2033” in place of the en dash. The figures used here are read from the values, not the padding, but the page needs the estate-wide repair already raised rather than a one-off fix.

What to watch

• The interval war. Vabysmo against Eylea HD against whatever extends furthest. Each increment of interval removes revenue from the category while improving care, and no pricing strategy recovers it.
• Compounding policy in the United States. The compounded channel is the effective price ceiling on anti-VEGF therapy. Any enforcement shift moves branded revenue more than any launch does.
• Intraocular lens pricing outside the United States. Implantables were flat on US strength against international competition. If that competition intensifies, the one device line in the franchise stops contributing growth at all.
• Prefilled syringe approvals. Apellis has a submission planned for the first half of 2026. Approval would validate the thesis that value is defended in the delivery format rather than the molecule.
• Dry eye conversion. Ocular health accelerating to 12% constant currency in the fourth quarter is the first sign that the consumer-style end of eye care can carry growth independently of surgery.
• Cataract procedure volumes in emerging markets. Consumables growth rests on them. It is the least fashionable and most reliable line in the entire market.

Ophthalmology is growing at six percent. What changed is which part of it you own: the vial, the lens, or the cassette and the console.