Abstract
In retina, we pride ourselves on vision—both literal and metaphorical. We are diagnosticians of nuance, surgeons of microns, and stewards of some of the most delicate structures in the human body. Yet, for all our technological sophistication, one of the most powerful tools available to us remains underutilized: the ability to reframe how we perceive the problems in front of us.
Perceptual reframing is not a new concept; it is rooted in cognitive psychology, decision science, and even philosophy. But in the context of retina specialty care, it carries particular relevance. Our field is evolving at a pace that challenges traditional models of thinking. Diseases we once defined in rigid categories now exist along spectrums. Treatments once considered definitive are now iterative. And patients—more informed, more engaged, and often more complex—require us to rethink not just what we do, but how we think about what we do.
This editorial is a call to examine our perceptual framework, to question our assumptions, and to consider how reframing can improve not only outcomes, but also the experience of care—for patients and physicians alike.
Historically, retina care has been structured around disease-centered models. We identify pathology, classify it, and apply evidence-based interventions. This approach has served us well, particularly in the era of antivascular endothelial growth factor (anti-VEGF) therapy, where protocol-driven care has dramatically improved outcomes for conditions such as neovascular age-related macular degeneration and diabetic macular edema.
But this model has limitations.
When we frame disease as static and treatment as linear, we risk oversimplifying the dynamic nature of retinal pathology. We may also inadvertently reduce the patient to a diagnosis rather than a person navigating a chronic condition. In doing so, we miss opportunities to tailor care in ways that reflect individual variability—not just biologically, but behaviorally and psychologically.
Perceptual reframing asks us to shift from a disease-centered model to a systems-oriented perspective. Instead of asking, “What is the diagnosis and what is the treatment?,” we might ask, “What is the trajectory of this condition, and how does this patient fit within it?” This subtle shift opens the door to more adaptive, personalized care.
Many retinal diseases are chronic, requiring ongoing monitoring and repeated interventions. For patients, this can feel like an endless cycle of appointments and injections. For physicians, it can become a logistical and emotional challenge—balancing clinical demands with the realities of practice management.
Photo courtesy of Kevin Caldwell Photography.
If we frame chronic disease as a burden, both patient and physician may approach care with a sense of fatigue or resignation. But if we reframe it as a partnership, the dynamic changes.
In this partnership model, the patient is not a passive recipient of care, but an active participant. Education becomes central—not as a one-time conversation, but as an ongoing dialogue. Expectations are aligned early and reinforced often. The goal is not simply to treat disease, but to co-manage it.
This reframing has practical implications; it encourages us to invest time in communication, to leverage ancillary staff more effectively, and to utilize digital tools for monitoring and engagement. The partnership model also fosters a sense of shared responsibility, which can improve adherence and satisfaction.
Advances in retinal imaging have transformed our ability to diagnose and monitor disease. Optical coherence tomography (OCT), widefield imaging, and angiography provide unprecedented detail. Yet, there is a risk in how we interpret these images.
Too often, we treat imaging as a snapshot—a static representation of pathology at a single point in time. But retinal disease is dynamic; fluid fluctuates, lesions evolve, and structural changes may lag behind functional outcomes or vice versa.
Perceptual reframing invites us to view imaging as part of a narrative, rather than a stand-alone data point. Serial imaging becomes a story of progression or stability. Subtle changes gain significance when viewed in context. And discrepancies between structure and function prompt deeper inquiry, rather than reflexive intervention.
This approach also has implications for treatment decisions. Rather than reacting to every fluctuation, we can adopt a more nuanced strategy—one that balances anatomic findings with visual acuity, patient-reported outcomes, and overall trajectory.
No discussion of retina care would be complete without acknowledging the economic realities of our field. Reimbursement models, drug costs, and practice efficiencies all influence decision-making. These factors are often framed as constraints—limitations that dictate what we can and cannot do.
But what if we reframed them as variables within a broader system?
This perspective encourages innovation; it challenges us to think creatively about care delivery—whether through extended dosing intervals, alternative treatment paradigms, or integration of new technologies. It also highlights the importance of value-based care, where outcomes are measured not just in clinical terms, but in cost-effectiveness and patient experience.
Perceptual reframing does not eliminate economic pressures, but it changes how we respond to them. It shifts us from a reactive stance to a proactive one.
In vitreoretinal surgery, decision-making is often framed in binary terms: operate or observe. But the reality is more complex. Timing, technique, and patient factors all influence outcomes.
Reframing surgical decisions as part of a continuum, rather than a discrete event, can enhance our approach. Preoperative optimization, intraoperative adaptability, and postoperative management are all interconnected. Each phase offers opportunities to influence outcomes.
This perspective also encourages humility. Even with the best planning and execution, variability exists. By acknowledging this, we remain open to learning and improvement.
We clinicians are not immune to cognitive bias. Anchoring, confirmation bias, and availability heuristics can influence our decisions. In retina, where patterns are familiar and time is limited, these biases can be particularly insidious.
Perceptual reframing serves as a countermeasure. By consciously questioning our initial impressions, we create space for alternative interpretations. This does not mean abandoning experience, but refining it.
