Advanced-Technology Cataract Surgery

Series No. 6

Sponsored by Alcon Laboratories, Inc.

CENTURION Vision System: My Experience

Experience with torsional energy.
BY DANIELE TOGNETTO, MD

I
have been using INFINITI Vision System with OZil tech- using a longitudinal pulse of energy to produce a burst of
nology since it was launched in 2006. From my first repulsion when a preset vacuum threshold is reached.10,11
hours, I noticed a significant improvement in followabil- In my clinic’s operating theater, we use different phaco
ity and a reduction in repulsion compared to my experi- machines. I exclusively use INFINITI Vision System with
ence using longitudinal phacoemulsification.1 At that OZil IP. I was impressed by the efficiency and perfor-
time, I got the impression that this torsional tip move- mance of this machine; so much so, I did not think that
ment was an innovation in cataract removal surgery. Over we could get any better.
time, I have come to believe the torsional modality leads
to a reduction in ultrasound time (UST) and cumulative MY EXPERIENCE WITH CENTURION
dissipated energy (CDE) compared to longitudinal modal- VISION SYSTEM
ity,1-3 since the torsional tip movement can result in less In 2013, Alcon launched the CENTURION Vision
chattering of material at the tip as the back-and-forward System. From my early experience with the CENTURION
movement of longitudinal modality is replaced by the Vision System, I feel it provides two main technical inno-
side-to-side tip movement of torsional modality. The vations that make this system unique and revolutionary:
reduction of chattering4,5 leads to an increase in removal • The Active Fluidics Technology
efficiency of the cataract removal procedure.1,2,6 • The CENTURION Energy Delivery, especially utilizing
The use of the torsional ultrasound modality has the INTREPID BALANCED Tip
been associated in the literature with a reduced loss of
endothelial cells and tissue damage compared to the ACTIVE FLUIDICS TECHNOLOGY
traditional longitudinal modality’s literature.1,2,6 Also, the In the CENTURION Vision System, the Active Fluidics
thermal profile of the tip’s movement has been shown to technology means that the irrigation inflow is not pas-
be lower using the torsional modality over the longitudi- sively linked to the static height of the bottle, but is con-
nal modality.7,8 trolled by dynamic compression of a soft bag by a plate
In 2012, colleagues and I published in the Journal of inside the system. This allows the CENTURION Vision
Cataract & Refractive Surgery a study entitled, “Stroke System to rapidly detect and compensate for dynamic
Dynamics and Frequency of 3 Phacoemulsification changes that affect the anterior chamber, leading to
Machines,”9 in which we compared the working frequen- enhanced chamber stability.
cy and the stroke dynamics of the phaco tip for three The rapid compensation is governed by the informa-
different systems. In contrast to other phaco delivery tion derived from a combination of a vacuum sensor
systems, The INFINITI Vision System with OZil technol- placed along the aspiration line, the known flow rate,
ogy showed a progressively increasing lateral movement and by a pressure sensor placed along the irrigation line.
according to the increased phaco power, almost without This technology, which responds to very small changes
any longitudinal movement, both at the end of the tip in pressure, allows the surgeon to select the target pres-
and at the incision site. sure inside the eye throughout the procedure. The system
The torsional tip’s movement may provoke a kind also incorporates a unique low-compliance design that
of “fogging” effect due to the pulverization of the lens reduces the storage of potential energy and postocclusion
material, reducing visibility in the anterior chamber. Also, surge. This allows two surgical advantages: enhanced con-
high-vacuum procedures using flared or tapered tips may trol of intraocular pressure throughout all stages of the
lead to material not moving completely through the tip. procedure, and the option to operate at a lower surgical
This occlusion by small, hard lens fragments could make target pressure.
it necessary to stop the procedure and clear the obstruc-
tion. These effects were overcome in 2009 with the inno- CENTURION ENERGY DELIVERY
vative OZil IP (Intelligent Phaco) software (Alcon). This The second innovation of CENTURION Vision System
enhancement helps surgeons avoid strong occlusions by is in energy delivery. I used the CENTURION Vision

