Surgical system and procedure for treatment of the trabecular meshwork and Schlemm's canal using a femtosecond laser

A target volume of ocular tissue is treated with a laser having a direction of propagation toward the target volume, where the target volume is characterized by a distal extent, a proximal extent, and a lateral extent. A layer of tissue at an initial depth corresponding to the distal extent of the target volume is initially photodisrupted using a femtosecond laser by scanning the laser in multiple directions defining an initial treatment plane. Tissue at one or more subsequent depths between the distal extent of the target volume and the proximal extent of the target volume is subsequently photodisrupted using a femtosecond laser by moving a focus of the laser in a direction opposite the direction of propagation of the laser and then scanning the laser in multiple directions defining an subsequent treatment plane. Photodisruption is repeated at different subsequent depths until tissue at the proximal extent of the target volume is photodisrupted.

TECHNICAL FIELD

The present disclosure relates generally to the field of medical devices and treatment of diseases in ophthalmology including glaucoma, and more particularly to systems, apparatuses, and methods for treating the trabecular meshwork and Schlemm's canal using a femtosecond laser.

BACKGROUND

Before describing the different types of glaucoma and current diagnosis and treatments options, a brief overview of the anatomy of the eye is provided.

Anatomy of the Eye

With reference toFIGS. 1-3, the outer tissue layer of the eye1includes a sclera2that provides the structure of the eye's shape. In front of the sclera2is a cornea3that is comprised of transparent layers of tissue that allow light to enter the interior of the eye. Inside the eye1is a crystalline lens4that is connected to the eye by fiber zonules5, which are connected to the ciliary body6. Between the crystalline lens4and the cornea3is an anterior chamber7that contains a flowing clear liquid called aqueous humor8. Encircling the perimeter of the crystalline lens4is an iris9which forms a pupil around the approximate center of the crystalline lens. A posterior chamber23is an annular volume behind the iris9and bounded by the ciliary body6, fiber zonules5, and the crystalline lens4. The vitreous humor10is located between the crystalline lens4and the retina11. Light entering the eye is optically focused through the cornea3and crystalline lens.

With reference toFIG. 2, the corneoscleral junction of the eye is the portion of the anterior chamber7at the intersection of the iris9, the sclera2, and the cornea3. The anatomy of the eye1at the corneoscleral junction includes a trabecular meshwork12. The trabecular meshwork12is a fibrous network of tissue that encircles the iris9within the eye1. In simplified, general terms the tissues of the corneoscleral junction are arranged as follows: the iris9meets the ciliary body6, the ciliary body meets with the underside of the scleral spur14, the top of the scleral spur serves as an attachment point for the bottom of the trabecular meshwork12. The ciliary body is present mainly in the posterior chamber, but also extends into the very corner of the anterior chamber7. The network of tissue layers that make up the trabecular meshwork12are porous and thus present a pathway for the egress of aqueous humor8flowing from the anterior chamber7. This pathway may be referred to herein as an aqueous humor outflow pathway, an aqueous outflow pathway, or simply an outflow pathway.

Referring toFIG. 3, the pathway formed by the pores in the trabecular meshwork12connect to a set of thin porous tissue layers called the uveal15, the corneoscleral meshwork16, and the juxtacanalicular tissue17. The juxtacanalicular tissue17, in turn, abuts a structure called Schlemm's canal18. The Schlemm's canal18carries a mixture of aqueous humor8and blood from the surrounding tissue to drain into the venous system though a system of collector channels19. As shown inFIG. 2, the vascular layer of the eye, referred to as the choroid20, is next to the sclera2. A space, called the suprachoroidal space21, may be present between the choroid20and the sclera2. The general region near the periphery of the wedge between the cornea3and the iris9, running circumferentially is called the irido-corneal angle13. The irido-corneal angle13may also be referred to as the corneal angle of the eye or simply the angle of the eye. The ocular tissues illustrated inFIG. 3are all considered to be within the irido-corneal angle13.

With reference toFIG. 4, two possible outflow pathways for the movement of aqueous humor8include a trabecular outflow pathway40and a uveoscleral outflow pathway42. Aqueous humor8, which is produced by the ciliary body6, flows from the posterior chamber23through the pupil into the anterior chamber7, and then exits the eye through one or more of the two different outflow pathways40,42. Approximately 90% of the aqueous humor8leaves via the trabecular outflow pathway40by passing through the trabecular meshwork12, into the Schlemm's canal18and through one or more plexus of collector channels19before draining through a drain path41into the venous system. Any remaining aqueous humor8leaves primarily through the uveoscleral outflow pathway42. The uveoscleral outflow pathway42passes through the ciliary body6face and iris root into the suprachoroidal space21(shown inFIG. 2). Aqueous humor8drains from the suprachoroidal space21, from which it can be drained through the sclera2.

The intra-ocular pressure of the eye depends on the aqueous humor8outflow through the trabecular outflow pathway40and the resistance to outflow of aqueous humor through the trabecular outflow pathway. The intra-ocular pressure of the eye is largely independent of the aqueous humor8outflow through the uveoscleral outflow pathway42. Resistance to the outflow of aqueous humor8through the trabecular outflow pathway40may lead to elevated intra-ocular pressure of the eye, which is a widely recognized risk factor for glaucoma. Resistance through the trabecular outflow pathway40may increase due a collapsed or malfunctioning Schlemm's canal18and trabecular meshwork12.

Referring toFIG. 5, as an optical system, the eye1is represented by an optical model described by idealized centered and rotationally symmetrical surfaces, entrance and exit pupils, and six cardinal points: object and image space focal points, first and second principal planes, and first and second nodal points. Angular directions relative to the human eye are often defined with respect to an optical axis24, a visual axis26, a pupillary axis28and a line of sight29of the eye. The optical axis24is the symmetry axis, the line connecting the vertices of the idealized surfaces of the eye. The visual axis26connects the foveal center22with the first and second nodal points to the object. The line of sight29connects the fovea through the exit and entrance pupils to the object. The pupillary axis28is normal to the anterior surface of the cornea3and directed to the center of the entrance pupil. These axes of the eye differ from one another only by a few degrees and fall within a range of what is generally referred to as the direction of view.

Glaucoma

Glaucoma is a group of diseases that can harm the optic nerve and cause vision loss or blindness. It is the leading cause of irreversible blindness. Approximately 80 million people are estimated to have glaucoma worldwide and of these, approximately 6.7 million are bilaterally blind. More than 2.7 million Americans over age 40 have glaucoma. Symptoms start with loss of peripheral vision and can progress to blindness.

There are two forms of glaucoma, one is referred to as closed-angle glaucoma, the other as open-angled glaucoma. With reference toFIGS. 1-4, in closed-angle glaucoma, the iris9in a collapsed anterior chamber7may obstruct and close off the flow of aqueous humor8. In open-angle glaucoma, which is the more common form of glaucoma, the permeability of ocular tissue may be affected by irregularities in the juxtacanalicular tissue17and inner wall of Schlemm's canal18a, blockage of tissue in the irido-corneal angle13along the trabecular outflow pathway40.

As previously stated, elevated intra-ocular pressure (IOP) of the eye, which damages the optic nerve, is a widely recognized risk factor for glaucoma. However, not every person with increased eye pressure will develop glaucoma, and glaucoma can develop without increased eye pressure. Nonetheless, it is desirable to reduce elevated IOP of the eye to reduce the risk of glaucoma.

Methods of diagnosing conditions of the eye of a patient with glaucoma include visual acuity tests and visual field tests, dilated eye exams, tonometry, i.e. measuring the intra-ocular pressure of the eye, and pachymetry, i.e. measuring the thickness of the cornea. Deterioration of vision starts with the narrowing of the visual field and progresses to total blindness. Imaging methods include slit lamp examination, observation of the irido-corneal angle with a gonioscopic lens and optical coherence tomography (OCT) imaging of the anterior chamber and the retina

Once diagnosed, some clinically proven treatments are available to control or lower the intra-ocular pressure of the eye to slow or stop the progress of glaucoma. The most common treatments include: 1) medications, such as eye drops or pills, 2) laser surgery, and 3) traditional surgery. Treatment usually begins with medication. However, the efficacy of medication is often hindered by patient non-compliance. When medication does not work for a patient, laser surgery is typically the next treatment to be tried. Traditional surgery is invasive, more high risk than medication and laser surgery, and has a limited time window of effectiveness. Traditional surgery is thus usually reserved as a last option for patients whose eye pressure cannot be controlled with medication or laser surgery.

Laser Surgery

With reference toFIG. 2, laser surgery for glaucoma targets the trabecular meshwork12to decrease aqueous humor8flow resistance. Common laser treatments include Argon Laser Trabeculoplasty (ALT), Selective Laser Trabeculoplasty (SLT) and Excimer Laser Trabeculostomy (ELT).

ALT was the first laser trabeculoplasty procedure. During the procedure, an argon laser of 514 nm wavelength is applied to the trabecular meshwork12around 180 degrees of the circumference of the irido-corneal angle13. The argon laser induces a thermal interaction with the ocular tissue that produces openings in the trabecular meshwork12. ALT, however, causes scarring of the ocular tissue, followed by inflammatory responses and tissue healing that may ultimately close the opening through the trabecular meshwork12formed by the ALT treatment, thus reducing the efficacy of the treatment. Furthermore, because of this scarring, ALT therapy is typically not repeatable.

SLT is designed to lower the scarring effect by selectively targeting pigments in the trabecular meshwork12and reducing the amount of heat delivered to surrounding ocular tissue. During the procedure, a solid-state laser of 532 nm wavelength is applied to the trabecular meshwork12between 180 to 360 degrees around the circumference of the irido-corneal angle13to remove the pigmented cells lining the trabeculae which comprise the trabecular meshwork. The collagen ultrastructure of the trabecular meshwork is preserved during SLT.12. SLT treatment can be repeated, but subsequent treatments have lower effects on IOP reduction.

ELT uses a 308 nm wavelength ultraviolet (UV) excimer laser and non-thermal interaction with ocular tissue to treat the trabecular meshwork12and inner wall of Schlemm's canal in a manner that does not invoke a healing response. Therefore, the IOP lowering effect lasts longer. However, because the UV light of the laser cannot penetrate deep into the eye, the laser light is delivered to the trabecular meshwork12via an optical fiber inserted into the eye1through an opening and the fiber is brought into contact with the trabecular meshwork. The procedure is highly invasive and is generally practiced simultaneously with cataract procedures when the eye is already surgically open. Like ALT and SLT, ELT also lacks control over the amount of IOP reduction.

None of these existing laser treatments represents an ideal treatment for glaucoma. Accordingly, what is needed are systems, apparatuses, and method for laser surgery treatment of glaucoma that effectively reduce IOP non-invasively without significant scarring of tissue, so the treatment may be completed in a single procedure and repeated at a later time if necessary.

SUMMARY

The present disclosure relates to a method of treating a target volume of ocular tissue of an irido-corneal angle of an eye with a laser having a direction of propagation toward the target volume of ocular tissue, where the target volume of ocular tissue is characterized by a distal extent, a proximal extent, and a lateral extent. The method includes initially photodisrupting tissue at an initial depth corresponding to the distal extent of the target volume of ocular tissue. To this end, light from a femtosecond laser is focused at a spot in the tissue at the initial depth. Optical energy sufficient to photodisrupt the tissue is then applied to the tissue by, for example, scanning the laser in multiple directions defining an initial treatment plane, to thereby photodisrupt an initial layer of tissue of the target volume.

