Dr Shaheer Aboobaker is a vitreoretinal specialist who lived and trained in South Africa before moving to Canada to take up a clinical fellowship in 2016. Now the managing partner at the Toronto Retina Institute in Canada, he is also the Institute’s co-director of clinical research and a passionate advocate for innovation in retinal care.

mivision’s editor, Melanie Kell caught up with Dr Aboobaker when he was in Australia, as a guest of Roche, to share his clinical experience using Vabysmo (faricimab) to treat neovascular age-related macular degeneration (nAMD), diabetic macular oedema (DMO), and retinal vein occlusion (RVO).

Q. You’ve been presenting to Australian ophthalmologists about clinical studies and your real-world experience with Vabysmo. What is the overarching clinical message you’re bringing to these meetings?

We’re really looking at the totality of the data – and there’s a great deal of it. What’s striking is the consistency across multiple cohorts, different geographic locations, different indications, and different study designs. That repeatability is reassuring. We’ve been drawing on Phase 3 data,1,2 Phase 4 data,3 extension studies4 and a growing body of real-world evidence, and the thread of the message remains remarkably coherent.

For those of us who’ve been in this field for a while, that’s meaningful. We’ve all stood at conferences and heard colleagues say, “We’re not seeing those trial outcomes in the real world – why is that?”. Some of the historical disconnect has been about the drug, but I think a lot of it has also been about study design.

Q. Can you elaborate on that? How does study design affect the translation of outcomes into practice?

I think Vabysmo’s trial design is probably more closely aligned to what we do day-to-day than anything we’ve seen. There’s a recent publication by Bhatia et al.5 comparing that design and its disease activity criteria to real-world protocols in the United Kingdom, and the two line up well. It will never be a perfect mirror, of course – trials are designed primarily to achieve regulatory approval – but the alignment is close enough that we’re not seeing major divergence between the clinical trial results and what we observe in practice.

The key element, I think, comes down to fluid tolerance. There’s been quite a bit of discussion in the retinal community around how much fluid is acceptable. My personal philosophy is to treat to dry – I don’t tolerate fluid. If biomarkers are changing, I want to react promptly rather than allow fluid to accumulate. And then there’s the question of extension intervals, whether you’re moving in two- or four-week increments. I think being reactive to change while also maintaining a low threshold for fluid is critical, and that’s reflected in how the trials were designed.

Q. Can you tell me a bit more about your personal tolerance to fluid?

It’s very much a philosophical position, and it can vary case by case. If a patient is genuinely pushing for extension and we’re having a thorough shared-decision conversation, I might sometimes soften my position slightly. But fundamentally, I believe fluid is a sign of disease activity. When it’s someone’s vision at stake – whether that’s my patient, or hypothetically a member of my own family – I’d rather err on the side of caution. Of course, you have to weigh that against the cumulative injection burden and infection risk. So, when a product offers better drying and the potential for extended intervals, both concerns can be addressed simultaneously. That’s a very nice synergy.

Q. What are you seeing at the Toronto Retina Institute in terms of real-world outcomes with Vabysmo?

We’re a high-volume, high-efficiency practice – there’s significant demand for our services, so durability really matters to us. I’ve been genuinely pleased with what we’re seeing. In our switch patients, we noticed a better drying effect early on. We were also part of the Phase 3 study,1 so we experienced that initial “wow” effect with treatment-naïve patients. And patients have really appreciated that we’ve been able to extend their intervals.

We went back and did a chart review across three Canadian centres, ours being one of them. We found we were extending switch patients by approximately three to four weeks compared with their previous treatment. We also saw better central retinal thickness, less intraretinal and subretinal fluid, and a higher proportion of patients achieving complete drying. That matched what we’d been seeing in real-world studies globally, as well as in the Phase 3 data.1

Q. Would you use Vabysmo as first-line in treatment-naïve patients?

If we’re being evidence-based – and we should be – in DMO, yes, I think there’s a strong case for Vabysmo as first-line. The Phase 3 data is compelling,2 and the post-hoc analyses show statistically significant differences in central retinal thickness and less macular leakage compared with the control arm. The evidence base is building.

In nAMD, it’s a little more nuanced. I wouldn’t say it’s 50:50, but I think we now have biomarkers that can help guide the decision in treatment-naïve cases. Specifically, I’d be looking at pigment epithelial detachments, subretinal hyperreflective material, or SHRM (subretinal hyperreflective material). The post-hoc analyses showed quite convincing data around reduction in PEDs (pigment epithelium detachments). And SHRM is a known precursor to potentially progressive fibrosis. If you believe in the anti-fibrotic effects of Ang-2 inhibition, getting

Vabysmo in before fibrosis is established could be genuinely beneficial. There’s also some emerging data around submacular haemorrhage as another potential biomarker to inform that decision. So, for treatment-naïve nAMD, it’s absolutely one of my top considerations.

