"The excellent red reflex, combined with the IOL guidance system, makes it possible for me to work quickly and precisely during refractive procedures."

Interview with Dr. Ulrich Jung, Medical Director at the ARTEMIS eye clinic, on his experience with the Proveo 8 and IOLcompass Pro

Patients place very high expectations on refractive procedures. They expect to gain full visual acuity without the need for glasses. Excellent red reflex as well as maximum accuracy throughout the entire procedure are required to meet these expectations. Dr. Ulrich Jung, Medical Director at the ARTEMIS eye clinic in Dillenburg, Germany, tested the Proveo 8 ophthalmic microscope from Leica Microsystems in combination with the positioning system IOLcompass Pro for intraocular lenses at his clinic. In this interview, he gave while visiting the company headquarters in Wetzlar, Germany, Dr. Jung reports his experiences with Proveo 8 and IOLcompass Pro.



Dr. Jung, please explain your area of expertise at the ARTEMIS eye clinic

Dr. Jung: At our clinic, I primarily perform operations on the anterior segment of the eye. These include cataract operations, operations on the cornea, conjunctiva and eyelids, plastic reconstructions and lacrimal duct surgeries. Dr. Jandeck and Dr. Hörle, our two retinal specialists on the team, are the experts in operations on the posterior section of the eye.

What is the significance of the red reflex for cataract operations?

Dr. Jung: The quality of the red reflex, in addition to the image quality, are the key issues in all cataract surgeries. Only a sharp and high-contrast image with the brightest red reflex possible in dilated pupils enables the surgeon to recognize details quickly and clearly, despite the opacities from the cornea, lens and vitreous humor that sometimes cause substantial interference.

The red reflex is also immensely helpful during capsulorhexis, even in opaque media. It is much easier to identify capsule tensions and folds in regredient red light and the blood vessel ruptures are easier to anticipate. The poorer the red reflex, the more difficult things become.

If there is no red reflex, it is possible to dye the capsule with trypan/methylene blue dye. However, if the patient has a good red reflection, it is much easier and quicker to perform the procedure.

What is your opinion of the red reflex with the new Proveo 8 system?

Dr. Jung: It's excellent! We are already somewhat spoiled by the red reflex quality of the Leica M844 microscope and its predecessor model with the OttoFlex illumination system. The red reflex of the new Proveo 8 and its LED light source appears to be even more uniform and highly contrasted than the red reflex of our current microscopes with halogen illumination, and we were already very satisfied with these microscopes.

Why is image quality important for the assistant during an operation?

Dr. Jung: Even an assistant new to the practice should be able to observe every important detail carefully throughout the operation and therefore needs to be able to see just as well as the surgeon. The stereopsis in the beam path of the assistant's microscope should be so good that the assistant is able to follow everything the surgeon is showing him or her. This means that comments such as 'this is above, this is below, here I am in front of the capsule, here I am behind the capsule' are self-explanatory and it ensures that procedures make sense and can be followed easily.

In Leica microscopes, the double beam path in particular is the prerequisite for good stereopsis and good image quality. This is also true for the assistant's tube.

"I think the Proveo 8 will become a standard fixture in operating rooms and a favorite among ophthalmic surgeons."

How would you summarize your experience with the Proveo 8 system?

Dr. Jung: Overall, very positively. It takes some time to get used to the new, wide and smooth stand. It's larger, similar in size to a small advertising column, and takes up more space. However, this stand can easily accommodate numerous types of auxiliary equipment that require little care and are used in the field of modern ophthalmic surgery.

When hygienists visited us in the operating room during the Proveo 8 test phase, they quickly smiled when they caught a glimpse of the large smooth surfaces and noticed the absence of any cables. Additionally, hygiene specialists can now clean everything much more effectively. One aspect that required some getting used to at first was that fact that previously, the microscope arm only rotated upward while the column and the base remained stationary.

In the new Proveo 8, the entire column now rotates above the base easily and ergonomically. Overall, this is a highly practical and elegant solution, which also happens to look great. I think the Proveo 8 will become a standard fixture in operating rooms and a favorite among ophthalmic surgeons.

What's your opinion of the image quality of the Proveo 8?

Dr. Jung: The image quality of the Proveo 8 is outstanding. We are already spoiled by Leica anyway, but in my subjective opinion, the illumination, contrast and image sharpness in this new microscope cannot be compared with other microscopes in the high-tech sector. And these other microscopes are by no means of poor quality. I think the Proveo 8 microscope is simply great!

What is the significance of IOL guidance technologies in modern refractive surgery?

Dr. Jung: These technologies are very important. In refractive surgery, it is important to correct the visual defect in the eye in the best possible way. For this reason, toric lens systems are a daily topic of discussion. Of course, patients ask, "What is best for me, my eyes and my life situation?" Some people are satisfied when they are able to see well again. "The glasses aren't really important. I like wearing them and I've always worn them, so I don't see a need to change that."

Some patients do not need and do not want every bell and whistle available in refractive treatment. Nevertheless, many patients say: "If it's possible to correct all of my visual defects with a special toric implant, I'd rather do that." We have to make sure that the axis is just right for these patients. Of course, we endeavor to guarantee this by using the highest level of precision during the implantation and the adjustment of the intraocular lens in the eye.

It is important to realize that an axis deviation of 10° reduces the desired toric lens effect by half. At an axis deviation of 30°, there is no positive effect on vision whatsoever. For this reason, we rely on achieving the highest possible level of precision. Ideally, the axis marking is controlled using digital imagery and based on the conjunctiva or iris vessel sample. This procedure is currently the most precise surgery that we have.

As a result, there is no need for us to carry out elaborate marking with the pendulum marker in the operating room because we have a very precise system in place with image recognition. It reacts to changes during the operation, such as bulb rotations and thus provides us with higher levels of safety. This is quite important and given the application safety available now, it won't be long until every operating room uses an IOL guidance system like this.

What is your opinion of the IOLcompass Pro lens positioning system from Leica Microsystems?

Dr. Jung: The excellent precision of the digital image recognition for axis marking in toric lenses is undisputed. It's very important that image recognition works reliably for use in operational practice. It should also continue to function when some of the distinctive features are omitted or changed in the digital image that result from tissue swelling with the displacement of vessels, small conjunctival hemorrhages or other similar situations. I want to work with the topography system that I trust the most to execute high precision measurements.

IOLcompass Pro can be combined seamlessly with my topography systems and my Leica microscope and does not force me to make additional investments. As soon as the preoperative digital image is stored above the live operating image, I have a precise axial position I can use to orient the position of the lens. The stable display of the astigmatic axis during the positioning process makes it possible to quickly and precisely carry out procedures without interruption.

How would you rate the cooperation with Leica Microsystems?

Dr. Jung: We are very satisfied with the service. This might have something to do with our close vicinity to the Leica Microsystems headquarters in Wetzlar, but we have yet to have any problems. We had a defective footswitch and within one day, we had a new replacement switch. In general, surgical microscopes are not maintenance-intensive or high-maintenance if used carefully. We have had very good experiences with Leica Microsystems.

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