Cencora closed on Retina Consultants of America on January 2, 2025. The announced headline value was $4.6 billion. The actual cash outlay at closing landed at $4.4 billion for an approximately 85% interest, with RCA physicians and management retaining the remaining minority stake through an equity rollover. The deal also included up to $500 million in contingent consideration tied to fiscal 2027 and 2028 performance milestones. Scope Research put the implied EBITDA multiple between 15x and 23x on estimated EBITDA of $200 million to $300 million. RCA's footprint at closing ran to more than 300 retina specialists in 250 or more locations across 23 states, generating more than 2 million patient visits annually. The platform was formed in March 2020 with a $350 million Webster Equity Partners investment, which means the physician founders who rolled equity at formation had a 4.5-year hold and a realization event that delivered a substantial return on their original capital.

That deal, at that multiple, on that timeline, tells you everything you need to know about how capital markets see the retina subspecialty. Retina trades at multiples that reflect something structurally different about the revenue model, well above the low end of ophthalmology.

The reason is that retina runs on pharmaceutical margin, not procedural margin. A retina practice's revenue per patient visit bears almost no resemblance to what a general ophthalmology practice collects for a comparable appointment. The difference sits inside the buy-and-bill structure for anti-VEGF therapies, and the difference is the reason capital markets price the subspecialty the way they do.

How Anti-VEGF Pharmaceutical Economics Drive Ophthalmology Retina Practice Revenue

Regeneron's Eylea and Eylea HD generated $5.97 billion in US net sales in 2024, an increase of 1% year over year. Eylea HD, the aflibercept 8mg formulation launched in August 2023, produced $1.20 billion in US sales in 2024. The wholesale acquisition cost on Eylea HD runs $2,625 per single-use vial. Roche's Vabysmo generated CHF 3.864 billion globally in 2024, approximately $4.4 billion, making it Roche's fastest-growing drug at 68% year-over-year growth.

The Medicare reimbursement structure for these drugs operates under Part B's buy-and-bill mechanism. The statutory rate is ASP plus 6%, which after sequestration lands at ASP plus 4.3%. New drugs pre-ASP reimburse at WAC plus 3%, which post-sequester effectively runs at WAC plus 1.35%. The practice purchases the drug, administers it during an office-based intravitreal injection, and bills Medicare for the drug cost plus the percentage add-on, plus the injection procedure separately under CPT 67028.

The margin mechanics are public. An OIG analysis put the physician margin on Lucentis at approximately $95 per vial. Industry analyses place the margin on aflibercept around $80 per vial, with Avastin compounded bevacizumab running $50 to $67. A busy retina specialist performing 5,000 intravitreal injections per year at $80 margin per vial generates $400,000 annually from drug margin alone, separate from the CPT 67028 professional fee and separate from the facility fee if the injection is performed in an ASC.

That's the revenue layer capital markets price, and it has no meaningful equivalent in comprehensive ophthalmology, refractive, cornea, glaucoma, or oculoplastics. The pharmaceutical rebate structure inside retina is a subspecialty-specific revenue stream that scales with injection volume and that has historically grown as the class of anti-VEGF drugs has expanded.

Why Ophthalmology Retina Practices Face a Professional-Fee Collapse Most People Miss

The CPT 67028 reimbursement story runs in the opposite direction of the drug revenue story. A Northwestern analysis by Dustin French and colleagues, covering 2003 through 2024, found that non-facility reimbursement for CPT 67028 declined 86.3% over that period. The 2025 Medicare non-facility payment sits at approximately $114.65 per injection. The procedural fee for the single most common retina procedure in the country has been collapsing for two decades.

That collapse is why the drug margin matters. If the professional fee for intravitreal injection were keeping pace with specialty inflation, the drug margin would be supplemental revenue. Because the professional fee has collapsed, the drug margin is the primary economics. A retina practice that lost access to anti-VEGF drug margin through any structural change, whether regulatory, reimbursement, or therapeutic substitution, would see its revenue per patient visit drop dramatically.