Please see page 3 for important information about these products. JULY 2015 INSERT TO CATARACT & REFRACTIVE SURGERY TODAY 1

CENTURION Vision System, INFINITI, INTREPID, and ACTIVE FLUIDICS are trademarks of Novartis. © Novartis 2015. All other brand/product names are the trademarks of their respective owners.
 Advanced-Technology Cataract Surgery Series No. 3

CENTURION VISION SYSTEM ENERGY DELIVERY

CENTURION Energy Delivery combines existing and new • Increasing in FP 3: This ability, unique to CENTURION
capabilities to enhance the efficiency of cataract removal: System, allows surgeon to “grab” and “hold” fragments
1. The Active Fluidics capabilities of CENTURION Vision for repositioning and the next round of phaco and aspi-
System. ration.
2. OZil torsional technology (including OZil IP). These choices help the surgeon achieve his or her prefer-
3. And especially with the enhanced performance of the ence regarding how to manage the interaction of bringing
BALANCED tip. materials to the tip (via aspiration), holding material to
With the CENTURION Vision System, in addition to the allow desired repositioning (vacuum), along with emulsifi-
Active Fluidics technology designed to maintain chamber sta- cation and repulsion of material at the tip (phaco energy
bility, the surgeon can choose CENTURION Energy Delivery delivery), and finally removal from the anterior chamber
capabilities in aspiration and vacuum to help (aspiration), with a wider range of choice than is available
on INFINITI Vision System. The result is the desired use of
• bring materials to the tip;
cumulative dissipated energy (CDE) needed to achieve cata-
• have materials at the tip behave the way the surgeon
ract removal efficiency.
prefers;
• move material through the tip. These capabilities are added to the OZil IP (Intelligent
With INFINITI Vision System, vacuum and aspiration can Phaco), where a surgeon-selected amount of longitudinal
be linear (or fixed) in foot pedal position 2 (FP 2). In FP 3, the energy can be employed to provide momentary repulsion
surgeon-selected parameters are always fixed. when a vacuum threshold is achieved.
With the CENTURION Vision System, vacuum and aspiration All the above work with all of the Alcon phaco tips.
can be linear (or fixed) in FP 2 and, can be either: However, due to the design of the BALANCED tip, where the
energy is focused at the distal end of the tip and the torsional
• Fixed in FP 3: Like INFINITI Vision System
amplitude is greater, the level of efficiency achieved is further
• Decreasing in FP 3: This ability, unique to CENTURION
enhanced.
System, allows the surgeon to reduce vacuum and flow
while applying phaco energy. It is designed to reduce the
surge at the occlusion break.

System with the INTREPID BALANCED tip, an innovative EXPERIENCE WITH INTREPID BALANCED TIP
design that has been specifically designed to enhance In order to test the effectiveness of the CENTURION
the characteristics of the OZil torsional motion. The Vision System with the INTREPID BALANCED tip, we
INTREPID BALANCED Tip has two opposite bends removed some hard cataracts. We first divided the nucle-
along its axis, with an overall profile similar to a straight us into two parts, and then removed the first half using
tip. The maximum lateral stroke of the tip is equal to the Mini Flared Kelman Tip and the second half using
180 µm, significantly higher than the typical Kelman tip, the INTREPID BALANCED tip. The total phaco time was
whose stroke can reach 120 µm. The inner diameter of noticeably shorter using the INTREPID BALANCED tip,12
the tip is 0.57 mm, and the outer diameter is 0.8 mm, which demonstrated the great efficiency of the new sys-
without any tapering or flaring along the length of the tem and tip.
tip. In my opinion, CENTURION Vision System advances
In my early experience with the CENTURION Vision the technological frontier in the field of cataract surgery.
System using this tip, I was impressed by its efficiency. Its use will be of a benefit for a wide range of surgical pro-
The lenticular fragments seem to disappear once cedures for surgeons of all levels of experience. n
engaged by the tip. The rapidity of the removal of the
lens goes hand-in-hand with the stability of the anterior Daniele Tognetto, MD, is Associate Professor of
chamber. The efficiency of the tip allows me to dissolve Ophthalmology at the Eye Clinic, University of Trieste,
hard cataracts in a very short time without the use of Ospedale Maggiore, Italy. He discloses no financial inter-
high amounts of energy. I felt confident with a stable est in the products or companies mentioned herein.
anterior chamber and had a sense of control throughout Professor Tognetto may be reached at +39 407 72449;
the procedure. [email protected].