Simple strategies can help. Taking a moment to consider differential diagnoses, seeking second opinions in ambiguous cases, and reflecting on outcomes can enhance decision-making. Over time, these practices become part of our cognitive framework.
Artificial intelligence (AI) and machine learning are poised to further transform retina care. Algorithms can analyze imaging, predict disease progression, and even suggest treatment strategies. These tools offer tremendous potential, but they also require a shift in perception.
If we view AI as a replacement for clinical judgment, we may resist its adoption. But if we reframe it as an augmentation—a tool that enhances our capabilities—the integration becomes more natural.
The challenge will be to maintain the human element of care. Empathy, communication, and ethical decision-making cannot be automated. Perceptual reframing will be essential in balancing technologic advancement with patient-centered care.
Reframing is not just an individual exercise; it is a cultural one. Training programs, professional societies, and practice environments all shape how we think.
Incorporating perceptual reframing into education can have lasting impact. Case-based discussions that explore multiple perspectives, mentorship that encourages questioning, and a culture that values adaptability contribute to this process.
Leadership plays a critical role. As senior clinicians and educators, we set the tone. By modeling reflective practice and openness to change, we influence the next generation.
Ultimately, the success of any reframing effort must be measured by its impact on patients. How do they perceive their care? Do they feel heard, understood, and engaged?
Patients bring their own frames of reference—shaped by experience, culture, and expectations. Aligning these with our clinical perspective is not always straightforward; it requires listening, empathy, and flexibility.
Reframing can help bridge this gap. By understanding how patients view their condition, we can tailor our communication and approach. This not only improves satisfaction but can also influence outcomes.
In This Issue
Panozzo and Bellisario 1 present a review on myopic traction maculopathy that evaluates clinicopathologic classification. The authors focus on type 1 intraretinal traction and type 2 vitreoretinal traction, with type 3 including mixed traction maculopathy. Of course, the goal remains the identification and approach to treatable traction maculopathy that positively impacts vision as well as anatomy. Zhang et al 2 used the TriNetX platform to evaluate the prevalence of myopia-related retinal detachments within the United States from 2015 to 2024 and noted increasing age, racial predilection for Asians and Caucasians, and a predilection for men moreso than women. Mesfin et al, 3 again using the TriNetX platform, described the risk of cataract surgery after retinal detachment in myopia. The study highlighted the role of increasing myopia and decreasing age at the time of cataract surgery as risks requiring close postoperative monitoring. Combined phacovitrectomy surgery, as espoused outside the US, may grossly reduce this risk. Siddiqui et al 4 describe the indications and outcomes for eyes successfully repaired with pneumatic retinopexy but requiring a secondary vitrectomy. Fortunately, only 2% of eyes in this series needed secondary surgery, with epiretinal membrane, macular hole, or vitreous opacities leading to vitrectomy. Of note, the authors cite the 81% primary success rate for pneumatic retinopexy reported in the PIVOT trial. Acaba-Berrocal et al 5 evaluate a curable hydrogel to close both pediatric and adult sclerotomies without the need for suturing. Scleral plugs have been discussed for wound closure, but the evolution of microincision vitrectomy surgery has greatly reduced the need for sutures. Uniquely, pediatric wounds are typically sutured either with or without silicone oil placement, leaving a gap that this approach may potentially address. Govindaraju et al 6 report OCT-detected outer retinal changes associated with indwelling silicone oil. Removal of the silicone oil resolved 90% of these changes, prompting the authors to suggest that silicone oil removal, when appropriate, may lead to improved final visual acuity. Gupta et al 7 reported on tracking of surgeons’ gaze during vitrectomy and membrane peeling and suggest that gaze behavior can differentiate expert surgeons from novice trainees and may establish a model for improved surgeon visualization during these procedures. Song et al 8 present data from 2 safety net hospitals in the LA County system focusing on the impact of the COVID-19 pandemic on presentation and outcomes for vitrectomy for diabetic retinopathy. As seen with other pandemic analyses, delays in care were prominent and associated with worse visual outcomes. Chahal et al 9 piloted the use of a large language model (LLM) chatbot to handle retina patient emergency phone calls and noted that, currently, human-based phone triage outperforms the majority of AI platforms. The authors suggest that the evolution of these LLM systems could lead to better management of emergency retina calls. Sastry et al 10 evaluated visual deficits in diabetic retinal disease and noted that racial and ethnic disparities continue to exist, although the etiologies for these disparities remain multifactorial and may not be amenable to simple fixes.
Groothoff et al 11 used another marker for socioeconomic disparity, the area deprivation index, to evaluate the impact of anti-VEGF treatment for diabetic macular edema and found no impact on treatment patterns or anatomic outcomes, potentially suggesting regional differences in handling socioeconomic deprivation. Momenaei et al 12 evaluate physician-directed pausing of anti-VEGF in the setting of branch retinal vein occlusion in 402 eyes. Of note, almost 40% of patients required re-institution of anti-VEGF after pausing treatment, reiterating the critical importance of long-term follow-up to enhance anatomic and visual preservation.
