On this episode of Retina Mentor Moments John W. Kitchens, MD is joined by Esther Lee Kim, MD to discuss their strategies for evaluating pipeline and recently-approved therapies and integrating them into their practice.
Dr. Kim is a retina specialist at the Orange County Retina Institute. For more on her career path, see Navigating A Career in Retina.
Building the foundation for a clinical trial program in a retina practice
Dr. Kim noted that her practice, founded in 1979 by John Magiano, is the oldest established retina practice in Orange County. Since its inception, the practice has grown to five retina specialists (soon to be six) across five locations and prides itself on staying current and offering the latest advances in retina care, and clinical trial participation is central to that mission.
Her practice partner Sanford Chen, who joined the practice earlier, helped build the foundation of its clinical trial program alongside Marinell Casiano, the practice’s clinical trial leader since the days of developing fluorescein angiograms on film. Dr. Kim emphasized that Casiano has remained integral to the program’s success ever since, and highlighted the need for an organized and motivated team to oversee clinical trial research.
She added that she was fortunate to join a practice that already ran clinical trials like a well-oiled machine, with established industry connections that gave her a structure to grow her career. Having like-minded partners who are open to new therapies and who bring prior experience with novel treatments, builds the comfort needed to move quickly.
As a result, her practice can typically introduce a new therapy in under 6 months. Surgical innovations are approached more cautiously, but the practice’s clinical trial infrastructure still helps new therapies reach patients soon after commercial approval. The primary remaining barrier is securing coverage and ensuring reimbursement for new treatments.
Starting small: How to launch a clinical trial program at your practice
Dr. Kim explained that launching a clinical trials program starts with curiosity and motivation to embrace the mindset and cultural shift required to recruit patients for studies. This translates to building a strong internal team to run trials and establishing industry relationships to build a reputation in the space.
Dr. Kitchens shared that his Kentucky practice began by identifying one or two trials they could commit to fully and recruit patients for. He added that joining the DRCR Retina Network was valuable because the organization is designed to answer clinical questions relevant to retina care and connects members with like-minded colleagues.
Life beyond the clinic: Sustaining passion in a retina career
Dr. Kim highlighted that retina specialists don’t need to confine themselves to clinical work alone; opportunities such as serving on educational or advisory boards, consulting, and speaking allow physicians to explore and expand other aspects of their career. She described drawing particular joy from consulting, advising, and speaking, where her strength lies in distilling complex ideas into their most meaningful essence.
She added that while it’s helpful to cast a wide net when starting out, being judicious about how and where time is spent is also important because there are only so many hours in the day. The goal is to find activities that bring value and joy, not just doing things for the sake of doing things. For Dr. Kitchens, finding things that fuel the passion that motivated him earlier on in his career is critical to maintaining his practice.
“Once you’ve been practicing for five to seven years, you'll hit a plateau. Finding a way to keep you engaged is critical because it makes your practice so much more fun and interesting, and I think it makes you a better doctor for your patients.”
Evaluating and selecting novel therapies for patients
Dr. Kim explained that she always personally reviews the data and safety profile of any new therapy before adopting it. While she makes a point of speaking with pharmaceutical reps, she also emphasized the importance of digging deeper into the underlying numbers rather than accepting reported percentages at face value.
She explained that although she considers herself to be an early adopter, she only proceeds with therapies that offer additional benefit to existing treatments and the benefit-to-risk ratio has to work in the patient’s favor.
“For therapies addressing an unmet need, prioritize treating patients who didn’t previously have therapy and have the most advanced signs of the disease or are most symptomatic. From there you can treat trickier cases where a new option is worth trying.”
As she’s grown more comfortable with newer therapies, she is increasingly willing to start treatment-naive patients rather than following a fail-first approach that can delay optimal outcomes and add unnecessary visits.
Dr. Kim added that trialing new medications across a broad range of patients rather than pigeonholing a therapy into one subtype (such as recalcitrant cases alone) is important. Staying open to testing a therapy across different patient populations, she said, avoids prematurely narrowing its perceived usefulness.
Navigating the insurance dilemma: First-line or fail-first
Dr. Kitchens noted that tiered therapy—starting patients on the most affordable option first—is often pushed by insurers, but this approach then reserves stronger, more effective treatments for later, potentially increasing the risk of disease progression.
This is particularly notable in wet AMD patients, where he noted feeling frustrated with having to hold back on offering specific therapies to recalcitrant patients due to insurance. As their doctor, he prefers to give them the best option available as a first-line treatment, such as second-generation anti-VEGF therapies like faricimab and aflibercept 8mg, that offer greater treatment durability and potentially reduced treatment burden for patients.1-3
The doctors agreed that during the uncertain insurance landscape of a drug’s first 6 months post-approval, selectively trying it in tough-to-treat patients can serve as a “canary in the coal mine” for gauging durability.
For example, if a patient who couldn’t go 4 weeks on aflibercept 2mg can extend to 6 weeks on the 8mg formulation, that’s a proof of concept that the drug offers greater durability. Similarly, if a diabetic patient has persistent fluid at 4 weeks on one agent but achieves dryness on another, that switch validates the decision.
What’s on the horizon: TKIs in retina care
Dr. Kitchens noted that 2026 has been a landmark year for clinical research, with new data on tyrosine kinase inhibitors (TKIs) suggesting the decades-long reign of anti-VEGF therapy may be entering a new era of extended treatment options.
Dr. Kim observed that TKIs are appealing for retina specialists because they do not require a new skill set or trip to the OR, making them easier to integrate as an addition to, instead of a replacement for, existing anti-VEGF regimens.
Both Drs. Kitchens and Kim encouraged that physicians trial TKIs across a range of patients to determine their optimal role, such as an adjunct that reduces injection frequency in recalcitrant patients or as a potential 6-, 9-, or 12-month option for patients caught early with small, treatment-responsive lesions.
Key takeaways
- Integrating and sustaining clinical trial research at a retina practice requires infrastructure and a culture of establishing industry relationships and being open to new therapies
- Starting a clinical trial program doesn’t require scale, committing to one or two studies and joining networks like the DRCR Retina Network can help smaller or newer practices build credibility and connections.
- Career longevity often depends on activities beyond clinical care that help doctors stay engaged and avoid burnout after the initial skill-building years of practice.
- Rigorous, personal evaluation of new therapies beyond reported data is key to responsible early adoption.
- Second-generation anti-VEGF therapies offer extended durability and reduced treatment burden,1-3 and new therapies like TKIs represent a promising addition—not a replacement—to existing anti-VEGF regimens, with potential roles in recalcitrant and early-stage disease.4