The method also includes subsequently photodisrupting tissue at one or more subsequent depths between the distal extent of the target volume of ocular tissue and the proximal extent of the target volume by moving a focus of the laser in a direction opposite the direction of propagation of the laser. To this end, light from a femtosecond laser is focused at a spot in the tissue at a subsequent depth. Optical energy sufficient to photodisrupt the tissue is then applied to the tissue by, for example, scanning the laser in multiple directions defining a subsequent treatment plane, to thereby photodisrupt a subsequent layer of tissue of the target volume. Photodisrupting at one or more subsequent depths is repeated at a plurality of different subsequent depths until tissue at the proximal extent of the target volume of ocular tissue is photodisrupted.

In additional aspects, the method includes, after photodisrupting the target volume of tissue, photodisrupting tissue debris or bubbles between the proximal extent of the target volume of ocular tissue and the distal extent of the target volume by moving the focus of the laser in the direction of propagation of the laser and rescanning the laser at one or more of the subsequent treatment planes and the initial treatment plane. The method may further include, repeating the initial photodisrupting of tissue and the subsequent photodisrupting of tissue one or more times.

The present disclosure also relates to a system for treating a target volume of ocular tissue of an irido-corneal angle of an eye with a laser, where the target volume of ocular tissue characterized by a distal extent, a proximal extent, and a lateral extent. The system includes a first optical subsystem including a focusing objective configured to be coupled to the eye, and a second optical subsystem including a laser source configured to output a laser beam. The second optical subsystem also includes a plurality of components configured to one or more of focus, scan, and direct the laser beam through the focusing objective, in a direction of propagation toward the target volume of ocular tissue.

The system further includes a control system coupled to the second optical subsystem and configured to control the focus and scan of the laser beam to initially photodisrupt tissue at an initial depth corresponding to the distal extent of the target volume of ocular tissue. To this end, the control system is configured to focus light from a femtosecond laser at a spot in the tissue at the initial depth, and then apply optical energy to the tissue, where the energy is sufficient to photodisrupt tissue. The control system controls the focus and scan of the laser beam during application of optical energy by being further configured to scan the laser in multiple directions defining an initial treatment plane, to thereby photodisrupt an initial layer of tissue of the target volume of ocular tissue.

The control system is also configured to control the focus and scan of the laser beam to subsequently photodisrupt tissue at one or more subsequent depths between the distal extent of the target volume of ocular tissue and the proximal extent of the target volume by moving a focus of the laser in a direction opposite the direction of propagation of the laser. To this end, the control system is configured to focus light from a femtosecond laser at a spot in the tissue at a subsequent depth, and then apply optical energy to the tissue, where the energy is sufficient to photodisrupt tissue. The control system controls the focus and scan of the laser beam during application of optical energy by being further configured to scan the laser in multiple directions defining a subsequent treatment plane, to thereby photodisrupt a subsequent layer of tissue of the target volume of ocular tissue.

In additional aspects, the control system is configured to control the focus and scan of the laser beam to photodisrupt tissue debris or bubbles between the proximal extent of the target volume of ocular tissue and the distal extent of the target volume of ocular tissue by moving the focus of the laser in the direction of propagation of the laser, after photodisrupting the target volume of ocular tissue, and rescanning the laser at one or more of the subsequent treatment planes and the initial treatment plane. The control system is further configured to control the focus and scan of the laser beam to repeat the initial photodisrupting of tissue and the subsequent photodisrupting of tissue one or more times.

The present disclosure also relates to a method of treating an eye comprising an anterior chamber, a Schlemm's canal, and a trabecular meshwork therebetween. The method includes initially photodisrupting ocular tissue at or near an interface of an inner wall of the Schlemm's canal and the trabecular meshwork. To this end, light from a femtosecond laser is focused at a spot in the ocular tissue at or near the interface of the inner wall of the Schlemm's canal and the trabecular meshwork. Optical energy sufficient to photodisrupt the tissue is then applied to the tissue. The method also includes subsequently photodisrupting ocular tissue of the trabecular meshwork. To this end, light from a femtosecond laser is focused at a spot in tissue of the trabecular meshwork. Optical energy sufficient to photodisrupt the tissue is then applied to the tissue. In additional aspects, the method includes, repeating the initial photodisrupting of ocular tissue and the subsequent photodisrupting of ocular tissue one or more times until an opening is formed between the anterior chamber and the Schlemm's canal.

The present disclosure also relates to a system for treating an eye comprising an anterior chamber, a Schlemm's canal, and a trabecular meshwork therebetween. The system includes a first optical subsystem including a focusing objective configured to be coupled to the eye, and a second optical subsystem including a laser source configured to output a laser beam. The second optical subsystem further includes a plurality of components configured to one or more of focus, scan, and direct the laser beam through the focusing objective, toward ocular tissue.

The system also includes a control system coupled to the second optical subsystem and configured to control the focus and the scan of the laser beam to initially photodisrupt ocular tissue at or near an interface of an inner wall of the Schlemm's canal and the trabecular meshwork. To this end, the control system is configured to focus light from a femtosecond laser at a spot in the ocular tissue at or near the interface of the inner wall of the Schlemm's canal and the trabecular meshwork, and then apply optical to the tissue, where the energy is sufficient to photodisrupt tissue. The control system is also configured to control the focus and scan of the laser beam to subsequently photodisrupt tissue of the trabecular meshwork. To this end, the control system is configured to focus light from a femtosecond laser at a spot in tissue of the trabecular meshwork, and then apply optical energy to the tissue, where the energy is sufficient to photodisrupt tissue. In additional aspects, the control system is further configured to control the focus and scan of the laser beam to repeat the initial photodisrupting of ocular tissue and the subsequent photodisrupting of ocular tissue one or more times until an opening is formed between the anterior chamber and the Schlemm's canal.

It is understood that other aspects of apparatuses and methods will become apparent to those skilled in the art from the following detailed description, wherein various aspects of apparatuses and methods are shown and described by way of illustration. As will be realized, these aspects may be implemented in other and different forms and its several details are capable of modification in various other respects. Accordingly, the drawings and detailed description are to be regarded as illustrative in nature and not as restrictive.

DETAILED DESCRIPTION

Disclosed herein are systems, apparatuses, and methods for safely and effectively reducing intra-ocular pressure (IOP) in the eye to either treat or reduce the risk of glaucoma. The systems, apparatuses, and methods enable access to the irido-corneal angle of the eye and integrate laser surgery techniques with high resolution imaging to precisely diagnose, locate, and treat abnormal ocular tissue conditions within the irido-corneal angle that may be causing elevated IOP.

An integrated surgical system disclosed herein is configured to reduce intraocular pressure in an eye having a cornea, an anterior chamber, and an irido-corneal angle comprising an aqueous humor outflow pathway formed of a trabecular meshwork, a Schlemm's canal, and one or more collector channels branching from the Schlemm's canal. The integrated surgical system also includes a first optical subsystem and a second optical subsystem. The first optical subsystem includes a window configured to be coupled to the cornea and an exit lens configured to be coupled to the window. The second optical subsystem includes an optical coherence tomography (OCT) imaging apparatus configured to output an OCT beam, a laser source configured to output a laser beam, and a plurality of components, e.g., lenses and mirrors, configured to condition, combine, or direct the OCT beam and the laser beam toward the first optical subsystem.

The integrated surgical system also includes a control system coupled to the OCT imaging apparatus, the laser source, and the second optical subsystem. The controller is configured to instruct the OCT imaging apparatus to output an OCT beam and the laser source to output a laser beam, for delivery through the cornea, and the anterior chamber into the irido-corneal angle. In one configuration, the control system controls the second optical subsystem, so the OCT beam and the laser beam are directed into the first optical subsystem along a second optical axis that is offset from the first optical axis and that extends into the irido-corneal angle along an angled beam path30.

Directing each of an OCT beam and a laser beam along the same second optical axis into the irido-corneal angle of the eye is beneficial in that it enables direct application of the result of the evaluation of the condition into the treatment plan and surgery with precision in one clinical setting. Furthermore, combining OCT imaging and laser treatment allows targeting the ocular tissue with precision not available with any existing surgical systems and methods. Surgical precision afforded by the integrated surgical system allows for the affecting of only the targeted tissue of microscopic size and leaves the surrounding tissue intact. The microscopic size scale of the affected ocular tissue to be treated in the irido-corneal angle of the eye ranges from a few micrometers to a few hundred micrometers. For example, with reference toFIGS. 2 and 3, the cross-sectional size of the normal Schlemm's canal18is an oval shape of a few tens of micrometers by a few hundred micrometers. The diameter of collector channels19and veins is a few tens of micrometers. The thickness of the juxtacanalicular tissue17is a few micrometers, the thickness of the trabecular meshwork12is around a hundred micrometers.

The control system of the integrated surgical system is further configured to instruct the laser source to modify a volume of ocular tissue within the outflow pathway to reduce a pathway resistance present in one or more of the trabecular meshwork, the Schlemm's canal, and the one or more collector channels by applying the laser beam to ocular tissue defining the volume to thereby cause photo-disruptive interaction with the ocular tissue to reduce the pathway resistance or create a new outflow pathway.

The laser source may be a femtosecond laser. Femtosecond lasers provide non-thermal photo-disruption interaction with ocular tissue to avoid thermal damage to surrounding tissue. Further, unlike other surgical methods, with femtosecond laser treatment opening surface incisions penetrating the eye can be avoided, enabling a non-invasive treatment. Instead of performing the treatment in a sterile surgical room, the non-invasive treatment can be performed in a non-sterile outpatient facility.

An additional imaging component may be included the integrated surgical system to provide direct visual observation of the irido-corneal angle along an angle of visual observation. For example, a microscope or imaging camera may be included to assist the surgeon in the process of docking the eye to the patient interface or an immobilizing device, location of ocular tissues in the eye and observing the progress of the surgery. The angle of visual observation can also be along the angled beam path30to the irido-corneal angle13through the cornea3and the anterior chamber7.

Images from the OCT imaging apparatus and the additional imaging component providing visual observation, e.g. microscope, are combined on a display device such as a computer monitor. Different images can be registered and overlaid on a single window, enhanced, processed, differentiated by false color for easier understanding. Certain features are computationally recognized by a computer processor, image recognition and segmentation algorithm can be enhanced, highlighted, marked for display. The geometry of the treatment plan can also be combined and registered with imaging information on the display device and marked up with geometrical, numerical and textual information. The same display can also be used for user input of numerical, textual and geometrical nature for selecting, highlighting and marking features, inputting location information for surgical targeting by keyboard, mouse, cursor, touchscreen, audio or other user interface devices.

