Retina on the Ropes: Tackling the Toughest Debates in Medical Retina at APVRS 2025

From polyp wars to fluid fights, APVRS 2025 put medical retina’s toughest calls on trial.

If medical retina had a suggestion box, this symposium pretty much emptied it…then set it on fire. On Day 2 of the 18th Congress of the Asia-Pacific Vitreo-Retina Society (APVRS 2025), experts took on the questions clinicians quietly argue about between clinics and conference halls: Should every polyp be closed? Are prophylactic antibiotics a safety net or a crutch? Is fluid always the enemy? And perhaps—most uncomfortably of all—when, if ever, can we stop treating?

Packed with data, dissent and healthy disagreement, the session tackled the real-world challenges and controversies in medical retina that refuse to stay neatly inside guidelines.

Polyp closure in PCV

The gloves came off early as the session zeroed in on one deceptively simple question: are we treating the polyp or the patient?

Arguing firmly in favor of polyp closure, Prof. Timothy Lai (Hong Kong) framed active polyps as ticking time bombs. “If you leave the polyp still active in an active disease, there’s actually a substantial risk of having a rupture but then leakage,” he warned.

He pointed to the EVEREST II trial, where combination therapy with photodynamic therapy (PDT) and ranibizumab delivered a 69% complete polyp closure rate, along with significantly better visual outcomes than ranibizumab monotherapy.¹ Backing this up with long-term data, Prof. Lai showed that early polyp regression pays dividends well into the future. “If you manage to close the polyp very early, patients improve by about three lines of vision,” he noted. In contrast, eyes with persistent polyps began to lose vision after four years.

According to Prof. Lai, “closing the polypoidal lesion is very important…to achieve visual acuity gain, reduce disease activity, reduce the risk of hemorrhage, reduce recurrence rate and minimize treatment burden.”

Taking the contrarian seat, Dr. Kelvin Teo (Singapore) challenged the idea that a closed polyp automatically equals better vision. “Very little mention of what’s actually important for patients of functional clinically important outcomes,” he said. “Vision improvement is mainly driven by disease activity. These are things that we see in intraretinal subocular fluid and not so much based on whether the polyp is open or closed.”

Dr. Teo highlighted studies showing comparable visual acuity outcomes regardless of polyp closure, cautioning that “chasing polyp closure may result in overtreatment with no clear benefit.” In one example, three extra anti-vascular endothelial growth factor (anti-VEGF) injections produced just a 13% increase in polyp regression²—hardly a slam dunk.

Looking further down the road, he cited six-year follow-up data³ indicating that “polyp status was not associated with best corrected visual acuity (BCVA) ultimately—the functional marker that we are all worried about.”

Prophylactic topical antibiotics

If there’s one thing guaranteed to stir the retina crowd, it’s the question of whether antibiotics are protecting our patients or just making us feel better.

Making the case for selective use, Dr. Sherman Valero (Philippines) was quick to distance himself from routine prescribing. He acknowledged that “routine blanket use of prophylactic antibiotics is scientifically unproven, unnecessary and can even be harmful.”

Still, he argued that abandoning them entirely ignores real-world nuance, favoring a risk-stratified approach over a rigid, one-size-fits-all protocol. As he put it, “Endophthalmitis when it strikes is not a statistical footnote. It’s a sight-destroying reality.”

Dr. Valero outlined specific high-risk scenarios where antibiotics might still earn their keep, including “injection in a high-risk situation where you have to inject that there is some infection in the eye,” patients with compromised host defenses, those undergoing repeated injections, cases involving intra-procedural breaches and simultaneous bilateral injections.

His bottom line was pragmatic rather than dogmatic. “Let’s be guided by the evidence, but also let’s be guided by prudence,” he concluded. “Protocol is a guide, not a scientific straight jacket.”

On the opposing side, Dr. Nor Fariza Ngah (Malaysia) pulled no punches in her critique of routine prophylaxis. “Topical antibiotics offer no proven benefit for intravitreal injection or any low risk surgery and may be very harmful,” she stated, noting that they show no reduction in infection risk and that routine use accelerates antimicrobial resistance.

Instead, Dr. Ngah doubled down on fundamentals, reminding the audience that “povidone-iodine is the evidence-based cornerstone” of endophthalmitis prevention, backed by robust clinical data. She also flagged practical downsides of antibiotic drops, from preservative-related ocular surface toxicity to added costs and workflow headaches for both patients and providers.

