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Centurion® Vision System for cataract surgery

The Centurion® Vision System is not only a new phacoemulsification system integrating some of the newest technologies, but is also the central part of the Cataract Refractive Suite by Alcon
Gabor Scharioth MD PhD
Aurelios Augenzentrum Recklinghausen,
Germany; Department of Ophthalmology, 
University of Szeged, Hungary
Cataract surgery is one of the oldest medical interventions in human history. In ancient times, the mature cataractous lens was dislocated into the vitreous cavity with a needle. Visual axis became clear and the patient could orientate. From the 19th century onwards, the lens was removed through a large incision of approximately 12mm in size, leaving the patient aphakic (intracapsular technique). Later, the incision size was reduced and the lens capsule was left in place (extracapsular technique). This allowed intraocular implantation of artificial intraocular lens in the posterior chamber and improved visual rehabilitation of patients after cataract surgery. This was the beginning of modern cataract surgery. 
A revolutionary step
The introduction of a machine-based technology to remove the cataractous lens through a small incision was the revolutionary step in modern cataract surgery. This technology is called ultrasound phacoemulsification and has evolved continuously over the last three decades. Today, cataract surgery is not only the lens removal through a self-sealing micro incision of approximately two millimetres with implantation of a intraocular lens with an advanced optic that for many patients results in a better vision that they ever had before in life, but is also the most frequently performed surgery with more then 700,000 cataract surgeries per year, in Germany alone. Continuous advancements in phacoemulsification technology standardised the surgery, making it reliable, and with very low risk for complications. 
Driving innovation
Alcon, as the leading company in this field, has supported modern cataract surgery from the beginning, with continuous development of surgical machines, devices and intraocular lenses. 
The Legacy® System was one of the most popular phacomachines in the 1990s. The system used traditional longitudinal phacoemulsification with straight tip. The introduction of the Infiniti® Vision System with OZil® technology (using torsional phacoemulsification with Kelman® tip) was a revolutionary step in modern cataract surgery; delivered ultrasound energy during cataract surgery could be reduced dramatically by using this technology. Over the past decade, the Infiniti® Vision System became the most popular phacomachine worldwide. In modern cataract surgery, a key unmet patients need is to improve the refractive outcomes to produce results comparable to those achieved with laser vision correction. While most of the ophthalmologists believe ±0.5D to be an acceptable range of post-cataract surgery refractive error, only 57% of patients are within that range, suggesting that there are unmet needs. 
The Cataract Refractive Suite
Alcon is introducing ‘The Cataract Refractive Suite’, to deliver the refractive outcomes that surgeons expect and which your patients desire. The Cataract Refractive Suite surrounds surgeons with best-in-class technologies, helping them to perform some of the most challenging steps in cataract surgery, with automation and precision. 
This starts with pre-operative measurements, advanced eye imaging, surgical procedure planning and IOL selection (VERION™ Image Guided System). If the clinic is equipped with femtosecond laser technology, the following step of the procedure precisely and accurately performs crucial steps of cataract surgery, including capsulotomy, lens pre-fragmentation and corneal incisions with the LenSx® Laser, resulting in fewer intraoperative complications and optimised postoperative lens positioning. The use of a modern microscope (LuxOR™) with increasead depth of focus and bright red-reflex enhances the surgeon´s control during the procedure. The central part of this suite concept will be a completely new phaco system – the Alcon Centurion® Vision System.
Centurion® Vision System
The Centurion® Vision System is a logical evolution of the Alcon Infiniti® System. The surgeon and the assisting team will find it easy to adapt. OZil® phacoemulsification handpieces from existing Infiniti® machines and automated insertion systems for intraocular lenses (AutoSert®) can be used on the new machine. The set up of the machine is easy and logical. The program is intuitive and guides users through the steps of surgery with ease. The machine has a modern design, with a smooth surface for cleaning and a robust chassis. Both the LenSx® Laser and the Centurion® are designed to work seamlessly with the VERION™ Image Guided System; this integration allows surgeons to see all incisions and IOL alignment in real time and enables accurate centring and positioning of multifocal and toric IOLs.
Over the last year, we had the chance to work with the new Alcon Centurion® Vision System phacomachine and have performed 1400 procedures with Centurion® to date. Before this, we were using the Alcon Infiniti® Vision System and other competing systems, and performed more then 3000 cataract surgeries in our clinic (Aurelios Augenzentrum Recklinghausen, Germany).  