OCT Imaging

The main imaging component of the integrated surgical system disclosed herein is an OCT imaging apparatus. OCT technology may be used to diagnose, locate and guide laser surgery directed to the irido-corneal angle of the eye. For example, with reference toFIGS. 1-3, OCT imaging may be used to determine the structural and geometrical conditions of the anterior chamber7, to assess possible obstruction of the trabecular outflow pathway40and to determine the accessibility of the ocular tissue for treatment. As previously described, the iris9in a collapsed anterior chamber7may obstruct and close off the flow of aqueous humor8, resulting in closed-angle glaucoma. In open-angle glaucoma, where the macroscopic geometry of the angle is normal, the permeability of ocular tissue may be affected, by blockage of tissue along the trabecular outflow pathway40or by the collapse of the Schlemm's canal18or collector channels19.

OCT imaging can provide the necessary spatial resolution, tissue penetration and contrast to resolve microscopic details of ocular tissue. When scanned, OCT imaging can provide two-dimensional (2D) cross-sectional images of the ocular tissue. As another aspect of the integrated surgical system, 2D cross-sectional images may be processed and analyzed to determine the size, shape and location of structures in the eye for surgical targeting. It is also possible to reconstruct three-dimensional (3D) images from a multitude of 2D cross-sectional images but often it is not necessary. Acquiring, analyzing and displaying 2D images is faster and can still provide all information necessary for precise surgical targeting.

OCT is an imaging modality capable of providing high resolution images of materials and tissue. Imaging is based on reconstructing spatial information of the sample from spectral information of scattered light from within the sample. Spectral information is extracted by using an interferometric method to compare the spectrum of light entering the sample with the spectrum of light scattered from the sample. Spectral information along the direction that light is propagating within the sample is then converted to spatial information along the same axis via the Fourier transform. Information lateral to the OCT beam propagation is usually collected by scanning the beam laterally and repeated axial probing during the scan. 2D and 3D images of the samples can be acquired this way. Image acquisition is faster when the interferometer is not mechanically scanned in a time domain OCT, but interference from a broad spectrum of light is recorded simultaneously, this implementation is called a spectral domain OCT. Faster image acquisition may also be obtained by scanning the wavelength of light rapidly from a wavelength scanning laser in an arrangement called a swept-source OCT.

The axial spatial resolution limit of the OCT is inversely proportional to the bandwidth of the probing light used. Both spectral domain and swept source OCTs are capable of axial spatial resolution below 5 micrometers (pa) with sufficiently broad bandwidth of 100 nanometers (nm) or more. In the spectral domain OCT, the spectral interference pattern is recorded simultaneously on a multichannel detector, such as a charge coupled device (CCD) or complementary metal oxide semiconductor (CMOS) camera, while in the swept source OCT the interference pattern is recorded in sequential time steps with a fast optical detector and electronic digitizer. There is some acquisition speed advantage of the swept source OCT but both types of systems are evolving and improving rapidly, and resolution and speed is sufficient for purposes of the integrated surgical system disclosed herein. Stand-alone OCT systems and OEM components are now commercially available from multiple vendors, such as Optovue Inc., Fremont, Calif., Topcon Medical Systems, Oakland, N.J., Carl Zeiss Meditec AG, Germany, Nidek, Aichi, Japan, Thorlabs, Newton, N.J., Santec, Aichi, Japan, Axsun, Billercia, Mass., and other vendors.

Femtosecond Laser Source

The preferred surgical component of the integrated surgical system disclosed herein is a femtosecond laser. A femtosecond laser provides highly localized, non-thermal photo-disruptive laser-tissue interaction with minimal collateral damage to surrounding ocular tissue. Photo-disruptive interaction of the laser is utilized in optically transparent tissue. The principal mechanism of laser energy deposition into the ocular tissue is not by absorption but by a highly nonlinear multiphoton process. This process is effective only at the focus of the pulsed laser where the peak intensity is high. Regions where the beam is traversed but not at the focus are not affected by the laser. Therefore, the interaction region with the ocular tissue is highly localized both transversally and axially along the laser beam. The process can also be used in weakly absorbing or weakly scattering tissue. While femtosecond lasers with photo-disruptive interactions have been successfully used in ophthalmic surgical systems and commercialized in other ophthalmic laser procedures, none have been used in an integrated surgical system that accesses the irido-corneal angle.

In known refractive procedures, femtosecond lasers are used to create corneal flaps, pockets, tunnels, arcuate incisions, lenticule shaped incisions, partial or fully penetrating corneal incisions for keratoplasty. For cataract procedures the laser creates a circular cut on the capsular bag of the eye for capsulotomy and incisions of various patterns in the lens for braking up the interior of the crystalline lens to smaller fragments to facilitate extraction. Entry incisions through the cornea opens the eye for access with manual surgical devices and for insertions of phacoemulsification devices and intra-ocular lens insertion devices. Several companies have commercialized such surgical systems, among them the IntraLase system now available from Johnson & Johnson Vision, Santa Ana, Calif., The LenSx and WaveLight systems from Alcon, Fort Worth, Tex., other surgical systems from Bausch and Lomb, Rochester, N.Y., Carl Zeiss Meditec AG, Germany, Ziemer, Port, Switzerland, and LENSAR, Orlando, Fla.

These existing systems are developed for their specific applications, for surgery in the cornea, and the crystalline lens and its capsular bag and are not capable of performing surgery in the irido-corneal angle13for several reasons. First, the irido-corneal angle13is not accessible with these surgical laser systems because the irido-corneal angle is too far out in the periphery and is outside of surgical range of these systems. Second, the angle of the laser beam from these systems, which is along the optical axis24to the eye1, is not appropriate to reaching the irido-corneal angle13, where there is significant scattering and optical distortion at the applied wavelength. Third, any imaging capabilities these systems may have do not have the accessibility, penetration depth and resolution to image the tissue along the trabecular outflow pathway40with sufficient detail and contrast.

In accordance with the integrated surgical system disclosed herein, clear access to the irido-corneal angle13is provided along the angled beam path30. The tissue, e.g., cornea3and the aqueous humor8in the anterior chamber7, along this angled beam path30is transparent for wavelengths from approximately 400 nm to 2500 nm and femtosecond lasers operating in this region can be used. Such mode locked lasers work at their fundamental wavelength with Titanium, Neodymium or Ytterbium active material. Non-linear frequency conversion techniques known in the art, frequency doubling, tripling, sum and difference frequency mixing techniques, optical parametric conversion can convert the fundamental wavelength of these lasers to practically any wavelength in the above mentioned transparent wavelength range of the cornea.

Existing ophthalmic surgical systems apply lasers with pulse durations longer than 1 ns have higher photo-disruption threshold energy, require higher pulse energy and the dimension of the photo-disruptive interaction region is larger, resulting in loss of precision of the surgical treatment. When treating the irido-corneal angle13, however, higher surgical precision is required. To this end, the integrated surgical system may be configured to apply lasers with pulse durations from 10 femtosecond (fs) to 1 nanosecond (ns) for generating photo-disruptive interaction of the laser beam with ocular tissue in the irido-corneal angle13. While lasers with pulse durations shorter than 10 fs are available, such laser sources are more complex and more expensive. Lasers with the described desirable characteristics, e.g., pulse durations from 10 femtosecond (fs) to 1 nanosecond (ns), are commercially available from multiple vendors, such as Newport, Irvine, Calif., Coherent, Santa Clara, Calif., Amplitude Systems, Pessac, France, NKT Photonics, Birkerod, Denmark, and other vendors.

Accessing the Irido-Corneal Angle

An important feature afforded by the integrated surgical system is access to the targeted ocular tissue in the irido-corneal angle13. With reference toFIG. 6, the irido-corneal angle13of the eye may be accessed via the integrated surgical system along an angled beam path30passing through the cornea3and through the aqueous humor8in the anterior chamber7. For example, one or more of an imaging beam, e.g., an OCT beam and/or a visual observation beam, and a laser beam may access the irido-corneal angle13of the eye along the angled beam path30.

An optical system disclosed herein is configured to direct a light beam to an irido-corneal angle13of an eye along an angled beam path30. The optical system includes a first optical subsystem and a second optical subsystem. The first optical subsystem includes a window formed of a material with a refractive index nwand has opposed concave and convex surfaces. The first optical subsystem also includes an exit lens formed of a material having a refractive index nx. The exit lens also has opposed concave and convex surfaces. The concave surface of the exit lens is configured to couple to the convex surface of the window to define a first optical axis extending through the window and the exit lens. The concave surface of the window is configured to detachably couple to a cornea of the eye with a refractive index ncsuch that, when coupled to the eye, the first optical axis is generally aligned with the direction of view of the eye.

The second optical subsystem is configured to output a light beam, e.g., an OCT beam or a laser beam. The optical system is configured so that the light beam is directed to be incident at the convex surface of the exit lens along a second optical axis at an angle α that is offset from the first optical axis. The respective geometries and respective refractive indices nx, and nwof the exit lens and window are configured to compensate for refraction and distortion of the light beam by bending the light beam so that it is directed through the cornea3of the eye toward the irido-corneal angle13. More specifically, the first optical system bends the light beam to that the light beam exits the first optical subsystem and enters the cornea3at an appropriate angle so that the light beam progresses through the cornea and the aqueous humor8in a direction along the angled beam path30toward the irido-corneal angle13.

Accessing the irido-corneal angle13along the angled beam path30provides several advantages. An advantage of this angled beam path30to the irido-corneal angle13is that the OCT beam and laser beam passes through mostly clear tissue, e.g., the cornea3and the aqueous humor8in the anterior chamber7. Thus, scattering of these beams by tissue is not significant. With respect to OCT imaging, this enables the use of shorter wavelength, less than approximately 1 micrometer, for the OCT to achieve higher spatial resolution. An additional advantage of the angled beam path30to the irido-corneal angle13through the cornea3and the anterior chamber7is the avoidance of direct laser beam or OCT beam light illuminating the retina11. As a result, higher average power laser light and OCT light can be used for imaging and surgery, resulting in faster procedures and less tissue movement during the procedure.

Another important feature provided by the integrated surgical system is access to the targeted ocular tissue in the irido-corneal angle13in a way that reduces beam discontinuity. To this end, the window and exit lens components of the first optical subsystem are configured to reduce the discontinuity of the optical refractive index between the cornea3and the neighboring material and facilitate entering light through the cornea at a steep angle.

Having thus generally described the integrated surgical system and some of its features and advantages, a more detailed description of the system and its component parts follows.

Integrated Surgical System

With reference toFIG. 7, an integrated surgical system1000for non-invasive glaucoma surgery includes a control system100, a surgical component200, a first imaging component300and an optional second imaging component400. In the embodiment ofFIG. 7, the surgical component200is a femtosecond laser source, the first imaging component300is an OCT imaging apparatus, and the optional second imaging component400is a visual observation apparatus, e.g., a microscope, for direct viewing or viewing with a camera. Other components of the integrated surgical system1000include beam conditioners and scanners500, beam combiners600, a focusing objective700, and a patient interface800.

The control system100may be a single computer or and plurality of interconnected computers configured to control the hardware and software components of the other components of the integrated surgical system1000. A user interface110of the control system100accepts instructions from a user and displays information for observation by the user. Input information and commands from the user include but are not limited to system commands, motion controls for docking the patient's eye to the system, selection of pre-programmed or live generated surgical plans, navigating through menu choices, setting of surgical parameters, responses to system messages, determining and acceptance of surgical plans and commands to execute the surgical plan. Outputs from the system towards the user includes but are not limited to display of system parameters and messages, display of images of the eye, graphical, numerical and textual display of the surgical plan and the progress of the surgery.