Her closing message was a call for discipline over habit. “Our responsibility as clinicians is to prioritize sterile techniques, evidence-based practice and also practice responsible antibiotic stewardship,” she ended.

Extended treatment intervals

Everyone wants fewer injections on the calendar, but as this session made clear, stretching intervals isn’t just a pharmacologic wish list item. It’s a system-level necessity.

Setting the scene, Dr. Luke Nicholson (UK) tackled the mounting pressure on anti-VEGF services as patient numbers continue to climb. “We’re expecting to see in the UK nearly 40,000 newly diagnosed neovascular AMD [age-related macular degeneration] a year. In a 20-year period, there’s probably a 60% rise in patients with neovascular AMD,” he said. With clinics already bursting at the seams, he added, “this demand that’s rising and lack of capacity is one reason why we’re desperate for long-acting drugs.”

Newer agents such as faricimab and aflibercept 8 mg have certainly raised hopes, showing impressive durability in both clinical trials and real-world data. But Dr. Nicholson urged the audience not to look at interval extension in isolation. “We are chasing durability, rightly so, less frequent injections…but again higher rates of IOIs [intraocular inflammation],” he cautioned.

He also turned the spotlight on biosimilars: attractive for their cost savings, but often requiring more frequent injections. Comparing different treatment strategies, Dr. Nicholson shared data showing that while faricimab monotherapy resulted in the fewest injections over two years, a step-therapy approach incorporating biosimilars could offer better value in resource-limited systems.⁴

The real-world dilemma, he suggested, comes down to strategy rather than slogans: “Is it a step therapy or monotherapy?”

Patient compliance

We can debate molecules, intervals and protocols all day, but none of it works if the patient simply doesn’t show up.

Dr. Adrian Koh (SIngapore) zeroed in on compliance as the quiet saboteur of otherwise solid treatment plans. “Non-adherence and non-persistence are perhaps underemphasized factors in our poor outcomes,” he said, defining non-adherence as “missing two or more treatments or monitoring visits scheduled as advised over 12 months.” In other words, the science may be sound, but execution is everything.

Drawing on data from the Barometer Global Survey, Dr. Koh reported that 15% of AMD patients and 18% of diabetic macular edema (DME) patients self-identified as non-adherent.⁵ The reasons were less about apathy and more about reality: self-payment for treatment, limited understanding of vision loss risks, referral delays and plain old treatment fatigue in patients facing long injection journeys.

Communication, it turns out, is a major pressure point. “Three out of all patients felt that the doctor needed more time which they did not have to answer questions,” Dr. Koh noted, underscoring the disconnect between packed clinic schedules and patient expectations.

To close that gap, he suggested several practical fixes: creating space for meaningful discussions, standardizing how information is delivered, addressing mental health needs and helping patients navigate employer-related barriers that make regular visits difficult.

Treatment cessation

Few questions spark more hallway debate than this one: once you start anti-VEGF, is there ever a safe, sensible off-ramp?

Opening the case for stopping—selectively—Prof. Andrew Chang (Australia) argued that treatment cessation can have a place in neovascular AMD management. “We can stop treatment in cases of neovascular AMD. This is a decision made by the treating clinician but in conjunction with patients,” he said.

He suggested considering cessation when treatment becomes futile or the response is clearly suboptimal, defining resistance as the “presence of SRF [subretinal fluid] or IRF [intraretinal fluid] despite regular less than six-weekly injections over a six-month period, or at least four injections during that period.”

Prof. Chang also raised the possibility of stopping in patients who remain inactive at their maximum treatment intervals. The catch, he cautioned, is vigilance. “You may consider it if a patient has been inactive for exit, but you really need to follow these patients carefully,” he said, pointing to the ever-present risk of recurrence once therapy is withdrawn.

Arguing firmly against the exit strategy, Dr. Wei Kiong Ngo (Singapore) reminded the audience that “neovascular AMD is a chronic progressing disease and the ongoing VEGF drive remains for the lifetime of the patient.” A quiet optical coherence tomography (OCT), he warned, does not equal a quiet disease: “even when OCT appears quiet, subclinical activity persists,” and the “majority retain the capacity to reactivate.”

Dr. Ngo backed this up with sobering data, citing recurrence rates of 30% to 50% even among patients who met carefully constructed exit criteria.⁶ He also highlighted the hemorrhagic risk of stopping therapy altogether. “A published case series reported multiple patients who developed significant hemorrhage after discontinuing therapy despite being labeled as stable,” he said, adding that “every eye that developed hemorrhage lost more than three lines of vision.”