2 INSERT TO CATARACT & REFRACTIVE SURGERY TODAY JULY 2015

© 2015 Novartis 07/15 CNT14080JS

1. Vasavada AR, Raj SM, Patel U. Comparison of torsional and microburst longitudinal CENTURION® Vision System Important Product INFINITI® Vision System
phacoemulsification: a prospective, randomized, masked clinical trial. Ophthalmic Surg Information
Lasers Imaging. 2010;41(1):109-114. CAUTION: Federal (USA) law restricts this device to sale by, or on the Caution: Federal law restricts this device to sale by, or on the order
2. Liu Y, Zeng M, Liu X, et al. Torsional mode versus conventional ultrasound mode order of, a physician. of, a physician.
phacoemulsification: Randomized comparative clinical study. J Cataract & Refract Surg.
2007;33(2):287-292. As part of a properly maintained surgical environment, it is recom- Indication: The INFINITI® Vision System is indicated for emulsification,
3. Rekas M, Montés-Micó R, Krix-Jachym K. Comparison of torsional and mended that a backup IOL Injector be made available in the event the separation,
longitudinal modes using phacoemulsification parameters. J Cataract Refract Surg. AutoSert® IOL Injector Handpiece does not perform as expected. and removal of cataracts, the removal of residual cortical material and
2009;35(10):1719-1724. lens epithelial cells, vitreous aspiration and cutting associated with
4. Davison, JA. Cumulative tip travel and implied followability of longitudinal and Indication: The CENTURION® Vision system is indicated for anterior vitrectomy, bipolar coagulation, and intra-ocular lens injec-
torsional phacoemulsification. J Cataract Refract Surg. 2008;34(6):986-990. emulsification, separation, irrigation, and aspiration of cataracts, tion. The INTREPID® AutoSert® IOL Injector Handpiece is intended
5. Fernández de Castro LE, Dimalanta RC, Solomon KD. Bead-flow pattern: residual cortical material and lens epithelial cells, vitreous aspiration to deliver qualified AcrySof® intraocular lenses into the eye following
Quantitation of fluid movement during torsional and longitudinal phacoemulsification. and cutting associated with anterior vitrectomy, bipolar coagulation, cataract removal.
J Cataract Refract Surg. 2010; 36(6):1018-1023. and intraocular lens injection. The AutoSert® IOL Injector Handpiece is
6. Christakis PG, Braga-Mele RM. Intraoperative performance and postoperative intended to deliver qualified AcrySof® intraocular lenses into the eye The following system modalities additionally support the described
outcome comparison of longitudinal, torsional, and transversal phacoemulsification following cataract removal. indications:
machines. J Cataract Refract Surg. 2012;38(2):234-241. - Ultrasound with UltraChopper® Tip achieves the functionality of
7. Zacharias J. Thermal characterization of phaco probes operated in torsional and The AutoSert® IOL Injector Handpiece achieves the functionality of cataract separation.
longitudinal modalities using alternative methodologies. Paper presented at: The injection of intraocular lenses. The AutoSert® IOL Injector Handpiece - The INTREPID® AutoSert® IOL Injector Handpiece achieves the
annual symposium of the ASCRS. 2011; San Diego, CA. is indicated for use with the AcrySof® lenses SN6OWF, SN6AD1, functionality of injection of intraocular lenses. The INTREPID®
8. Jun B, Berdahl JP, Kim T. Thermal study of longitudinal and torsional SN6AT3 through SN6AT9, as well as approved AcrySof® lenses that AutoSert® IOL Injector Handpiece is indicated for use with AcrySof®
ultrasound phacoemulsification: tracking the temperature of the corneal are specifically indicated for use with this inserter, as indicated in the lenses SN60WF, SN6AD1, SN6AT3 through SN6AT9, as well as ap-
surface, incision, and handpiece. J Cataract Refract Surg. 2010;36(5):832- approved labeling of those lenses. proved AcrySof® lenses that are specifically indicated for use with this
837. inserter, as indicated in the approved labeling of those lenses.