The control system100is connected to the other components200,300,400,500of the integrated surgical system1000. Control signals from the control system100to the femtosecond laser source200function to control internal and external operation parameters of the laser source, including for example, power, repetition rate and beam shutter. Control signals from the control system100to the OCT imaging apparatus300function to control OCT beam scanning parameters, and the acquiring, analyzing and displaying of OCT images.

Laser beams201from the femtosecond laser source200and OCT beams301from the OCT imaging apparatus300are directed towards a unit of beam conditioners and scanners500. Different kind of scanners can be used for the purpose of scanning the laser beam201and the OCT beam301. For scanning transversal to a beam201,301, angular scanning galvanometer scanners are available for example from Cambridge Technology, Bedford, Mass., Scanlab, Munich, Germany. To optimize scanning speed, the scanner mirrors are typically sized to the smallest size, which still support the required scanning angles and numerical apertures of the beams at the target locations. The ideal beam size at the scanners is typically different from the beam size of the laser beam201or the OCT beam301, and different from what is needed at the entrance of a focusing objective700. Therefore, beam conditioners are applied before, after or in between individual scanners. The beam conditioner and scanners500includes scanners for scanning the beam transversally and axially. Axial scanning changes the depth of the focus at the target region. Axial scanning can be performed by moving a lens axially in the beam path with a servo or stepper motor.

The laser beam201and the OCT beam301are combined with dichroic, polarization or other kind of beam combiners600to reach a common target volume or surgical volume in the eye. In an integrated surgical system1000having a femtosecond laser source200, an OCT imaging apparatus300, and a visual observation device400, the individual beams201,301,401for each of these components may be individually optimized and may be collinear or non-collinear to one another. The beam combiner600uses dichroic or polarization beam splitters to split and recombine light with different wavelength and/or polarization. The beam combiner600may also include optics to change certain parameters of the individual beams201,301,401such as beam size, beam angle and divergence. Integrated visual illumination, observation or imaging devices assist the surgeon in docking the eye to the system and identifying surgical locations.

To resolve ocular tissue structures of the eye in sufficient detail, the imaging components300,400of the integrated surgical system1000may provide an OCT beam and a visual observation beam having a spatial resolution of several micrometers. The resolution of the OCT beam is the spatial dimension of the smallest feature that can be recognized in the OCT image. It is determined mostly by the wavelength and the spectral bandwidth of the OCT source, the quality of the optics delivering the OCT beam to the target location in the eye, the numerical aperture of the OCT beam and the spatial resolution of the OCT imaging apparatus at the target location. In one embodiment, the OCT beam of the integrated surgical system has a resolution of no more than 5 μm.

Likewise, the surgical laser beam provided by the femtosecond laser source200may be delivered to targeted locations with several micrometer accuracy. The resolution of the laser beam is the spatial dimension of the smallest feature at the target location that can be modified by the laser beam without significantly affecting surrounding ocular tissue. It is determined mostly by the wavelength of the laser beam, the quality of the optics delivering the laser beam to target location in the eye, the numerical aperture of the laser beam, the energy of the laser pulses in the laser beam and the spatial resolution of the laser scanning system at the target location. In addition, to minimize the threshold energy of the laser for photo-disruptive interaction, the size of the laser spot should be no more than approximately 5 μm.

It should be noted that, while the visual observation beam401is acquired by the visual observation device400using fixed, non-scanning optics, the OCT beam301of the OCT imaging apparatus300is scanned laterally in two transversal directions. The laser beam201of the femtosecond laser source200is scanned in two lateral dimensions and the depth of the focus is scanned axially.

For practical embodiments, beam conditioning, scanning and combining the optical paths are certain functions performed on the laser, OCT and visual observation optical beams. Implementation of those functions may happen in a different order than what is indicated inFIG. 7. Specific optical hardware that manipulates the beams to implement those functions can have multiple arrangements with regards to how the optical hardware is arranged. They can be arranged in a way that they manipulate individual optical beams separately, in another embodiment one component may combine functions and manipulates different beams. For example, a single set of scanners can scan both the laser beam201and the OCT beam301. In this case, separate beam conditioners set the beam parameters for the laser beam201and the OCT beam301, then a beam combiner combines the two beams for a single set of scanners to scan the beams. While many combinations of optical hardware arrangements are possible for the integrated surgical system, the following section describes in detail an example arrangement.

Beam Delivery

In the following description, the term beam may—depending on the context—refer to one of a laser beam, an OCT beam, or a visual observation beam. A combined beam refers to two or more of a laser beam, an OCT beam, or a visual observation beam that are either collinearly combined or non-collinearly combined. Example combined beams include a combined OCT/laser beam, which is a collinear or non-colinear combination of an OCT beam and a laser beam, and a combined OCT/laser/visual beam, which is a collinear or non-collinear combination of an OCT beam, a laser beam, and a visual beam. In a collinearly combined beam, the different beams may be combined by dichroic or polarization beam splitters, and delivered along a same optical path through a multiplexed delivery of the different beams. In a non-collinear combined beam, the different beams are delivered at the same time along different optical paths that are separated spatially or by an angle between them. In the description to follow, any of the foregoing beams or combined beams may be generically referred to as a light beam. The terms distal and proximal may be used to designate the direction of travel of a beam, or the physical location of components relative to each other within the integrated surgical system. The distal direction refers to a direction toward the eye; thus an OCT beam output by the OCT imaging apparatus moves in the distal direction toward the eye. The proximal direction refers to a direction away from the eye; thus an OCT return beam from the eye moves in the proximal direction toward the OCT imaging apparatus.

Referring toFIG. 8, an example integrated surgical system is configured to deliver each of a laser beam201and an OCT beam301in the distal direction toward an eye1, and receive each of an OCT return beam and the visual observation beam401back from the eye1. Regarding the delivery of a laser beam, a laser beam201output by the femtosecond laser source200passes through a beam conditioner510where the basic beam parameters, beam size, divergence are set. The beam conditioner510may also include additional functions, setting the beam power or pulse energy and shutter the beam to turn it on or off. After existing the beam conditioner510, the laser beam210enters an axial scanning lens520. The axial scanning lens520, which may include a single lens or a group of lenses, is movable in the axial direction522by a servo motor, stepper motor or other control mechanism. Movement of the axial scanning lens520in the axial direction522changes the axial distance of the focus of the laser beam210at a focal point.

In accordance with a particular embodiment of the integrated surgical system, an intermediate focal point722is set to fall within, and is scannable in, the conjugate surgical volume721, which is an image conjugate of the surgical volume720, determined by the focusing objective700. The surgical volume720is the spatial extent of the region of interest within the eye where imaging and surgery is performed. For glaucoma surgery, the surgical volume720is the vicinity of the irido-corneal angle13of the eye.

A pair of transverse scanning mirrors530,532rotated by a galvanometer scanner scan the laser beam201in two essentially orthogonal transversal directions, e.g., in the x and y directions. Then the laser beam201is directed towards a dichroic or polarization beam splitter540where it is reflected toward a beam combining mirror601configured to combine the laser beam201with an OCT beam301.

Regarding delivery of an OCT beam, an OCT beam301output by the OCT imaging apparatus300passes through a beam conditioner511, an axially moveable focusing lens521and a transversal scanner with scanning mirrors531and533. The focusing lens521is used set the focal position of the OCT beam in the conjugate surgical volume721and the real surgical volume720. The focusing lens521is not scanned for obtaining an OCT axial scan. Axial spatial information of the OCT image is obtained by Fourier transforming the spectrum of the interferometrically recombined OCT return beam301and reference beams302. However, the focusing lens521can be used to re-adjust the focus when the surgical volume720is divided into several axial segments. This way the optimal imaging spatial resolution of the OCT image can be extended beyond the Rayleigh range of the OCT signal beam, at the expense of time spent on scanning at multiple ranges.

Proceeding in the distal direction toward the eye1, after the scanning mirrors531and533, the OCT beam301is combined with the laser beam201by the beam combiner mirror601. The OCT beam301and laser beam201components of the combined laser/OCT beam550are multiplexed and travel in the same direction to be focused at an intermediate focal point722within the conjugate surgical volume721. After having been focused in the conjugate surgical volume721, the combined laser/OCT beam550propagates to a second beam combining mirror602where it is combined with a visual observation beam401to form a combined laser/OCT/visual beam701.

The combined laser/OCT/visual beam701traveling in the distal direction then passes through the focusing objective700, and a window801of a patient interface, where the intermediate focal point722of the laser beam within the conjugate surgical volume721is re-imaged into a focal point in the surgical volume720. The focusing objective700re-images the intermediate focal point722, through the window801of a patient interface, into the ocular tissue within the surgical volume720.

A scattered OCT return beam301from the ocular tissue travels in the proximal direction to return to the OCT imaging apparatus300along the same paths just described, in reverse order. The reference beam302of the OCT imaging apparatus300, passes through a reference delay optical path and return to the OCT imaging apparatus from a moveable mirror330. The reference beam302is combined interferometrically with the OCT return beam301on its return within the OCT imaging apparatus300. The amount of delay in the reference delay optical path is adjustable by moving the moveable mirror330to equalize the optical paths of the OCT return beam301and the reference beam302. For best axial OCT resolution, the OCT return beam301and the reference beam302are also dispersion compensated to equalize the group velocity dispersion within the two arms of the OCT interferometer.

When the combined laser/OCT/visual beam701is delivered through the cornea3and the anterior chamber7, the combined beam passes through posterior and anterior surface of the cornea at a steep angle, far from normal incidence. These surfaces in the path of the combined laser/OCT/visual beam701create excessive astigmatism and coma aberrations that need to be compensated for.

With reference toFIGS. 9aand 9b, in an embodiment of the integrated surgical system1000, optical components of the focusing objective700and patient interface800are configured to minimize spatial and chromatic aberrations and spatial and chromatic distortions.FIG. 9ashows a configuration when both the eye1, the patient interface800and the focusing objective700all coupled together.FIG. 9bshows a configuration when both the eye1, the patient interface800and the focusing objective700all detached from one another.

The patient interface800optically and physically couples the eye1to the focusing objective700, which in turn optically couples with other optic components of the integrated surgical system1000. The patient interface800serves multiple functions. It immobilizes the eye relative to components of the integrated surgical system; creates a sterile barrier between the components and the patient; and provides optical access between the eye and the instrument. The patient interface800is a sterile, single use disposable device and it is coupled detachably to the eye1and to the focusing objective700of the integrated surgical system1000.

The patient interface800includes a window801having an eye-facing, concave surface812and an objective-facing, convex surface813opposite the concave surface. The window801thus has a meniscus form. With reference toFIG. 9c, the concave surface812is characterized by a radius of curvature re, while the convex surface813is characterized by a radius of curvature rw. The concave surface812is configured to couple to the eye, either through a direct contact or through index matching material, liquid or gel, placed in between the concave surface812and the eye1. The window801may be formed of glass and has a refractive index nw. In one embodiment, the window801is formed of fused silica and has a refractive index nwof 1.45. Fused silica has the lowest index from common inexpensive glasses. Fluoropolymers such as the Teflon AF are another class of low index materials that have refractive indices lower than fused silica, but their optical quality is inferior to glasses and they are relatively expensive for high volume production. In another embodiment the window801is formed of the common glass BK7 and has a refractive index nwof 1.50. A radiation resistant version of this glass, BK7G18 from Schott AG, Mainz, Germany, allows gamma sterilization of the patient interface800without the gamma radiation altering the optical properties of the window801.