Rather than stopping outright, Dr. Ngo advocated for playing the long game—maximally extended dosing intervals, newer long-acting agents, novel delivery platforms, gene therapies and home-based monitoring tools—options that keep VEGF suppression in place without slamming the door on treatment entirely.

Managing IOP and fluid

Leave it to retina to end on two deceptively simple questions: how much pressure is too much, and how much fluid is too much?

Prof. Wai-Ching Lam (Canada) kicked things off by unpacking the link between anti-VEGF injections and intraocular pressure (IOP). While short-term IOP spikes are almost a given, he explained, the long-term picture is more variable. “Several studies have shown long-term IOP elevation following intravitreal injection in different populations ranges between 2.6 to 12 percent,” he reported.

He outlined a familiar list of risk factors for sustained IOP elevation: male gender, South Asian ethnicity, older age, AMD, a high cumulative number of injections and pre-existing glaucoma. The clinical takeaway was practical and pointed: “clinicians should be aware of the risk factors of IOP elevation in patients receiving intravitreal injection such as history of glaucoma or high number and frequency of injections.”

The session then pivoted to its final—and arguably most polarizing—debate: should we ever tolerate fluid in neovascular AMD?

Arguing for a more relaxed stance, Dr. Paul Mitchell (Australia) suggested that not all fluid deserves the same level of alarm. “Persistent subretinal fluid has little impact on visual outcomes,” he said, while drawing a firm line at the retina itself: “persistent intraretinal fluid, of course, is associated with lower visual outcomes.”

Citing data from unpublished studies on aflibercept 8 mg and faricimab, Dr. Mitchell noted that roughly 20% of patients still had subretinal fluid at one year. The visual penalty, however, was minimal: “a third of a letter lower” than in patients with completely dry retinas.

His conclusion was measured: subretinal fluid “can be tolerated” if vision is stable, but treatment should be escalated if the fluid is subfoveal, substantial, increasing or accompanied by vision loss.

Taking a hard-line opposing view, Dr. Keiko Kataoka (Japan) argued that any fluid is a red flag. “The presence of fluid indicates disease activity,” she warned, adding that “increasing disease activity means the risk of sudden subretinal hemorrhage.”

She presented data showing that 90% of eyes that developed submacular hemorrhage had evidence of exudation at the visit immediately before the bleed. “Essentially the OCT was giving us a warning sign that we failed to act on aggressively enough,” Dr. Kataoka emphasized.

Her closing message left little room for compromise: fluid “acts as a physical buffer between the RPE [retinal pigment epithelium] and the retina, causing a progressive photoreceptor cell death over time,” and “dry is the only endpoint that eliminates the risk of undertreating active disease and prevents hemorrhage.”

Editor’s Note: This content is intended exclusively for healthcare professionals. It is not intended for the general public. Products or therapies discussed may not be registered or approved in all jurisdictions, including Singapore. Reporting for this story took place during the 18th Congress of the Asia-Pacific Vitreo-Retina Society (APVRS 2025) from 12-14 December in Manila, Philippines.

References

Koh A, Lai TYY, Takahashi K, et al. Efficacy and safety of ranibizumab with or without verteporfin photodynamic therapy for polypoidal choroidal vasculopathy: A randomized clinical trial. JAMA Ophthalmol. 2017;135(11):1206-1213.
Teo KYC, Jordan-Yu JM, Tan ACS, et al. Efficacy of a novel personalised aflibercept monotherapy regimen based on polypoidal lesion closure in participants with polypoidal choroidal vasculopathy. Br J Ophthalmol. 2022;106(7):987-993.
Teo KYC, Park KH, Ngah NF, et al. Six-year outcomes in subjects with polypoidal choroidal vasculopathy in the EVEREST II study. Ophthalmol Ther. 2024;13(4):935-954.
Bressler NM, Kaiser PK, Do DV, et al. Biosimilars of anti-vascular endothelial growth factor for ophthalmic diseases: A review. Surv Ophthalmol. 2024;69(4):521-538.
Barometer Global Survey. Bayer Global. Available at: https://www.amdbarometer.org/barometer-global-survey. Accessed on December 13, 2025.
Sarraf D, Khanani AM, Sadda SR, et al. Pigment epithelial detachment thickness and variability affects visual outcomes in patients with neovascular age-related macular degeneration. Retina. 2024;44(1):10-19.