Deals in the surgical ophthalmic equipment and products market reached a record high of 31 deals in 2022, with PE backed transactions also attaining new highs. Johan Ottosson, senior associate and Dr Victor Chua, senior partner at Mansfield Advisors see significant opportunities for this sector of the market
Global surgical ophthalmic equipment and products deals grew with a CAGR of 19% 2018‒2022 to a record high of 31 deals last year. PE or PE backed deals grew faster than the market overall with a CAGR of 26.6%, reaching a record 13 deals in 2022, almost twice that of the previous year.
Recent notable PE deals include Eurazeo’s acquisition of Dutch Ophthalmic Research Center International (DORC, led by CEO Pierre Billardon) for an estimated €300m in 2019, and CVC’s acquisition of Rayner Surgical Group (led by CEO Tim Clover) for an undisclosed amount in 2021.
The most active investor in recent years however has been TPG Capital. Since its 2016 acquisition of US-based Beaver-Visitec International’s (BVI, led by president and CEO Shervin Korangy) TPG Capital has proceeded to roll-up multiple, mainly European, ophthalmology assets. Through this, TPG Capital has built a leading global platform estimated to have seen a revenue growth of circa 19% CAGR between 2017 and 2021.
Investor interest in the space is driven by attractive market fundamentals such as an ageing population, increasing treatment of pathologies, better access to healthcare, as well as stable public or insurance funding. Ophthalmic procedures tend to be inexpensive because they are almost always day-cases, and impactful because good vision is so important to normal productive life.
We therefore expect ophthalmic procedure growth exceeding growth in other surgical specialities. There are significant roll-up opportunities for investors in this space, notably in the US and Western Europe.
A large and fast-growing market
We estimate the global ophthalmology equipment and surgical products market to be worth circa £20bn in 2023. Around 84% of this market is made up of equipment and products for the operating room (see Figure One).
The market for inside the operating room can broadly be broken down into products for the front of the eye, or the anterior segment (covering cataract, glaucoma, and refractive surgery), and products for the back of the eye, or the posterior segment (covering vitreoretinal surgery).
The anterior segment is by far the largest of the two, with a market size of about 10x that of the posterior segment. It is also forecast to grow at a faster rate, with an expected CAGR of 6.5% 2023‒2027 (see Figure Two).
In this article we focus on the cataract and vitrectomy (VR) segments as the largest ones in the anterior and posterior segments respectively.
Cataracts and vitrectomies
In the cataract space (the largest part of the anterior segment), intraocular lenses (IOLs) represent about 67% of the total market value. We forecast future market growth in this space to be largely driven by the multifocal (premium) IOL segment.[1] Although multifocal IOLs are usually not covered by public pay healthcare systems, nor by statutory health insurance systems, we believe that growth in this sector will be driven an increasing global middle class willing to pay for these products in full (private pay), or in part (co-pay).[2]
We expect the market for monofocal lenses to grow at around 3.7% globally until 2025. We expect almost all the increase to be driven exclusively by volume growth, since these products are largely commoditised and are experiencing strong downward price pressures.
In the VR space, we expect growth to be driven by surgical pack sales, as well as – to a lesser extent ‒ by disposable instruments (despite being a faster growing segment).
Fundamental drivers
Strong market growth in the sector is supported by solid fundamentals, including:
An ageing population Age is one of the main drivers of both cataract and VR surgery and, according to data from World Population Prospects, 16% of the world’s population (or 1.55 billion people) will be over age 65 by 2050, up from 9% in 2019 (or 639 million people).
Increasing treatment of pathologies and increasing access to healthcare Cataract procedures in China, for instance, are estimated to have doubled in the period between 2014‒2019, from 1.5 million to 3 million procedures.[3] Even so, this still means that only about 213 per 100,000 population procedures were carried out, compared to 1,310 in France, 1,049 in Germany,[4] or 998 in England (FY22).[5] We would expect a significant growth in the number of procedures over time in China and other similarly under-penetrated markets, notably in APAC
Increasing prevalence of diabetes (mainly related to VR) Diabetes is a significant determinant of VR surgery, and the prevalence of diabetes around the world is expected to rise to 10.2% or 578 million people by 2030 (9.3% or 463 million people in 2019) and 10.9% or 700 million people by 2045. Prevalence rates are higher in urban areas and in high-income countries, meaning we expect to see growth even in currently highly penetrated markets[6]
An expanding middle class willing to pay for premium IOLs (related to cataract surgery only) Market Scope forecasts the multifocal IOL market to grow with a CAGR of 11.7% until 2025 (compared to 3.7% for monofocal IOLs)[7]
In addition to these favourable factors, investments in this space will also benefit from stable revenue streams from public or statutory health insurance payors. We expect this market to remain attractive over the long term.