Returning toFIGS. 9aand 9b, the window801is surrounded by a wall803of the patient interface800and an immobilization device, such as a suction ring804. When the suction ring804is in contact with the eye1, an annular cavity805is formed between the suction ring and the eye. When vacuum applied to the suction ring804and the cavity via a vacuum tube a vacuum pump (not shown inFIGS. 9aand 9b), vacuum forces between the eye and the suction ring attach the eye to the patient interface800during surgery. Removing the vacuum releases or detach the eye1.

The end of the patient interface800opposite the eye1includes an attachment interface806configured to attach to the housing702of the focusing objective700to thereby affix the position of the eye relative to the other components of the integrated surgical system1000. The attachment interface806can work with mechanical, vacuum, magnetic or other principles and it is also detachable from the integrated surgical system.

The focusing objective700includes an aspheric exit lens710having an eye-facing, concave surface711and a convex surface712opposite the concave surface. The exit lens710thus has a meniscus form. While the exit lens710shown inFIGS. 9aand 9bis an aspheric lens giving more design freedom, in other configurations the exit lens may be a spherical lens. Alternatively, constructing the exit lens710as a compound lens, as opposed to a singlet, allows more design freedom to optimize the optics while preserving the main characteristics of the optical system as presented here. With reference toFIG. 9c, the concave surface711is characterized by a radius of curvature ry, while the convex surface712is characterized by an aspheric shape. The aspheric convex surface712in combination with the spherical concave surface711result in an exit lens710having varying thickness, with the outer perimeter edges715of the lens being thinner than the central, apex region717of the lens. The concave surface711is configured to couple to the convex surface813of the window801. In one embodiment, the exit lens710is formed of fused silica and has a refractive index nxof 1.45.

FIGS. 10aand 10bare schematic illustrations of components of the integrated surgical system ofFIGS. 7 and 8functionally arranged to form an optical system1010having a first optical subsystem1001and a second optical subsystem1002that enable access to a surgical volume720in the irido-corneal angle. Each ofFIGS. 10aand 10binclude components of the focusing objective700and the patient interface800ofFIG. 9a. However, for simplicity, the entirety of the focusing objective and the patient interface are not included inFIGS. 10aand 10b. Also, for additional simplicity inFIG. 10a, the planar beam-folding mirror740ofFIGS. 9aand 9bis not included and the combined laser/OCT/visual beam701shown inFIG. 9ais unfolded or straightened out. It is understood by those skilled in the art that adding or removing planar beam folding mirrors does not alter the principal working of the optical system formed by the first optical subsystem and the second optical subsystem.FIG. 10cis a schematic illustration of a beam passing through the first optical subsystem ofFIGS. 10aand10b.

With reference toFIG. 10a, a first optical subsystem1001of the integrated surgical system1000includes the exit lens710of a focusing objective700and the window801of a patient interface800. The exit lens710and the window801are arranged relative to each other to define a first optical axis705. The first optical subsystem1001is configured to receive a beam, e.g., a combined laser/OCT/visual beam701, incident at the convex surface712of the exit lens710along a second optical axis706, and to direct the beam toward a surgical volume720in the irido-corneal angle13of the eye.

During a surgical procedure, the first optical subsystem1001may be assembled by interfacing the convex surface813of the window801with the concave surface711of the exit lens710. To this end, a focusing objective700is docked together with a patient interface800. As a result, the concave surface711of the exit lens710is coupled to the convex surface813of the window801. The coupling may be by direct contact or through a layer of index matching fluid. For example, when docking the patient interface800to focusing objective700, a drop of index matching fluid can be applied between the contacting surfaces to eliminate any air gap that may be between the two surfaces711,813to thereby help pass the combined laser/OCT/visual beam701through the gap with minimal Fresnel reflection and distortion.

In order to direct the beam toward the surgical volume720in the irido-corneal angle13of the eye, the first optical subsystem1001is designed to account for refraction of the beam701as it passes through the exit lens710, the window801and the cornea3. To this end, and with reference toFIG. 10c, the refractive index nxof the exit lens710and the refractive index nwof the window801are selected in view of the refractive index ncof the cornea3to cause appropriate beam bending through the first optical subsystem1001so that when the beam701exits the subsystem and passes through the cornea3, the beam path is generally aligned to fall within the irido-corneal angle13.

Continuing with reference toFIG. 10cand beginning with the interface between the window801and the cornea3. Too steep of an angle of incidence at the interface where the combined laser/OCT/visual beam701exits the window801and enters the cornea3, i.e., at the interface between the concave surface812of the window and the convex surface of the cornea3, can create excessive refraction and distortion. To minimize refraction and distortion at this interface, in one embodiment of the first optical subsystem1001, the refractive index of the window801is closely matched to the index of the cornea3. For example, as describe above with reference toFIGS. 9aand 9b, the window801may have a refractive index lower than 1.42 to closely match the cornea3, which has a refractive index of 1.36.

Excessive refraction and distortion at the interface where the combined laser/OCT/visual beam701exits the window801and enters the cornea3may be further compensated for by controlling the bending of the beam701as it passed through the exit lens710and the window801. To this end, in one embodiment of the first optical subsystem1001the index of refraction nwof the window801is larger than each of the index of refraction nxof the exit lens710and the index of refraction ncof the cornea3. As a result, at the interface where the combined laser/OCT/visual beam701exits the exit lens710and enters the window801, i.e., interface between the concave surface711of the exit lens and the convex surface813of the window, the beam passes through a refractive index change from high to low that cause the beam to bend in a first direction. Then, at the interface where the combined laser/OCT/visual beam701exits the window801and enters the cornea3, i.e., interface between the concave surface812of the exit lens and the convex surface of the cornea, the beam passes through a refractive index change from low to high that cause the beam to bend in a second direction opposite the first direction.

The shape of the window801is chosen to be a meniscus lens. As such, the incidence angle of light has similar values on both surfaces812,813of the window801. The overall effect is that at the convex surface813the light bends away from the surface normal and at the concave surface812the light bends towards the surface normal. The effect is like when light passes through a plan parallel plate. Refraction on one surface of the plate is compensated by refraction on the other surface a light passing through the plate does not change its direction. Refraction at the entering, convex surface712of the exit lens710distal to the eye is minimized by setting the curvature of the entering surface such that angle of incidence β of light701at the entering surface is close to a surface normal707to the entering surface at the intersection point708.

Here, the exit lens710, the window801, and the eye1are arranged as an axially symmetric system with a first optical axis705. In practice, axial symmetry is an approximation because of manufacturing and alignment inaccuracies of the optical components, the natural deviation from symmetry of the eye and the inaccuracy of the alignment of the eye relative to the window801and the exit lens710in a clinical setting. But, for design and practical purposes the eye1, the window801, and the exit lens710are considered as an axially symmetric first optical subsystem1001.

With continued reference toFIG. 10a, a second optical subsystem1002is optically coupled to the first optical subsystem1001at an angle α relative to the first optical axis705of the first optical subsystem1001. The advantage of this arrangement is that the both optical subsystems1001,1002can be designed at a much lower numerical aperture compared to a system where all optical components are designed on axis with a common optical axis.

The second optical subsystem1002includes a relay lens750that, as previously described with reference toFIG. 8, generates a conjugate surgical volume721of the surgical volume720within the eye. The second optical subsystem1002includes various other components collectively indicated as an optical subsystem step1003. Referring toFIG. 8, these components may include a femtosecond laser source200, an OCT imaging apparatus300, a visual observation device400, beam conditioners and scanners500, and beam combiners600.

The second optical subsystem1002may include mechanical parts (not shown) configured to rotate the entire subsystem around the first optical axis705of the first optical subsystem1001. This allows optical access to the whole 360-degree circumference of the irido-corneal angle13of the eye1.

With reference toFIG. 10b, flexibility in arranging the first and second optical subsystems1001,1002, relative to each other may be provided by an optical assembly1004interposed between the optical output of the second optical subsystem1002and the optical input of the first optical subsystem1001. In one embodiment, the optical assembly1004may include one or more planar beam-folding mirrors740, prisms (not shown) or optical gratings (not shown) configured to receive the optical output, e.g., combined laser/OCT/visual beam701, of the second optical subsystem1002, change or adjust the direction of the combined laser/OCT/visual beam, and direct the beam to the optical input of the first optical subsystem1001while preserving the angle α between the first optical axis705and the second optical axis706.

In another configuration, the optical assembly1004of planar beam-folding mirrors740further includes mechanical parts (not shown) configured to rotate741the assembly around the first optical axis705of the first optical subsystem1001while keeping the second optical subsystem1002stationary. Accordingly, the second optical axis706of the second optical subsystem1002can be rotated around the first optical axis705of the first optical subsystem1001. This allows optical access to the whole 360-degree circumference of the irido-corneal angle13of the eye1.

With considerations described above with reference toFIGS. 9a, 9band 9c, the design of the first optical subsystem1001is optimized for angled optical access at an angle α relative to the first optical axis705of the first optical subsystem1001. Optical access at the angle α compensates for optical aberrations of the first optical subsystem1001. Table 1 shows the result of the optimization at access angle α=72 degrees with Zemax optical design software package. This design is a practical embodiment for image guided femtosecond glaucoma surgery.

This design produces diffraction limited focusing of 1030 nm wavelength laser beams and 850 nm wavelength OCT beams with numerical aperture (NA) up to 0.2. In one design, the optical aberrations of the first optical subsystem are compensated to a degree that the Strehl ratio of the first optical subsystem for a beam with numerical aperture larger than 0.15 at the irido-corneal angle is larger than 0.9. In another design, the optical aberrations of the first optical subsystem are partially compensated, the remaining uncompensated aberrations of the first optical system are compensated by the second optical subsystem to a degree that the Strehl ratio of the combined first and second optical subsystem for a beam with numerical aperture larger than 0.15 at the irido-corneal angle is larger than 0.9.

Calibration

The femtosecond laser source200, OCT imaging apparatus300, and visual observation device400of the integrated surgical system1000are first individually calibrated to ensure their internal integrity and then cross-calibrated for system integrity. The essential part of system calibration is to ensure that the when the surgical focus of a laser beam201is commanded to a location of a surgical volume720, as identified by the OCT imaging apparatus and/or the visual observation device400, the achieved location of the focus matches the commanded location of the focus within a certain tolerance, typically within 5 to 10 μm. Also, graphical and cursor outputs, images, overlays displayed on a user interface110, such as a computer monitor, and user inputs of ocular tissue surgical volume720locations accepted from the user interface110should correspond to actual locations in tissue within predetermined tolerances of similar accuracy.

