Fast and Fundus: Real-world retina decisions from the EnVision 2026 panel

At Envision Summit 2026, the “Fast and Fundus” retina panel delivered rapid-fire case discussions grounded in practical decision-making. Moderated by Maria Berrocal, MD, the session moved from anterior segment masqueraders to retinal detachment strategy, proliferative diabetic retinopathy (PDR), symptomatic floaters, and geographic atrophy—each case highlighting how anatomy, vitreous status, and real-world patient factors drive management. The discussion repeatedly returned to one central theme: treat the patient in front of you, not just the pathology.

Recurrent Vitreous Hemorrhage: Look Forward Before You Look Back

The session opened with a 63-year-old patient with glaucoma and multiple episodes of vitreous hemorrhage without vascular disease. The ultimate diagnosis was optic–iris chafing from a malpositioned 3-piece IOL—an anterior segment problem presenting as a posterior segment emergency. As Berrocal demonstrated, transillumination revealed extensive iris damage. “You don’t really appreciate how bad the iris is unless you transilluminate these eyes,” she explained.

The case underscored the importance of evaluating the lens and sulcus position in unexplained hemorrhage. Rather than removing the IOL outright, posterior optic capture stabilized the lens and prevented further chafing. The outcome was durable. The takeaway was clear: recurrent vitreous hemorrhage is not always retinal. Careful anterior segment examination can prevent unnecessary posterior intervention.

Dislocated IOLs: Preserve When Possible

The panel then turned to late IOL dislocation, debating reposition versus exchange, anterior chamber IOLs, and bag complex management. Age, endothelial health, activity level, and corneal status all factored into decision-making. Several panelists emphasized preserving the capsular bag complex when feasible to minimize trauma and inflammation. The discussion reflected a generational shift—while anterior chamber IOLs were once common, they are less frequently used today. The broader point: surgical choice should be individualized, not reflexive. “What I have found is that many ambulance service centers don't have A/C IOL on hand. So that is usually, an issue. Because frankly, we used to do A/C IOLs, but they just don't carry them,” pointed out Chan.

Symptomatic Floaters: A Cultural Shift in Surgery

Berrocal presented a 40-year-old patient with 20/20 vision but visually disabling floaters sparked one of the most animated exchanges. Historically, surgeons were reluctant to operate. But panelists acknowledged evolving practice patterns.

“I need the patient to talk me into it,” Fromal noted, emphasizing careful counseling before elective vitrectomy. Another panelist added that properly selected patients are often “incredibly happy after they have a vitrectomy for floaters.” The panel agreed that reassurance and observation remain first-line, with close follow-up and clear return precautions. However, small-gauge vitrectomy in carefully chosen patients has become increasingly accepted—particularly when floaters interfere with daily function. Laser vitreolysis, by contrast, was broadly discouraged.

Retinal Detachment: The Buckle Renaissance

Perhaps the strongest consensus emerged around scleral buckling. Slides demonstrated higher single-surgery success rates (SSSR) for buckle compared with vitrectomy in primary detachments (91.2% vs 84.2%), with even higher success in non-drainage segmental buckling.

“Primary buckle rarely fails,” Fromal remarked, noting that postoperative PVR is more commonly seen after primary vitrectomy. The discussion extended beyond anatomy. Positioning burden, travel restrictions, and cataract progression were central considerations. Slides highlighted longer convalescence and higher cataract rates after PPV.

Berrocal framed it bluntly: “We don’t take into account the realities of the patient.” For patients unlikely to position reliably—or those with significant lifestyle demands, segmental buckle may offer both anatomical and practical advantages.

Pneumatic Retinopexy: Strategic and Cost-Conscious

In uninsured patients or OR-limited settings, pneumatic retinopexy remains a powerful tool. The panel emphasized its lower cost, minimal retinal displacement compared with vitrectomy, and office-based feasibility. While cooperation is required—and flying is prohibited—the group agreed that pneumatic can be definitive therapy or a temporizing bridge.

Proliferative Diabetic Retinopathy: PRP Endures

A case of PDR with preserved vision reinforced the durability of panretinal photocoagulation. Although anti-VEGF has transformed care, high global loss-to-follow-up rates remain concerning. “We cannot mindlessly inject, inject, inject without knowing the status of the vitreous,” Berrocal cautioned. Slides illustrated how anti-VEGF in a partially attached hyaloid can precipitate tractional detachment. The angiofibrotic shift and fibrosis risk further complicate management. The message was pragmatic: PRP provides resilience when follow-up is uncertain.

Geographic Atrophy: Timing Remains the Challenge

The panel closed with a longitudinal case of an 89 year old patient, tracing nearly a decade of geographic atrophy progression. Year by year, subtle enlargement of atrophy gave way to measurable functional decline. What began as preserved 20/20 vision slowly progressed to 20/40 and worse, with increasing central involvement. The images made the natural history tangible: slow, relentless expansion rather than sudden collapse.

The discussion quickly turned from what was happening to when to intervene. Bahtt noted, “Up until this timeframe, we really didn’t have another option,” reflecting how recently therapeutic choices for nonexudative AMD have emerged. That historical context framed the current dilemma: now that treatments exist, identifying the right patient—and the right moment—has become the new challenge.

The patient in question was in his early 90s but highly active, frustrated by difficulty seeing the golf ball on the fairway. The case forced the panel to weigh anatomical progression against functional impact. Should treatment begin when lesions enlarge? When visual acuity drops? When symptoms interfere with lifestyle? The panel acknowledged that current therapies slow lesion growth but do not restore lost vision. That distinction matters in counseling. The magnitude of benefit, measured in slowed expansion over time, must be balanced against injection burden, visit frequency, and potential adverse events.

There was also recognition that not all geographic atrophy progresses at the same rate. Some lesions remain extrafoveal for years; others encroach centrally more rapidly. Predicting trajectory remains imperfect. “I think we need AI to help us tell us which patients we really should be treating,” Beroccal remarked, circling back on topics covered in earlier sessions at EnVision 2026 on use of AI in clinical practice.

Reference:

1. Bahtt N, Berrocal M, Chan P, et al. Fast and Fundus. Presented at: Envision Summit 2026; February 12-16; Rio Grande, Puerto Rico. Fast and Fundus: Real-World Retina Decisions From the Envision 2026 Panel