The regulatory overhang is real. The OIG, MedPAC, and Health Affairs have repeatedly flagged the ASP plus 6% mechanism as an incentive to use higher-priced branded anti-VEGF agents rather than compounded Avastin. Switching all Medicare patients from branded agents to Avastin would save Medicare an estimated $1.5 to $2.9 billion annually according to OIG analyses. The Inflation Reduction Act's Part B drug negotiation provisions begin in IPAY 2028, which brings aflibercept and other high-spend Part B drugs into scope.

Biosimilar competition adds pressure from a different direction. Byooviz from Samsung Bioepis and Biogen launched at $1,130 per vial in July 2022, a 42% discount to Lucentis. Cimerli from Coherus, now owned by Sandoz after a $170 million acquisition in January 2024, launched at $869 per vial and is the only interchangeable Lucentis biosimilar. Aflibercept biosimilars are expected to enter the market between 2025 and 2027, which would compress margin on the Eylea franchise directly.

What Ophthalmology Retina Looks Like at Scale and Why Capital Keeps Flowing In

RCA isn't the only retina platform. Approximately 40 PE-backed eye care MSOs operate in the US, and almost all of them employ retina specialists. US Retina, Pacific Retina Partners, and retina divisions inside larger platforms like EyeCare Partners all compete for the same practice targets. JAMA Health Forum published a 2022 study, updated in Ophthalmology in 2024, finding that PE-acquired retina practices increased aflibercept use by 6.5 injections per practice-quarter, approximately a 22% increase, with Medicare aflibercept spend rising 21% per practice-quarter.

That utilization increase is the reason PE platforms compete for retina practices specifically. The underlying asset performs differently in private equity hands because the rebate economics scale with injection volume, and PE operators optimize for injection volume within the bounds of clinical appropriateness and regulatory compliance.

The subspecialty supply-demand dynamic compounds the valuation. SF Match data on the vitreoretinal fellowship match showed programs growing from 101 to 119 between 2014 and 2019, with positions filled increasing from 118 to 123 and vacancies doubling from 18 to 37. Retina specialists remain one of the most undersupplied subspecialties in ophthalmology relative to the aging population's demand for anti-VEGF therapy.

The Ophthalmology Subspecialty Story Capital Allocators Are Still Underweighting

Valeda from LumiThera received de novo FDA authorization in November 2024 as the first FDA-authorized treatment for dry age-related macular degeneration. The treatment protocol runs 9 sessions over 3 to 5 weeks, repeated every 4 months, up to 54 treatments per eye over 2 years. Alcon acquired LumiThera in 2025, bringing the photobiomodulation modality into a major ophthalmic device maker's portfolio. Category III CPT coding became effective January 1, 2025.

Geographic atrophy drugs are the newer story. Apellis Syfovre launched in February 2023 and generated approximately $445 million in the first nine months of 2024 US sales. Astellas Izervay, acquired through the $5.9 billion Iveric Bio buyout, generated approximately $289 million in the first nine months of its FY3/2025. Both drugs were rejected or withdrawn in the EU, but the US market remains open and growing.

The retina subspecialty carries real structural risk, specifically biosimilar entry, Part B drug negotiation, dosing interval extension with Eylea HD and Vabysmo, and the Regeneron DOJ False Claims Act case that remains unresolved. But the structural defensibility comes from the same source as the structural risk. Retina practices run on pharmaceutical economics that are embedded in the treatment pathway for a growing population of patients with an aging-driven disease class. The subspecialty trades at 15 to 23 times EBITDA because capital markets have priced the defensibility of the revenue layer that sits underneath the procedure, not because the underlying clinical work is easy or stable.

This article is for general educational purposes and is not legal or financial advice.

Verdira is a healthcare acquisition platform focused on ophthalmology practices. Physician ownership. Transparent structure. No volume quotas. If you're a practice owner thinking about succession or a physician exploring ownership, we're open to thoughtful conversations.

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