One embodiment of this spatial calibration procedure starts with imaging calibrated scales and scaling magnifications of the OCT imaging apparatus300and/or the visual observation device400and their displays in a way that the scale value on the display matches the real scale of the calibration target. Then laser calibration patters are exposed or burned into transparent calibration targets, and the calibration patterns are subsequently imaged. Then, the intended patterns and the actual burned patterns are compared with the imaging system of the integrated surgical system1000or by a separate microscope. If they do not match within the specified tolerance, the scaling parameters of the surgical patterns are re-scaled by adjusting the scaling of the laser beam scanners. This procedure is iterated, if necessary, until all spatial calibrations are within tolerance.

Minimally Invasive Surgical Treatments

FIG. 11is a three-dimensional schematic illustration of anatomical structures of the eye relevant to the surgical treatment enabled by the integrated surgical system1000. To reduce the IOP, laser treatment targets ocular tissues that affect the trabecular outflow pathway40. These ocular tissues may include the trabecular meshwork12, the scleral spur14, the Schlemm's canal18, and the collector channels19. The trabecular meshwork12has three layers, the uveal15, the corneoscleral meshwork16, and the juxtacanalicular tissue17. These layers are porous and permeable to aqueous, with the uveal15being the most porous and permeable, followed by the corneoscleral meshwork16. The least porous and least permeable layer of the trabecular meshwork12is the juxtacanalicular tissue17. The inner wall18aof the Schlemm's canal18, which is also porous and permeable to aqueous, has characteristics similar to the juxtacanalicular tissue17.

FIG. 12includes a three-dimensional illustration of a treatment pattern P1to be applied by the integrated surgical system1000to affect the surgical volume900of ocular tissue shown inFIG. 11, and a two-dimensional schematic illustration of the treatment pattern P1overlaying anatomical structures to be treated.FIG. 13is a three-dimensional schematic illustration of the anatomical structures of the eye including an opening902through the that results from the application of the laser treatment pattern ofFIG. 12. The opening902provides and outflow pathway40that reduces the flow resistance in the ocular tissue to increase aqueous flow from the anterior chamber7into the Schlemm's canal18and thereby reduce the IOP of the eye.

Surgical treatments reduce outflow pathway resistance while minimizing ocular tissue modification through design and selection of laser treatment patterns. A treatment pattern is considered to define a collection of a laser-tissue interaction volumes, referred to herein as cells. The size of a cell is determined by the extent of the influence of the laser-tissue interaction. When the laser spots, or cells, are spaced close along a line, the laser creates a narrow, microscopic channel. A wider channel can be created by closely spacing a multitude of laser spots within the cross section of the channel. The arrangement of the cells may resemble the arrangement of atoms in a crystal structure.

With reference toFIG. 12, a treatment pattern P1may be in the form of a cubic structure that encompasses individual cells arranged in regularly spaced rows, columns and sheets or layers. The treatment pattern P1may be characterized by x, y, z dimensions, with x, y, z coordinates of the cells being calculated sequentially from neighbor to neighbor in the order of a column location (x coordinate), a row location (y coordinate), and a layer location (z coordinate). A treatment pattern P1as such, defines a three-dimensional model of ocular tissue to be modified by a laser or a three-dimensional model of ocular fluid to be affected by a laser.

A treatment pattern P1is typically defined by a set of surgical parameters. The surgical parameters may include one or more of a treatment area A that represents a surface area or layer of ocular tissue through which the laser will travel. The treatment area A is determined by the treatment height, h, and the lateral extent of the treatment, w. A treatment thickness t that represents the level to which the laser will cut into the ocular tissue from the distal extent or border of the treatment volume at or near Schlemm's canal18to the proximal extent or border at or near the surface of the trabecular meshwork12. Thus, a laser applied in accordance with a treatment pattern may affect or produce a surgical volume that resembles the three-dimensional model of the treatment pattern, or may affect fluid located in an interior of an eye structure resembled by the three-dimensional model.

Additional surgical parameters define the placement of the surgical volume or affected volume within the eye. For example, with reference toFIGS. 11 and 12, placement parameters may include one or more of a location l that represents where the treatment is to occur relative to the circumferential angle of the eye, and a treatment depth d that represents a position of the three-dimensional model of ocular tissue or ocular fluid within the eye relative to a reference eye structure. In the following, the treatment depth d is shown and described relative to the region where the anterior chamber7meets the trabecular meshwork12. Together, the treatment pattern and the placement parameters define a treatment plan.

A femtosecond laser provides highly localized, non-thermal photo-disruptive laser-tissue interaction with minimal collateral damage to surrounding ocular tissue. Photo-disruptive interaction of the laser is utilized in optically transparent tissue. The principal mechanism of laser energy deposition into the ocular tissue is not by absorption but by a highly nonlinear multiphoton process. This process is effective only at the focus of the pulsed laser where the peak intensity is high. Regions where the beam is traversed but not at the focus are not affected by the laser. Therefore, the interaction region with the ocular tissue is highly localized both transversally and axially along the laser beam.

With reference toFIGS. 11 and 12, in accordance with embodiments disclosed herein a surgical volume900of ocular tissue to be treated is identified by the integrated surgical system1000and a treatment pattern P1corresponding to the surgical volume is designed by the integrated surgical system. Alternatively, the treatment pattern P1may be designed first, and then an appropriate surgical volume900for applying the treatment pattern may be identified. The surgical volume900of ocular tissue may comprise portions of the trabecular meshwork12and the Schlemm's canal18. For example, the surgical volume900of ocular tissue shown inFIG. 11includes portions of the uveal15, the corneoscleral meshwork16, the juxtacanalicular tissue17, and the inner wall18aof the Schlemm's canal18. The treatment pattern P1defines a laser scanning procedure whereby a laser is focused at different depth locations in ocular tissue and then scanned in multiple directions to affect a three-dimensional volume of tissue comprising multiple sheets or layers of affected tissue.

With reference toFIGS. 12 and 13, during a laser scanning procedure, a surgical laser701may scan ocular tissue in accordance with the treatment pattern P1to form an opening902that extends from the anterior chamber7, through each of the uveal15, the corneoscleral meshwork16, the juxtacanalicular tissue17of the trabecular meshwork12, and the inner wall18aof the Schlemm's canal18. While the example opening902inFIG. 13is depicted as a continuous, single lumen defining a fluid pathway, the opening may be defined an arrangement of adjacent pores forming a sponge like structure defining a fluid pathway or a combination thereof. While the example opening902inFIG. 13is in the shape of a cube, the opening may have other geometric shapes.

The movement of the laser as it scans to affect the surgical volume900follows the treatment pattern P1, which is defined by a set of surgical parameters that include a treatment area A and a thickness t. The treatment area A is defined by a width w and a height h. The width may be defined in terms of a measure around the circumferential angle. For example, the width w may be defined in terms of an angle, e.g., 90 degrees, around the circumferential angle.

Referring toFIGS. 11 and 12, an initial placement of the laser focus within the eye is defined by a set of placement parameters, including a depth d and a location l. The location l defines a point around the circumferential angle of the eye at which laser treatment will begin, while the depth d defines a point between the anterior chamber7and the Schlemm's canal18where the laser treatment begins or ends. The depth d is measured relative to the region where the anterior chamber7meets the trabecular meshwork12. Thus, a first point that is closer to the Schlemm's canal18side of the trabecular meshwork12may be described as being deeper than a second point that is closer to the anterior chamber7side of the trabecular meshwork12. Alternatively, the second point may be described as being shallower than the first point.

With reference toFIG. 13, the opening902resulting from laser application of the treatment pattern P1resembles the surgical volume900and is characterized by an area A and thickness t similar to those of the surgical volume and the treatment pattern. The thickness t of the resulting opening902extends from the anterior chamber7and through the inner wall18aof the Schlemm's canal18, while the area A defines the cross-section size of the opening902.

In accordance with embodiments disclosed herein, during a laser scanning procedure, a laser focus is moved to different depths d in ocular tissue and then scanned in two lateral dimensions or directions as defined by a treatment pattern P1to affect a three-dimensional volume900of ocular tissue comprising multiple sheets or layers of affected tissue. The two lateral dimensions are generally orthogonal to the axis of movement of the laser focus. With reference toFIG. 13, the movement of a laser focus during laser scanning is described herein with reference to x, y, and z directions or axes, wherein: 1) movement of the laser focus to different depths d through the thickness t of treatment pattern P1or the volume900of tissue corresponds to movement of the focus along the z axis, 2) movement of the laser focus in two dimensions or directions orthogonal to the z axis corresponds to movement of the laser focus along the width w of the treatment pattern P1or the volume900of tissue in the x direction, and movement of the laser focus along the height h of the treatment pattern P1or the volume900of tissue in the y direction.

As used herein scanning of the laser focus generally corresponds to a raster type movement of the laser focus in the x direction, the y direction, and the z direction. The laser focus may be located at a point in the z direction and then raster scanned in two dimensions or directions, in the x direction and the y direction. The focal point of the laser in the z direction may be referred to as a depth d within the treatment pattern P1or the volume900of tissue. The two direction raster scanning of the laser focus defines a layer of laser scanning, which in turn produces a layer of laser-affected tissue.

During laser scanning, pulse shots of a laser are delivered to tissue within the volume of ocular tissue corresponding to the treatment pattern P1. Because the laser interaction volume is small, on the order of a few micrometers (m), the interaction of ocular tissue with each laser shot of a repetitive laser breaks down ocular tissue locally at the focus of the laser. Pulse duration of the laser for photo-disruptive interaction in ocular tissue can range from several femtoseconds to several nanoseconds and pulse energies from several nanojoules to tens of microjoules. The laser pulses at the focus, through multiphoton processes, breaks down chemical bonds in the molecules, locally photo-dissociate tissue material and create gas bubbles in wet tissue. The breakdown of tissue material and mechanical stress from bubble formation fragments the tissue and create clean continuous cuts when the laser pulses are laid down in proximity to one another along geometrical lines and surfaces.

Table 2 includes examples of treatment pattern parameters and surgical laser parameters for treating tissue. The range of the parameter set is limited by practical ranges for the repetition rate of the laser and the scanning speed of the scanners.

With reference toFIGS. 11, 12, 13, 14aand14b, in one type of laser scanning procedure, the scanning begins at the end of the treatment pattern P1adjacent the anterior chamber7and proceeds in a direction that generally corresponds to the direction of propagation of the laser701. More specifically, and with reference toFIG. 14a, the laser scanning proceeds in the z direction toward an anatomical structure, e.g., the inner wall18aof the Schlemm's canal18, while the direction of propagation of the laser701also proceeds toward same anatomical structure, e.g., the inner wall18aof the Schlemm's canal18.

Laser scanning in this manner, however, may be ineffective at producing the desired opening902between the anterior chamber7and the Schlemm's canal18due to interference by gas bubbles produced during laser application. As noted above, femtosecond lasers generate a very short pulse of optical energy. When a beam of such pulses is focused to a very small volume of space characterized by a small cross-sectional area, a non-linear effect occurs within the focus spot. When such a focus spot is directed onto tissue, the tissue is photodisrupted (broken down) leaving a small bubble of gas. This process is essentially non-thermal and requires a tiny amount of energy. The result is that the surrounding tissue is not affected.

