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The Impact of a Stable Red Reflex and Enhanced Focus in Cataract Surgery

Interview with Ike Ahmed: “I was captivated by Proveo’s unparalleled and consistent red reflex throughout the entire procedure.”

In cataract surgery, ophthalmologists rely on the red reflex which provides ideal contrast to visualize the capsule, lens and anterior chamber structure. A new illumination technology in the latest of ophthalmic microscopes now appears to provide great breadth of red reflex enhancement throughout the entire procedure.


Dr. Ike Ahmed is one of the first ophthalmologists having tested the Proveo 8 microscope which features the CoAx4 illumination. He is assistant professor and the director of the Glaucoma and Advanced Anterior Segment Surgery fellowship at the University of Toronto, Canada.


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Would you please explain your field of work and describe the challenges you are dealing with?

Ike Ahmed: My focus lies primarily on complicated cataract cases, lens implants and glaucoma surgery. I have an academic practice, I am teaching residence fellows and medical students regularly. I am also very actively involved in research and innovation in medical technology and education as well. In the three different centers within the greater Toronto area where I operate I am working with different microscopes, different technologies and surgical tools.

My interest lies as well in the development of surgical instrumentation and some of my own devices for lens implants as well. I really take a lot of interest and pride in optimizing the surgical field as best possible, which includes the documentation and recording of cases to learn from and to teach.

One of the things in eye surgery which is most challenging is that we have to see what we are doing. In some cases this can be difficult, especially in complicated cataract or glaucoma procedures. Visualization can be challenging because of the view or because of the pathology.

Enhancing technology can help us to achieve optimal visualization, whether that is with microscopes or with one of the newer technologies like 3D heads up display, surgical guidance systems and OCT guided procedures. I am fascinated by the possibility to expand our work beyond what we can see with a basic microscope set up!

Which importance does the red reflex for cataract surgery have? In which way does Proveo 8 make a difference?

Ike Ahmed: One of the challenges with visualization is enhancing the red reflex particularly during phacoelmusification, cataract extraction and also during the intraocular lens surgery. The red reflex gives us the ideal contrast as well as the important depth in terms of where we are working within the eye.

So one of the important features of a microscope is to ensure the red reflex and optimal visualization throughout the entire procedure – not only during capsulorhexis, but during lens extraction as well.

One of the benefits especially with Proveo 8 is the way the illumination is achieved by using four coaxial LED light sources. The optics of the microscope and the innovative additional depth of focus allow us to enhance the ability to visualize the procedure throughout the entire case.

That is the experience I had with the Proveo 8. I appreciate the benefit of having the enhance visualization whether it means of the red reflex or it means of the tissue itself. Optimizing the quality of view is one thing that is beneficial.

But there is another thing that I think is pretty cool: I like to zoom in to see what I am doing with a high magnification. Normally, that means frequent refocusing. But the enhanced focusing features of the Proveo 8 microscope, which is called FusionOptics, allows us to maintained focused over a larger depth – which means we are less working with the foot pedal, we can see more, and we can do better surgery. I found that helps.

Which impact does the quality of the assistant’s view have on the surgery?

Ike Ahmed: I always have an assistant whether a resident or a fellow working with me. I am also often assisting them during surgery and so it is absolutely critical that the quality of the assistant’s scope is the same as the surgeon’s scope.

By having maintenance of the red reflex and having magnification linked with the surgeon ensures that I have the optimal teaching environment. That is one thing I really liked and enjoyed with the microscope. It is important with all microscopes in terms of what I can do as far as teaching and visualizing.

Do technologies like IOL guidance systems or intraoperative OCT play a role in your OR?

Ike Ahmed: We are still early with it. The technological merger of diagnostics and microscope – because I think that’s where we are going with this – leads to enhanced workflow and accuracy. But we are going to learn more where we are going with this.

The OCT for retina and cornea is a nice way to determine tissue plane and optimal dissection. In cataract/IOL surgery we are looking at this for optimal lens positioning. Its use for angle visualization is potentially cool for glaucoma surgery. We are still early in this and I am excited where this may go.

If you summarize your experience with Proveo 8 in one sentence, what would you say?

Ike Ahmed: It was pretty mind blowing – I was captivated by the unparalleled and consistent red reflex and tissue visualization throughout the entire procedure.