Dominant players
The cataract equipment space is dominated by large global players, whereas VR has some regional players.
The global market for surgical ophthalmic equipment and products is dominated by Alcon and Bausch + Lomb. These offer a full range of products, from equipment to instruments and consumables, covering both the cataract and VR segments.
Other global players have decided to focus primarily on the anterior segment (for instance Carl Zeiss Meditec and Johnson & Johnson). The larger players are followed by a tail of smaller more regional ones often focusing on IOLs (notably UK-based Rayner and Netherlands-based Ophtec) and consumables.
Players focusing on equipment for the posterior segment tend to be smaller and more regional, for instance DORC, in Western Europe and the USA, Oertli mainly in DACH, and Appasamy Associates in India. We believe this regionalisation is due to the smaller market size of the VR space compared to the cataract sector; the dominance of Alcon in the US (which until now has limited European player growth in that market); and the low priority historically placed on large Asian markets such as India (India instead is served by local, lower-cost players such as Appasamy).
Though a rough divide between players focusing on the anterior and posterior segments can be made for smaller players, several companies mainly focused on VR (such as BVI, DORC and Oertli) offer either dual-function machines, capable of performing both cataract and VR surgeries, or offer other products that span both segments. We have, therefore, included these in the Cataract and VR segment in Figure Three.
Consolidation
There is significant deal activity and the market for equipment, instruments, disposables and liquids is consolidating. Deal numbers hit record levels in 2022 (see Figure Four).
There is an identifiable trend for consolidation of equipment providers with other providers of ophthalmic products, such as consumables. Hence, under TA Associates ownership, Belgium-based IOL manufacturer PhysIOL in 2017 acquired Optikon, an Italian provider of phacoemulsification systems (used in cataract surgery), VR devices, and diagnostic equipment (PhysIOL/Optikon was acquired by BVI the year after).
Further, in 2019, Hoya (Public, TSE/TYO) acquired Germany-based Fritz Ruck and US-based Mid Labs, providing the company with VR machines, probes, and surgical packs.
The most active investor in recent years has been TPG Capital, which since its 2016 acquisition of BVI, has proceeded to roll-up multiple regional, mainly European, ophthalmology assets into its platform. Targets have included Vitreq (Netherlands), PhysIOL/Optikon (Belgium/Italy), and Arcadophta (France) (see Figure Five).
Through these acquisitions, BVI has significantly expanded its portfolio from being a company primarily focused on single-use devices in refractive, cataract and retina, to one now covering most of the areas covered by its global competitors (see Figure Six).
Because of this significant roll-up, BVI has almost doubled in size since the TPG Capital takeover, growing at an estimated CAGR of circa 19% in the years 2017‒2021 to reach revenue of approximately €320m.
Opportunities in sight
The ophthalmology product space is ripe for investment.
Prospective investors will benefit from several attractive market fundamentals – such as an ageing population, increasing treatment of pathologies and increasing access to healthcare, as well as stable public or insurance funding.
We also see significant roll-up opportunities for investors interested in building ophthalmology platforms focusing on either cataract, VR, or both.
We believe that any platform play should initially focus on the US and Western Europe where there are more numerous attractive assets. Any play should attempt to leverage the assets’ varying geographical presence to accelerate international expansion.
Once a platform has been established, additional longer-term growth should be achievable through growing the instruments and consumables space, expanding to geographies outside of the US and Western Europe (notably China, India, and the rest of APAC), and encompassing the refractive and glaucoma segments (which we estimate to be worth £4.4bn globally combined in 2023).
NOTES
1 Multifocal lenses allow for vision at a range of distances. This contrasts with monofocal lenses which provide focus at only one distance.
2 Co-pay is where the patient pays the difference between the cost of a standard cataract procedure with a monofocal lens, and a premium procedure with a multifocal lens. This is allowed in some countries, though not for instance in the UK.
3 Market Scope ‒ 2020 IOL Market Report Mid-Year Update
4 Eurostat Surgical operations and procedures performed in hospitals: cataract surgery 2019.
5 NHS Digital
6 Saeedi, et. al. Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas, 9th edition, Diabetes Research and Clinical Practice, Volume 157, 2019, 107843, ISSN 0168-8227
7 Market Scope ‒ 2020 IOL Market Report Mid-Year Update
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