However, when a femtosecond laser beam is scanned over the surface of a tissue, the laser treatment of this initial surface layer generates a layer of bubbles over the area of the treatment. When the laser scans the layer of tissue below or deeper than the initial surface layer, these bubbles create a shadow effect that scatters the incident laser light, effectively blocking further treatment of the tissue. This renders further laser treatment of tissue beneath or deeper that the initial surface layer ineffective.

An example of this effect within the context of glaucoma surgery is illustrated inFIGS. 14aand 14b. InFIG. 14a, the focus of the laser beam701is initially located at a depth d1. This depth d1places the laser focus in an initial layer904of tissue. For example, initial layer904of tissue may be at the interface between the uveal15of the trabecular meshwork12and the anterior chamber7. In this instance, this depth location of the laser focus is referred to a null depth and the initial layer904to be treated corresponds to the surface of the uveal15facing the anterior chamber7. Once the laser focus is positioned at the initial depth d1, the focus is scanned in multiple directions while being maintained at the initial depth. With reference toFIG. 14a, the multiple directions are the x direction and y direction, where the x direction is into the plane ofFIG. 14a.

With reference toFIG. 14b, the raster scanning in the multiple directions results in the photodisruption of the initial layer904of tissue and the formation of a layer of bubbles906at the initial layer of tissue. The focus of the laser beam701is then moved in the z direction toward the inner wall18aof the Schlemm's canal18to another depth d2. This depth d2places the laser focus at a subsequent layer908of tissue deeper than the initial layer904. For example, the deeper layer of tissue may comprise the uveal15of the trabecular meshwork12. Once the laser focus is positioned at the subsequent layer908, the focus is raster scanned in multiple directions while being maintained at that depth. However, in this instance, the layer of bubbles906scatters the incident laser light, effectively blocking further treatment of the tissue at the subsequent layer908.

With reference toFIGS. 11, 12, 13, 15a-15g, in accordance with embodiments disclosed the above ineffective laser treatment is avoided by implementing a laser scanning procedure, whereby the laser scanning begins at the end of the treatment pattern P1adjacent the Schlemm's canal18and proceeds in a direction generally opposite to or against the direction of propagation of the laser701. More specifically, and with reference toFIG. 15a, the laser scanning starts at an anatomical structure, e.g., the inner wall18aof the Schlemm's canal18and proceeds away from that structure in the z direction toward the anterior chamber7, while the direction of propagation of the laser701proceeds toward the that structure.

With this scanning procedure, the laser beam of femtosecond pulses is focused within a volume of ocular tissue at an initial depth or distance from a surface of the volume of tissue. An initial layer of tissue at the initial depth is treated, which generates a layer of bubbles at the area of the initial layer. After treatment of the initial layer of tissue, the laser is refocused to a subsequent layer of tissue that is shallower than the initial layer of tissue, i.e., at a depth that is closer to the surface of the volume of ocular tissue than the initial depth. Since the layer of bubbles at the area of the initial layer is below the second layer, the bubbles do not obstruct the second layer. This process is repeated until the laser scans, layer-by-layer through the volume of ocular tissue to the surface of the volume of tissue.

An example of this scanning procedure within the context of glaucoma surgery is illustrated inFIGS. 15a-15g. InFIG. 15a, the focus of the laser beam701is initially located at a depth d1. This depth d1places the laser focus in an initial layer910of tissue. For example, initial layer910of tissue may comprise the inner wall18aof the Schlemm's canal18. Once the laser focus is positioned at the initial depth d1, the focus is scanned in multiple directions while being maintained at the initial depth d1. With reference toFIG. 15a, the multiple directions are the x direction and y direction, where the x direction is into the plane ofFIG. 15a.

With reference toFIG. 15b, the laser scanning in multiple directions results in the photodisruption of the initial layer910of tissue and the formation of a layer of bubbles912at the location of the initial layer of tissue. The focus of the laser beam701is then moved in the z direction toward the anterior chamber7to a subsequent depth d2. The subsequent depth d2places the laser focus at a subsequent layer914of tissue less deep than the initial layer910of tissue. For example, the subsequent layer914of tissue may comprise a portion of the inner wall18aof the Schlemm's canal18, the juxtacanalicular tissue17, and the corneoscleral meshwork16. Once the laser focus is positioned at the subsequent depth d2, the focus is scanned in multiple directions while being maintained at the subsequent depth d2. Since the layer of bubbles912is beneath the subsequent layer914, the bubbles do not obstruct laser access to or block photodisruption of the subsequent layer.

With reference toFIG. 15c, the laser scanning in multiple directions results in the photodisruption of the subsequent layer914of tissue and the formation of a layer of bubbles916at the location of the subsequent layer of tissue. The focus of the laser beam701is then moved in the z direction toward the anterior chamber7to a subsequent depth d3. The subsequent depth d3places the laser focus at a subsequent layer918of tissue less deep than the subsequent layer914of tissue. For example, the subsequent layer914of tissue may comprise a portion of the juxtacanalicular tissue17and the corneoscleral meshwork16. Once the laser focus is positioned at the subsequent depth d3, the focus is scanned in multiple directions while being maintained at the subsequent depth d3. Since the layers of bubbles912,916are beneath the subsequent layer918, the bubbles do not obstruct laser access to or block photodisruption of the subsequent layer.

With reference toFIG. 15d, the laser scanning in multiple directions results in the photodisruption of the subsequent layer918of tissue and the formation of a layer of bubbles920at the location of the subsequent layer of tissue. The focus of the laser beam701is then moved in the z direction toward the anterior chamber7to a subsequent depth d4. The subsequent depth d4places the laser focus at a subsequent layer922of tissue less deep than the subsequent layer918of tissue. For example, the subsequent layer922of tissue may comprise a portion of the corneoscleral meshwork16and the uveal15. Once the laser focus is positioned at the subsequent depth d4, the focus is scanned in multiple directions while being maintained at the subsequent depth d4. Since the layers of bubbles912,916,920are beneath the subsequent layer922, the bubbles do not obstruct laser access to or block photodisruption of the subsequent layer.

With reference toFIG. 15e, the laser scanning in multiple directions results in the photodisruption of the subsequent layer922of tissue and the formation of a layer of bubbles924at the location of the subsequent layer of tissue. The focus of the laser beam701is then moved in the z direction toward the anterior chamber7to a subsequent depth d5. The subsequent depth d5places the laser focus at a subsequent layer926of tissue less deep than the subsequent layer922of tissue. For example, the subsequent layer926of tissue may comprise the uveal15. Once the laser focus is positioned at the subsequent depth d5, the focus is scanned in multiple directions while being maintained at the subsequent depth d5. Since the layers of bubbles912,916,920,924are beneath the subsequent layer926, the bubbles do not obstruct laser access to or block photodisruption of the subsequent layer.

With reference toFIG. 15f, the laser scanning in multiple directions results in the photodisruption of the subsequent layer926of tissue and the formation of a layer of bubbles928at the location of the subsequent layer of tissue. The focus of the laser beam701is then moved in the z direction toward the anterior chamber7to a subsequent depth d6. The subsequent depth d6places the laser focus at a subsequent layer930of tissue less deep than the subsequent layer926of tissue. For example, the subsequent layer930of tissue may comprise the uveal15and the inner surface of the uveal facing the anterior chamber7. Once the laser focus is positioned at the subsequent depth d6, the focus is scanned in multiple directions while being maintained at the subsequent depth d6. Since the layers of bubbles912,916,920,924,928are beneath the subsequent layer930, the bubbles do not obstruct laser access to or block photodisruption of the subsequent layer.

With reference toFIG. 15g, the laser scanning in multiple directions results in the photodisruption of the subsequent layer930of tissue and the formation of a layer of bubbles932at the location of the subsequent layer of tissue. Photodisruption of this subsequent layer930of tissue results in the formation of an opening902between the anterior chamber7and the Schlemm's canal18, thus completing the laser treatment procedure.

With reference toFIG. 16a, upon completion of the laser scanning the opening902may be partially obstructed or occluded by the gas bubbles912,916,920,924,928created during treatment. Thus, in accordance with embodiments disclosed herein, the direction of the laser scanning described with reference toFIGS. 15a-15gmay be reversed in order to push any remaining bubbles into the Schlemm's canal18thereby clearing the opening902, as shown inFIG. 16b.

FIG. 17is a flowchart of a method of treating a target volume of ocular tissue with a laser having a direction of propagation toward the target volume of ocular tissue. With reference toFIG. 12, the target volume60of ocular tissue is characterized by a distal extent62, a proximal extent64, and a lateral extent66. The distal extent62corresponds to the part or point of the target volume60that is most distal along the direction of propagation of the laser701. The proximal extent64corresponds to the part or point of the target volume60that is most proximal along the direction of propagation of the laser701. The lateral extent66corresponds to the distance or width w of the target volume60along the circumference angle.

The method, which may be performed by the integrated surgical system1000ofFIGS. 7-10b, begins at a point in a surgical procedure where access to the irido-corneal angle has already been obtained and the target volume60of ocular tissue has already been identified for treatment. Systems and methods for accessing the irido-corneal angle are described in U.S. patent application Ser. No. 16/036,883, entitled Integrated Surgical System and Method for Treatment in the Irido-Corneal Angle of the Eye, the disclosure of which is hereby incorporated by reference. Systems and method for identifying volumes of ocular tissue for treatment and designing treatment patterns reference are described in U.S. patent application Ser. No. 16/125,588, entitled Non-Invasive and Minimally Invasive Laser Surgery for the Reduction of Intraocular Pressure in the Eye, the disclosure of which is hereby incorporated by reference.

At block1702, the integrated surgical system1000initially photodisrupts tissue at an initial depth d1corresponding to the distal extent62of the target volume60of ocular tissue is. To this end, and with reference toFIG. 15a, the integrated surgical system1000focuses light from a femtosecond laser701at a spot in the tissue at the initial depth d1and applies optical energy to the tissue, which energy is at a level sufficient to photodisrupt the tissue. Optical energy is applied by scanning the laser701in multiple directions defining an initial treatment plane910at the initial depth d1to thereby photodisrupt an initial layer of tissue of the target volume of ocular tissue. With reference toFIG. 13, the scanning may be in the form of a raster scan where the laser is scanned in a first direction along the lateral extent66, i.e., the x direction, and then slightly repositioned in a second direction. i.e., the y direction, and then scanned again along the lateral extent.

As an additional aspect of the initial photodisruption process of block1702, the integrated surgical system1000may detect the distal extent62of the target volume of ocular tissue. To this end, in one configuration images captured by the OCT imaging apparatus300are processed by the control system100to detect the distal extent62of the target volume using known techniques. In another configuration, the integrated surgical system1000may include a multiphoton imaging apparatus (not shown) that provides a visual indication on a display of the user interface110that is indicative of the location of the focus of the laser701relative to the distal extent62of the target volume60of ocular tissue. The integrated surgical system1000may also determine the lateral extent66of the target volume60of ocular tissue based on OCT imaging.