Q. Let’s look ahead. What excites you most in terms of emerging treatments?

I could spend an entire hour on this! In wet AMD and other neovascular conditions, I’m watching the potential for extended dosing with real interest – the port delivery system, gene therapy, and tyrosine kinase inhibitors are all very topical right now. Home OCT (optical coherence tomography) technology is also something I find transformative. The idea of a patient being able to test themselves daily, with results transmitted via the cloud and a flag raised if fluid changes by as little as 10 microns – that could genuinely be life changing, both for patients and their families, and could allow us to safely extend the intervals between clinic visits.

In dry AMD – which is perhaps the most exciting frontier right now – our patients have waited so long for therapies that can meaningfully slow or reverse disease. The complement inhibitors offer a slowing effect, which is meaningful. But what really speaks to me is cell therapy. We’re seeing Phase 1 studies where patients with centre-foveal geographic atrophy – some of the most advanced cases imaginable – are gaining 13 to 14 letters of vision, two to three lines.6 For someone who’s been told there is no hope, two to three lines could be life changing. That’s enormously exciting.

Q. You have a strong interest in artificial intelligence (AI). What role do you see AI playing in the management of nAMD?

AI is advancing quickly in diagnostic imaging. There are already device-agnostic AI platforms that sit above OCT systems and can analyse imaging data, whether that’s at an optometrist’s practice, a general ophthalmology clinic, or a specialist retina centre. The ability to quantify biomarkers, like intraretinal fluid volume, subretinal fluid volume, or drusen volume with precision, is very useful, both clinically and in research.

One application I’ve come across recently, that I find particularly fascinating, is generative AI that produces an intravenous fluorescein angiography – essentially a leakage map – derived entirely from a fundus photograph. No dye, no lengthy test, but you get similar diagnostic information. If that proves reliable, it could significantly speed up clinic workflows and give us richer data from a single, simple investigation.

My own work in AI is in a slightly different space – I serve as Chief Medical Officer at MediversAI, a company focused on using AI to support cataract surgical training. We use tool-tracking to map the steps of a procedure and generate objective competency metrics, so trainers can see exactly where a surgical trainee sits relative to their peers and a global standard. Right now, surgical assessment is largely subjective. This doesn’t replace that, but it complements it powerfully. And there’s no reason it couldn’t extend beyond cataract surgery – retinal procedures, corneal surgery, oculoplastics, anything performed under a microscope.

Q. What can be done to make macular disease care more equitable and accessible?

Two things stand out for me. The first is screening. Some of my colleagues are doing extraordinary work using AI to extend diabetic retinopathy screening outreach – catching disease early in a population that tends to be younger, where early intervention can have an enormous impact on a person’s entire working life.

The second is biosimilars. I know it sounds incongruous coming from someone who is deeply passionate about innovation, but I think biosimilars will play a genuine role in reducing the cost burden on health systems, and that should ultimately mean more patients getting access to the care they need. We’re already seeing a stream of biosimilars as earlier agents come off patent. I think appropriate post-marketing surveillance is essential, but I welcome the broader interest in this space. More companies, more research, more resources – all of that should drive better patient outcomes. It’s a genuinely fascinating time to be working in retinal disease.

Q. What drives your passion for this particular field? Why macular disease?

I feel genuinely very blessed for the work that we get to do, for the impact that we hopefully have on our patients’ lives. The satisfaction we receive from patients – it’s very humbling.

The ability to offer cutting-edge treatments to patients who have no other options – that’s probably some of the most rewarding work you can do in medicine. To be able to restore hope into another human’s life, when they’ve been told by so many, for so long, that there isn’t any. That’s it, really. That’s what gets me up in the morning.

Q. And finally, aside from a whirlwind tour of Australia, how has this speaker tour contributed to your professional career?

Doing a speaker tour almost feels like a real career milestone – a bucket list item, honestly. It’s an opportunity I had never really conceived of. Every country, every individual I speak to, describes variations on the same challenges but with slightly different perspectives. Hearing those different viewpoints gives you a much richer sense of where the field is heading and what people are grappling with day-to-day.

It’s quite a ‘pinch me’ moment, to be honest – for that little South African kid inside me.

Dr Shaheer Aboobaker MBChB Dip Ophth (SA) MMed (UCT) FC Ophth (SA) FRCSC is the Managing Partner and Co-Director of Clinical Research at the Toronto Retina Institute in Canada.

Dr Aboobaker’s academic and research interests include advancements in technology and innovative therapies. He is an investigator in over 20 global clinical trials. He serves as Chief Medical Officer for MediversAI, a health tech startup working to integrate AI into surgical training and evaluation. He is an advisor and speaker for multiple companies in the retina space.

He was in Australia as a guest of Roche.

References available at mivision.com.au.