9. Tognetto D, Cecchini P, Leon P, et al. Stroke dynamics and frequency of Warnings: Appropriate use of CENTURION® Vision System
3 phacoemulsification machines. J Cataract Refract Surg. 2012;38(2):333- parameters and accessories is important for successful procedures. Warnings: Appropriate use of INFINITI® Vision System parameters
342. Use of low vacuum limits, low flow rates, low bottle heights, high and accessories is important for successful procedures. Use of low
10. Cionni, R.J., A.S. Crandall, and D. Felsted, Length and frequency of power settings, extended power usage, power usage during occlusion vacuum limits, low flow rates, low bottle heights, high power
intraoperative occlusive events with new torsional phacoemulsification conditions (beeping tones), failure to sufficiently aspirate viscoelastic settings, extended power usage, power usage during occlusion
software. J Cataract Refract Surg. 2011;37(10):1785-1790. prior to using power, excessively tight incisions, and combinations conditions (beeping tones), failure to sufficiently aspirate viscoelastic
11. Ratnarajan G, Packard R, Ward M. Combined occlusion-triggered of the above actions may result in significant temperature increases prior to using power, excessively tight incisions, and combinations
longitudinal and torsional phacoemulsification during coaxial microincision at incision site and inside the eye, and lead to severe thermal eye of the above actions may result in significant temperature increases
cataract surgery: Effect on 30-degree mini-flared tip behavior. J Cataract tissue damage. at incision site and inside the eye, and lead to severe thermal eye
Refract Surg. 2011;37(5):825-829. tissue damage.
12. Solomon KD, Lorente R, Cionni RJ, Fanney D. Prospective, randomized Good clinical practice dictates the testing for adequate irrigation and
clinical study using novel phaco system with intraocular system target aspiration flow prior to entering the eye. Ensure that tubings are not Adjusting aspiration rates or vacuum limits above the preset values,
pressure control and existing phaco system. Paper presented at: The occluded or pinched during any phase of operation. or lowering the IV pole below the preset values, may cause chamber
ASCRS/ASOA Symposium & Congress; April 28, 2014; Boston. shallowing or collapse which may result in patient injury.
The consumables used in conjunction with ALCON® instrument When filling handpiece test chamber, if stream of fluid is weak or
products constitute a complete surgical system. Use of consumables absent, good fluidics response will be jeopardized. Good clinical
and handpieces other than those manufactured by Alcon may affect practice dictates the testing for adequate irrigation and aspiration
system performance and create potential hazards. flow prior to entering the eye.

AEs/Complications: Inadvertent actuation of Prime or Tune while a Ensure that tubings are not occluded or pinched during any phase
handpiece is in the eye can create a hazardous condition that may of operation.
result in patient injury. During any ultrasonic procedure, metal
particles may result from inadvertent touching of the ultrasonic AEs/Complications: Use of the INFINITI® Vision System handpieces
tip with a second instrument. Another potential source of metal in the absence of irrigation flow and/or in the presence of reduced or
particles resulting from any ultrasonic handpiece may be the result of lost aspiration flow can cause excessive heating and potential thermal
ultrasonic energy causing micro abrasion of the ultrasonic tip. injury to adjacent eye tissues.

ATTENTION: Refer to the Directions for Use and Operator’s Manual for ATTENTION: Refer to the directions for use for a complete listing of
a complete listing of indications, warnings, cautions and notes. indications, warnings and precautions.

© 2013 Novartis 11/13 INF13044MS

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Cataract & Refractive Surgery Today