At block1704and with reference toFIGS. 15b-15f, the integrated surgical system1000subsequently photodisrupts tissue at one or more subsequent depths d2-d6between the distal extent62of the target volume60of ocular tissue and the proximal extent64of the target volume of ocular tissue is by moving a focus of the laser701in a direction opposite the direction of propagation of the laser. To this end, the integrated surgical system1000focuses light from a femtosecond laser701at a spot in the tissue at the one or more subsequent depths d2-d6and applies optical energy to the tissue, which energy is at a level sufficient to photodisrupt the tissue. Optical energy is applied by scanning the laser701in multiple directions defining a subsequent treatment plane914,918,922,926,930at a respective different depth d2-d6, to thereby photodisrupt one or more subsequent layers of tissue of the target volume60of ocular tissue. With reference toFIG. 13, the scanning may be in the form of a raster scan where the laser is scanned in a first direction along the lateral extent66, i.e., the x direction, and then slightly repositioned in a second direction. i.e., the y direction, and then scanned again along the lateral extent.

As an additional aspect of the subsequent photodisruption process of block1704, the integrated surgical system1000may detect the proximal extent64of the target volume60of ocular tissue. To this end, in one configuration images captured by the OCT imaging apparatus300are processed by the control system100to detect the proximal extent64of the target volume60using known techniques. In another configuration, the integrated surgical system1000may include a multiphoton imaging apparatus (not shown) that provides a visual indication on a display of the user interface110that is indicative of the location of the focus of the laser701relative to the proximal extent64of the target volume60of ocular tissue. In yet another configuration, the integrated surgical system1000may include an opto-mechanical imaging apparatus (not shown) that provides a visual indication on a display of the user interface110that is indicative of the location of the focus of the laser701relative to the proximal extent64of the target volume60of ocular tissue.

At block1706, the integrated surgical system1000determines if the proximal extent64of the target volume60of ocular tissue has been photodisrupted. If the proximal extent64has not been photodisrupted, the process return to block1704and the integrated surgical system1000repeats the photodisrupting at one or more subsequent depths until tissue at the proximal extent64of the target volume60of ocular tissue is photodisrupted.

Returning to block1706and with reference toFIG. 16a, if the proximal extent64has been photodisrupted, the process proceeds to block1708and the integrated surgical system1000photodisrupts tissue debris or bubbles906between the proximal extent64of the target volume60of ocular tissue and the distal extent62of the target volume by moving the focus of the laser701in the direction of propagation of the laser. To this end, the integrated surgical system1000focuses light from a femtosecond laser701at a spot in the volume of tissue debris or bubbles906at the one or more subsequent depths and applies optical energy to the tissue debris or bubbles. Optical energy is applied by scanning the laser701in multiple directions along one or more of the previously-scanned treatment planes910,914,918,922,926,930to photodisrupt tissue debris or bubbles906between the proximal extent64and the distal extent62of the photodisrupted target volume60.

At block1710, the integrated surgical system1000may determine to repeat the treatment of the photodisrupted target volume60of ocular tissue or to end the treatment. If treatment is repeated, the process returns to block1702, where the integrated surgical system1000repeats the initial photodisrupting of tissue, and then proceeds to blocks1704and1706, where the system repeats the subsequent photodisrupting of tissue one or more times. If treatment is not to be repeated, the process proceeds to block1712, where treatment ends.

Regarding the use of a multiphoton imaging apparatus to detect the distal extent62of the target volume of ocular tissue, or the proximal extent64of the target volume, such an apparatus is configured to present an image of a second harmonic light that results from an encounter between the focus of the laser701and tissue. When the focus of the laser701is not encountering tissue, the intensity of the second harmonic light is zero or very low. When the focus is encountering tissue, the intensity of the second harmonic light increases. Based on this, a distal extent62such as shown inFIG. 12may be detected by first advancing the focus of the laser701through the trabecular meshwork12and the inner wall18aof the Schlemm's canal and into the Schlemm's canal18, where the focus will not encounter light and the intensity of the second harmonic light is zero or very low, and then retracting the focus back toward the inner wall18aof the Schlemm's canal and detecting that the focus is at the inner wall when an increase in the intensity of the second harmonic light is noted on the display.

Regarding the use of an opto-mechanical imaging apparatus to detect the proximal extent64of the target volume60of ocular tissue, such an apparatus is configured to direct a first beam of light and a second beam of light to be incident with the target volume and to align the first beam of light and the second beam of light relative to each other and relative to the laser beam such that the first beam of light and the second beam light intersect at a point corresponding to the focus of the laser. The apparatus is also configured to capture an image of a first spot corresponding to the first beam of light, and a second spot corresponding to the second beam of light relative to the proximal extent64of the target volume60of ocular tissue. The first and second spots appear in the image as two separate visible spots on the surface of the proximal extent64when the focus is away from the surface, and as a single, overlapping spot when the focus is on the surface. Accordingly, the proximal extent64is detected when the spots overlap.

With reference toFIGS. 7-10b, a surgical system1000for implementing the method ofFIG. 17includes a first optical subsystem1001including a focusing objective700configured to be coupled to the eye1, and a second optical subsystem1002including a laser source200configured to output a laser beam201/701. The second optical subsystem1002also includes a plurality of components1003configured to one or more of focus, scan, and direct the laser beam through the focusing objective, in a direction of propagation toward the target volume of ocular tissue.

The surgical system1000further includes a control system100coupled to the second optical subsystem1002and configured to control the focus and scan of the laser beam701to photodisrupt tissue at an initial depth corresponding to the distal extent of the target volume of ocular tissue. To this end, the control system100is configured to focus light from a femtosecond laser source200at a spot in the tissue at the initial depth and then apply optical energy to the tissue, where the energy is sufficient to photodisrupt tissue. The control system100controls the focus and scan of the laser beam701during application of optical energy by being further configured to scan the laser in multiple directions defining an initial treatment plane, to thereby photodisrupt an initial layer of tissue of the target volume of ocular tissue.

The control system100is also configured to control the focus and scan of the laser beam701to photodisrupt tissue at one or more subsequent depths between the distal extent of the target volume of ocular tissue and the proximal extent of the target volume of ocular tissue by moving a focus of the laser in a direction opposite the direction of propagation of the laser. To this end, the control system100is configured to focus light from a femtosecond laser source200at a spot in the tissue at a subsequent depth and then apply optical energy to the tissue, where the energy is sufficient to photodisrupt tissue. The control system100controls the focus and scan of the laser beam701during application of optical energy by being further configured to scan the laser in multiple directions defining a subsequent treatment plane, to thereby photodisrupt a subsequent layer of tissue of the target volume of ocular tissue.

The control system100is also configured to control the focus and scan of the laser beam701to photodisrupt tissue debris or bubbles between the proximal extent of the target volume of ocular tissue and the distal extent of the target volume by moving the focus of the laser in the direction of propagation of the laser, after photodisrupting the target volume of ocular tissue. The control system100is further configured to control the focus and scan of the laser beam701to repeat the initial photodisrupting of tissue and the subsequent photodisrupting of tissue one or more times.

FIG. 18is a flowchart of a method of treating an eye comprising an anterior chamber, a Schlemm's canal, and a trabecular meshwork therebetween. The method, which may be performed by the integrated surgical system1000ofFIGS. 7-10b, begins at a point in a surgical procedure where access to the irido-corneal angle has already been obtained and one or more anatomical structures of the eye that are to be treated have been located.

At block1802and with reference toFIGS. 15aand 15b, the integrated surgical system1000initially photodisrupts ocular tissue at or near an interface of an inner wall18aof the Schlemm's canal18and the trabecular meshwork12. To this end, the integrated surgical system1000focuses light from a femtosecond laser701at a spot in the ocular tissue at or near the interface of the inner wall18aof the Schlemm's canal18and the trabecular meshwork12and applies optical energy to the tissue, which energy is at a level sufficient to photodisrupt the tissue.

As an additional aspect of the initial photodisruption process of block1802, the integrated surgical system1000may detect ocular tissue at or near the interface of the inner wall18aof the Schlemm's canal18and the trabecular meshwork12. To this end, in one configuration images captured by the OCT imaging apparatus300are processed by the control system100to detect the interface of the inner wall18aof the Schlemm's canal18and the trabecular meshwork12using known techniques. In another configuration, the integrated surgical system1000may include a multiphoton imaging apparatus (not shown) that provides a visual indication on a display of the user interface110that is indicative of the location of the focus of the laser701relative to the interface of the inner wall18aof the Schlemm's canal18and the trabecular meshwork12. The integrated surgical system1000may also determine a lateral extent66of ocular tissue to be photodisrupted based on OCT imaging.

At block1804and with reference toFIGS. 15c-15f, the integrated surgical system1000subsequently photodisrupts ocular tissue of the trabecular meshwork12. To this end, the integrated surgical system1000focuses light from a femtosecond laser701at a spot in tissue of the trabecular meshwork12and applies optical energy to the tissue, which energy is at a level sufficient to photodisrupt the tissue.

As an additional aspect of the subsequent photodisruption process of block1804, the integrated surgical system1000may detect a proximal extent of tissue of the trabecular meshwork. To this end, in one configuration images captured by the OCT imaging apparatus300are processed by the control system100to detect the proximal extent64of the tissue of the trabecular meshwork using known techniques. In another configuration, the integrated surgical system1000may include a multiphoton imaging apparatus (not shown) that provides a visual indication on a display of the user interface110that is indicative of the location of the focus of the laser701relative to the proximal extent64of the tissue of the trabecular meshwork. In yet another configuration, the integrated surgical system1000may include an opto-mechanical imaging apparatus (not shown) that provides a visual indication on a display of the user interface110that is indicative of the location of the focus of the laser701relative to the proximal extent64of the tissue of the trabecular meshwork

At block1806, the integrated surgical system1000determines if an opening is formed between the anterior chamber and the Schlemm's canal. If an opening has not been formed, the process return to block1802and the integrated surgical system1000repeats the initial photodisrupting of ocular tissue and then proceeds to block1804and repeats the subsequent photodisrupting of ocular tissue one or more times until an opening is formed between the anterior chamber and the Schlemm's canal. If an opening has been formed, the process proceeds to block1808, where treatment ends.

With reference toFIGS. 7-10b, a system1000for implementing the method ofFIG. 18includes a first optical subsystem1001including a focusing objective700configured to be coupled to the eye1, and a second optical subsystem1002including a laser source200configured to output a laser beam201/701. The second optical subsystem1002also includes a plurality of components1003configured to one or more of focus, scan, and direct the laser beam through the focusing objective, toward ocular tissue.

The surgical system1000further includes a control system100coupled to the second optical subsystem1002and configured to control the focus and scan of the laser beam701to initially photodisrupt ocular tissue at or near an interface of an inner wall of the Schlemm's canal and the trabecular meshwork. To this end, the control system100is configured to focus light from a femtosecond laser source200at a spot in the ocular tissue at or near the interface of the inner wall of the Schlemm's canal and the trabecular meshwork, and then apply optical to the tissue, where the energy is sufficient to photodisrupt tissue.

The control system100is also configured to control the focus and scan of the laser beam701to subsequently photodisrupt tissue of the trabecular meshwork. To this end, the control system100is configured to focus light from a femtosecond laser at a spot in tissue of the trabecular meshwork, and then apply optical energy to the tissue, where the energy is sufficient to photodisrupt tissue. The control system100is further configured to control the focus and scan of the laser beam701to repeat the initial photodisrupting of ocular tissue and the subsequent photodisrupting of ocular tissue one or more times until an opening is formed between the anterior chamber and the Schlemm's canal.