Clinician Confidence in Ophthalmology Biosimilars Remains Low Across Europe

Biosimilar uptake in ophthalmology is lagging well behind other therapy areas in Europe, and a new industry analysis suggests that without coordinated action from clinicians, payers, and policy makers, the specialty could miss out on an estimated €747 million in savings over the next 5 years.1

The IQVIA Institute for Human Data Science published a case study in February 2026 examining barriers to biosimilar adoption in ophthalmology, with a focus on the recent European entry of aflibercept biosimilars. Funded by Sandoz, the report drew on 142 in-depth interviews conducted between late 2024 and early 2025 with ophthalmologists, retina specialists, hospital and retail pharmacists, payers, nurses, and patient advocacy group representatives across France, Germany, Italy, Spain, and the UK. The study sought to assess why uptake had stalled in a specialty where prior biosimilar experience was limited and what structural and educational interventions could change that trajectory.

A High-Burden Specialty With Limited Biosimilar History

Retinal diseases, including wet age-related macular degeneration (wAMD), diabetic macular edema, and retinal vein occlusion, imposed a substantial and growing burden on European health systems. In 2022, approximately 67 million people in Europe were affected by age-related macular degeneration—a figure expected to increase by 15% by 2050.2 The standard of care relied on frequent intravitreal anti–vascular endothelial growth factor injections, placing sustained demand on already-strained ophthalmology services facing clinician shortages, limited clinic infrastructure, and growing waitlists.

Biologics accounted for more than 40% of total pharmaceutical expenditure in the EU in 2023 and 2024, up from 28% in 2014. Biosimilars, despite generating €75 billion in cumulative list-price savings in Europe as of mid-2025, represented only about 5% of biologics spending.

The entry of ranibizumab biosimilars in Europe beginning in 2022 offered the specialty its first real-world test of biosimilar adoption—and the results were instructive. Ranibizumab biosimilars reached only 40% penetration 6 quarters after launch, compared with 50% to 60% or more seen in other therapy areas over comparable periods. The report attributed this largely to the absence of a prefilled syringe (PFS) formulation for the biosimilar at launch—a critical shortcoming in a specialty where PFS had become the standard delivery format due to efficiency, reduced contamination risk, and ease of use in high-volume injection settings.

By contrast, 9 companies received European Commission approval for aflibercept biosimilars, with launches beginning in late 2025, and all were expected to offer PFS presentations.

Confidence Scores Reveal a Knowledge Gap

Stakeholder confidence in biosimilars varied widely by country but was low overall. On a 1-to-7 scale, average biosimilar confidence scores in France, Germany, and Spain each came in at 2 or below. Italy registered a score of 3.5, while the UK led with an average of 5.5, a gap the report linked in part to earlier guidance from professional bodies such as the British and Eire Association of Medical Retina Specialists (BEAMS), which published a position statement in 2025 recommending first-line use of aflibercept and ranibizumab biosimilars for wAMD and calling for ring-fencing a portion of biosimilar savings for ophthalmology capacity reinvestment.

Across countries, cost-effectiveness and reliable supply emerged as the two primary enablers of adoption. As one retina specialist in the UK noted in an interview, “A big driving influence is the fact that the biosimilars are expected to be more cost-effective. The next enabler will be—I hope—that there will be a good supply chain, so we won't have an issue in terms of access to these treatments."

Three Systemic Barriers Identified

The report identified 3 structural barriers that cut across the 5 markets studied.

First, limited familiarity with biosimilars among ophthalmologists left many clinicians defaulting to reference products. Prescribing habits in the specialty tended to be conservative, given the precision and risk associated with intravitreal therapies. In the absence of targeted education, clinicians with little prior biosimilar exposure were unlikely to switch without clear evidence and institutional guidance.

Second, the poor experience with ranibizumab biosimilars shaped perceptions that could carry forward. Despite aflibercept biosimilars offering PFS formats, the feature most commonly cited as absent and most strongly linked to ranibizumab's limited uptake, residual skepticism from prior experience was expected to require active, product-specific communication to overcome it.

Third, fragmented decision-making across national, regional, and hospital levels delayed formulary access. Treatment guidelines frequently lagged behind market entry and lacked enforceability, leaving significant discretion to individual prescribers in a context where stakeholder confidence was already limited.

Pathways to Overcome Barriers

The report outlined 5 strategic enablers for improving biosimilar adoption. Targeted education campaigns—tailored not only to ophthalmologists but also to ophthalmic nurses, optometrists, and pharmacists—were identified as foundational. Patient advocacy groups were highlighted as especially effective dissemination partners, particularly in countries like Spain, where these organizations actively hosted workshops, webinars, and peer support groups.

Strengthening the real-world evidence base on biosimilar comparability, safety, and cost-effectiveness was identified as critical for hospital procurement teams and payers. Timely guideline updates coordinated through professional societies were also emphasized; the BEAMS position statement and National Health Service England's September 2025 treatment pathway recommendation, which designated aflibercept biosimilar as first-line alongside ranibizumab biosimilar for wAMD, were cited as models for proactive guidance ahead of market entry.

Reinvesting savings into ophthalmology services was presented as a mechanism both to address long-standing capacity bottlenecks and to create provider-level incentives for biosimilar adoption. Finally, well-designed tender-based procurement was noted as a lever for competitive pricing, with the report cautioning that single-winner tenders risked reducing supplier diversity and supply reliability and citing the UK's active multi-lot aflibercept biosimilar tender as an example of a more balanced approach.

The report estimated cumulative list-price savings from aflibercept biosimilars of €747 million between 2026 and 2031 across the 5 markets studied, with a range of €241 million to €1.4 billion depending on adoption rates and price dynamics. The authors noted that broader sustainability pressures extended well beyond ophthalmology: between 2024 and 2030, 69 biologics were anticipated to lose exclusivity in Europe, representing approximately €28 billion in pre-expiry value, yet only 29% of those molecules had a biosimilar currently in development.

The ophthalmology space, the authors argued, offered a concentrated test case for whether education, evidence, guideline reform, reinvestment, and procurement design could unlock benefits that had so far remained out of reach. "Overcoming barriers to biosimilar adoption in ophthalmology requires a multifaceted effort that spans education, evidence generation, guideline alignment, strategic reinvestment, and procurement reforms," they wrote.

References

1. IQVIA Institute for Human Data Science. Unlocking Biosimilar Potential: Ophthalmology Case Study. February 5, 2026. Accessed March 5, 2026. https://www.iqvia.com/insights/the-iqvia-institute/reports-and-publications/reports/unlocking-biosimilar-potential-2026
2. Li JQ, Welchowski T, Schmid M, Mauschitz MM, Holz FG, Finger RP. Prevalence and incidence of age-related macular degeneration in Europe: a systematic review and meta-analysis. Br J Ophthalmol. 2020;104(8):1077-1084. doi:10.1136/bjophthalmol-2019-314422