New fluidics
In the past decade, energy delivery during cataract surgery was improved by using modern technologies like torsional phacoemulsification with OZil®. Incision size was reduced to two millimetres and below; this resulted in less trauma to the eye and faster recovery. But reduced incision size decreased infusion capability, while the smaller lumen of the phaco tip required higher aspiration and/or vacuum. The fluidics misbalance was managed by increased infusion bottle height of up to 120cm. This results in high intraocular pressure during cataract surgery with the risk of damaging intraocular tissues (for example, optic nerve). As traditional infusion systems work passively with gravity, there is a delay in compensation of fluid loss. This results in weak anterior chamber stability.
The new Active Fluidics® technology in the Centurion® Vision System overcomes these problems. There is a continuous active management of fluidics controlling all aspects of fluidics during cataract surgery. An important part of this technology is a new pump system and fluidics management system. Even very small amounts of fluid could be moved in this system in a very controlled manner. Sudden changes are managed proactively. To optimise this technology, the machine is set for the patient´s eye level compared to the level of the aspiration pump. As different handpieces and tips with different inner lumens could be preferred by the surgeons, resulting in different resistance to flow, the machine is also set for this (irrigating factor). An optimal/optimised management of fluidics has also taken into account that fluid is not only aspirated by the machine but also lost by leakage from incisions during the surgery. To improve Active Fluidics®, the machine is set for an estimated leakage/loss of fluid. 
This integrated, automated system that intelligently optimises chamber stability, allows surgeons to proactively target and have the system work to maintain the intraocular pressure they deem appropriate for the patient during the procedure. It seems that phacoemulsification with lower intraocular pressures and Active Fluidics® technology decreases intraoperative lens capsule/iris movement and increases anterior chamber stability. In our experience, this results in lower complication rates (for example, lens capsule breaks). This increases safety of cataract surgery and, is in our opinion, a major step towards the perfect optimal cataract surgery. 
Increased efficiency
Over the past decade, the Kelman® tip and OZil® technology became very popular, and became the gold standard in phacoemulsification for many surgeons. OZil® technology is using torsional phacoemulsification. This results in a more effective energy delivery to lens material and improved followability by eliminating the repulsion associated with the jackhammer effect of longitudinal ultrasound. The new Intrepid® Balanced tip enhances emulsification by maximising displacement of the distal end of the tip. This effectively helps to reduce delivered ultrasound energy and to minimise side effects. We found that the preset power could be reduced by at least 20% while using the Intrepid® Balanced tip.
Some surgeons never favoured bend tip design (Kelman® tip) and could therefore not use the advantages of torsional ultrasound. The new Intrepid® Balanced tip seems to improve acceptance from surgeons who prefer straight tip design. 
Safety first
The new Active Fluidics® technology in the Centurion® Vision System includes a new concept for irrigation. The irrigation solution is in a soft bag that will be placed in a bag-loading bay. The machine will continuously estimate the remaining irrigation solution and show the calculated volume on the screen. The circulating nurse is less fixed to the machine and illumination in the operating room could be dimmed without risk to missing a low fluid level in the irrigation bottle. If the remaining volume is below 100ml, the machine produces acoustic and visual warning signs. In case of an almost empty irrigation bag, first aspiration is automatically stopped while irrigation is still on. 
A simple but effective precaution is the luer lock connection of the irrigation tubing to the phaco handpiece and the new disposable irrigation–aspiration handpieces. This eliminates the risk of disconnection and sudden loss of anterior chamber during cataract surgery. These innovations prevent one of the most dangerous situations during phacoemulsification.
Reducing incision size requires improved irrigation sleeve design. The new Intrepid® sleeves will not just allow sub-2mm incision cataract surgery but will also increase anterior chamber stability due to advanced design. The new Intrepid® sleeve reduces displacement of the phaco tip within the sleeve. This stabilises irrigation and reduces the risk for thermal damage to the surrounding tissue. 
The new wireless footswitch optimises safety in the operating room. No cable is present on the floor between the Centurion® Vision System and the footswitch. It allows the surgeon to control all major steps during the entire surgery. During the past year, we have not encountered a problem related to the connection between the console and the wireless footswitch. 
Ready for the future 
The Centurion® Vision System is not only a new phacoemulsification system integrating some of the newest technologies but is also the central part of the Cataract Refractive Suite by Alcon. It allows the use of proven technologies such as OZil® and AutoSert® from the current Alcon Infiniti® Vision System but is also designed to adapt future new technologies such as the Intrepid® Rhexis device. Video overlay is already available and if surgeries are recorded, will document every surgical step. An interactive interface will also allow integration of future technologies such as a head up display.