Shiratori et al 13 compare faricimab with high-dose aflibercept in patients with nAMD, noting excellent response to either intravitreal agent. High-dose aflibercept was associated with a faster resolution interval but not a better anatomic or visual outcome, suggesting that anti-VEGF treatment itself is the key component to enhanced outcomes in nAMD.
Nagayama et al 14 revisit the use of brolucizumab intravitreal injection combined with sub-Tenon injection of triamcinolone acetonide for diabetic macular edema and noted significant decrease in injection frequency without evidence of significant vasculitis. As detailed by the ASRS ReST committee, brolucizumab-associated irreversible vision loss has virtually eliminated this treatment approach in the US and many other countries. Levenson et al 15 used accelerometer-measured physical activity to assess the correlation between physical activity and diabetic retinopathy, noting that increased physical activity decreases the presence of diabetic retinopathy. The authors suggested that wearable technology may play a future role in personalizing diabetic management. Lyons et al 16 used a pooled cohort equation to prevent heart failure calculation to stratify heart failure risk and correlated this with OCT angiography (OCTA) vascular changes observed in those patients with elevated risk. Naik et al 17 evaluated 2 methods for managing postoperative vitreous hemorrhage and suggested that intraoperative fluorescein angiography decreased the incidence of recurrent hemorrhage, potentially better delineating both the cause leading to recurrent hemorrhage and enhancing its treatment. Zhang et al 18 identified 50 cases of delayed scleral buckle removal from the Bascom Palmer Eye Institute and noted culture positivity in 40% of the removed buckles. After buckle removal, 8.3% of eyes developed recurrent retinal detachment. Guedes et al 19 report scleral fixation of the MA60AC intraocular lens (IOL) with 10.0 Prolene suture vs Akreos IOL fixation with polytetrafluoroethylence suture and noted higher complications in the Akreos IOL group; the differences were not statistically significant. Dey Sarkar et al 20 present OCT biomarkers for Torpedo retinopathy and propose an updated classification system. Shah et al 21 present a small case series evaluating ultra-widefield swept-source OCTA imaging in diabetic retinopathy and suggest this less invasive imaging may guide earlier clinical interventions. Hilgert et al 22 present a case series focused on choroidal neovascularization (CNV) associated with extensive macular atrophy and pseudodrusen, noting that early diagnosis and targeted anti-VEGF treatment is associated with improving vision. Khoussine et al 23 used adaptive optic imaging to uncover photoreceptor alterations associated with visual distortion from cystoid macular edema (CME) and postulate these alterations are responsible for visual blurring after resolution of CME. Li et al 24 present a case of fluctuating subretinal fluid in a 67-year-old woman who underwent delayed photodynamic therapy (PDT) when seen with fluid resolution at the time of planned PDT. The authors suggest ongoing screening to minimize visual compromise. Pandiri et al 25 present a 67-year-old man with visual blurring in the setting of CME with systemic multiple myeloma. Of note, use of topical dorzolamide led to improvement. Alshehri et al 26 report a 40-year-old woman with a full-thickness macular hole in the setting of macular telangiectasia type 2 repaired with an inverted inner limiting membrane flap and 20% sulfur hexafluoride. Marrero et al 27 present a 20-year-old woman with a serous retinal detachment associated with a cavitary disc maculopathy managed with optic nerve sheath fenestration and juxtapapillary laser photocoagulation. Meshkin et al 28 report 3 cases of inherited retinal disease as a risk factor for paclitaxel maculopathy. Fortunately, discontinuation of paclitaxel led to resolution of CME and visual recovery. Pandiri et al 29 describe a 29-year-old woman presenting with immediate visual loss secondary to acute macular outer retinopathy after rapid electrolyte repletion. The authors suggest the importance of electrolye balance in homeostatic regulation of retinal function. Su and Sobol 30 report a 70-year-old man with leptovitelliform maculopathy evaluated with long-term multimodal imaging, noting progressive collapse of the vitelliform lesions that resulted in outer retinal atrophy.
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In retina specialty care, we often concentrate on restoring vision. But perhaps we should help ourselves, and our patients, to focus more broadly on how we see: how we interpret, decide, and interact through our visual environment.
Perceptual reframing is not a technique to be applied in isolation; it is a commitment to a mindset of questioning assumptions and embracing complexity. It challenges us to move beyond the familiar, and to engage with our patients in a more thoughtful, deliberate way.
As our field continues to evolve, this mindset will be increasingly important. The challenges we face—clinical, economic, and technologic—are not easily solved with traditional approaches. They require new ways of thinking.
In the end, perceptual reframing is about more than improving retina specialty care; it is about sustaining our sense of purpose in a demanding field. Perceptual reframing reminds us that even as we navigate complexity, we have the capacity to adapt, to innovate, and to see differently.
And in seeing differently, we may find that we are better equipped to treat—not just disease, but the people who live with it.
“The real voyage of discovery consists not in seeking new landscapes, but in having new eyes.” —Marcel Proust
