# Patent

## Title
System and method for plasma-mediated modification of tissue

## Abstract

A method for cataract surgery on an eye of a patient includes scanning a first focus position of a first pulsed laser beam at a first pulse energy of between one-half microjoule and 50 microjoules in a first scanning pattern to photodisrupt a first tissue structure portion with a plurality of pulses of the first laser beam to form an incised surface; and afterwards, scanning a second focus position of a second pulsed laser beam having a second pulse energy being between 50 microjoules and 5,000 microjoules in a second scanning pattern that is co-registered to the first scanning pattern to further photodisrupt the same first tissue structure portion with the second laser beam to further separate segments of the first tissue structure along the incised surface.

## Background
RELATED APPLICATION DATA
The present application is a continuation of U.S. patent application Ser. No. 13/023,483, filed Feb. 8, 2011, which claims the benefit under 35 U.S.C. §119 to U.S. provisional application Ser. No. 61/302,437 filed on Feb. 8, 2010. The foregoing application is hereby incorporated by reference into the present application in its entirety.


FIELD
The present invention relates to ophthalmic surgical procedures and systems, especially cataract surgery of the crystalline lens.
BACKGROUND
Cataract extraction is one of the most commonly performed surgical procedures in the world with estimated 2.5 million cases performed annually in the United States and 9.1 million cases worldwide in 2000. This was expected to increase to approximately 13.3 million estimated global cases in 2006. This market is composed of various segments including intraocular lenses for implantation, viscoelastic polymers to facilitate surgical maneuvers, disposable instrumentation including ultrasonic phacoemulsification tips, tubing, and various knives and forceps. Modern cataract surgery is typically performed using a technique termed phacoemulsification in which an ultrasonic tip with an associated water stream for cooling purposes is used to sculpt the relatively hard nucleus of the lens after performance of an opening in the anterior lens capsule termed anterior capsulotomy or more recently capsulorhexis. Following these steps as well as removal of residual softer lens cortex by aspiration methods without fragmentation, a synthetic foldable intraocular lens (IOL) is inserted into the eye through a small incision.
One of the earliest and most critical steps in the procedure is the performance of capsulorhexis. This step evolved from an earlier technique termed can-opener capsulotomy in which a sharp needle was used to perforate the anterior lens capsule in a circular fashion followed by the removal of a circular fragment of lens capsule typically in the range of 5-8 mm in diameter. This facilitated the next step of nuclear sculpting by phacoemulsification. Due to a variety of complications associated with the initial can-opener technique, attempts were made by leading experts in the field to develop a better technique for removal of the anterior lens capsule preceding the emulsification step. The concept of the Continuous Curvilinear Capsulorhexis (CCC) is to provide a smooth continuous circular opening through which not only the phacoemulsification of the nucleus can be performed safely and easily, but also for easy insertion of the intraocular lens. It provides both a clear central access for insertion, a permanent aperture for transmission of the image to the retina by the patient, and also a support of the IOL inside the remaining capsule that would limit the potential for dislocation. Subsequent to the step of anterior CCC, and prior to IOL insertion the steps of hydrodissection, hydrodilineation and phaco emulsification occur. These are intended to identify and soften the nucleus for the purposes of removal from the eye. These are the longest and thought to be the most dangerous step in the procedure due to the mechanical manipulation and the use of pulses of ultrasound that may lead to inadvertent ruptures of the posterior lens capsule, posterior dislocation of lens fragments, and potential damage anteriorly to the corneal endothelium and/or iris and other delicate intraocular structures. The central nucleus of the lens, which undergoes the most opacification and thereby the most visual impairment, is structurally the hardest and requires special techniques. A variety of surgical maneuvers employing ultrasonic fragmentation and also requiring considerable technical dexterity on the part of the surgeon have evolved, including sculpting, cracking and chopping of the lens, the so-called “divide and conquer technique” and a whole host of similarly creatively named techniques, such as phaco chop, etc. These are all subject to the usual complications associated with delicate intraocular maneuvers. Similar limitations exist in other ophthalmic procedures for which the present invention is particularly suited.
What is needed are ophthalmic methods, techniques and apparatus to advance the standard of care of cataract and other ophthalmic pathologies.
SUMMARY
The aforementioned problems and needs are addressed by providing a method of treating a lens of a patient using various scanned patterns of optical energy, especially to soften and/or segment the crystalline lens for removal.
One embodiment is directed to a system for cataract surgery on an eye of a patient, comprising: a first laser source configured to deliver a first laser beam in a pulsed form at a first pulse energy; a second laser source configured to deliver a second laser beam in a pulsed form at a second pulse energy greater than the first pulse energy; an scanning optical system, configured to: receive the first and second laser beams; and adjust a first focus position of the first laser beam, and a second focus position of the second laser beam, in up to three dimensions to direct the first and second laser beams onto one or more targeted tissue structure portions of the eye of the patient; a controller operatively coupled to the scanning optical system and configured to cause the scanning optical system to adjust the first focus position to photodisrupt a first tissue structure portion with the first laser beam, and subsequently adjust the second focus position to further photodisrupt the first tissue structure portion with the second laser beam. The first pulse energy may be between about one-half microjoule and about 50 microjoules. The second pulse energy may be between about 50 microjoules and about 5,000 microjoules. The first laser source may be configured to produce laser pulses having a first pulse duration between about 100 femtoseconds and about 10 picoseconds. The second laser source may be configured to produce laser pulses having a second pulse duration between about 10 picoseconds and about 10 nanoseconds. The controller may be configured to control the optical system to direct the first and second laser beams based upon a predetermined treatment pattern. The first tissue structure portion may be a portion of a crystalline lens of the eye. The controller may be operatively coupled to the first and second laser sources, and configured to control the first and second pulse energies. The predetermined pattern may be selected to divide the lens into two or more discrete segments. The predetermined pattern may comprise a three-dimensional pattern wherein two or more pulses are targeted for two or more different depths within the targeted tissue structure portion. The predetermined pattern may comprise a first grouping of pulses to be directed to the targeted tissue structure portion, and a second grouping of pulses to be directed to the targeted tissue structure portion, such that the first grouping is comprised of a substantially distinct range of pulse energies relative to the second grouping. The first grouping may comprise a relatively low pulse energy and the second grouping may comprise a relatively high pulse energy. The first grouping may be directed to the targeted tissue structure portion before the second grouping. The first grouping may be directed to a deeper portion of the targeted tissue structure portion than the second grouping. The system may further comprise a third grouping directed to the targeted tissue structure portion at a depth different than that of the first or second groupings.
Another embodiment is directed to a method of laser cataract surgery on an eye of a patient, comprising: positioning a three-dimensional laser irradiation pattern relative to one or more tissue structures of the eye; irradiating, with a pulsed laser source at a first pulse energy in accordance with the pattern, one or more targeted portions of the one or more tissue structures of the eye; irradiating again, with the pulsed laser source at a second pulse energy higher than the first pulse energy in accordance with the pattern, the one or more targeted portions of the one or more tissue structures of the eye.
Another embodiment is directed to a method of treating a lens of a patient's eye includes generating a light beam, deflecting the light beam using a scanner to form a treatment pattern of the light beam, delivering the treatment pattern to the lens of a patient's eye to create a plurality of cuts in the lens in the form of the treatment pattern to break the lens up into a plurality of pieces, and removing the lens pieces from the patient's eye.
Another embodiment is directed to a method of treating a lens of a patient's eye that includes generating a light beam, deflecting the light beam using a scanner to form a treatment pattern of the light beam, delivering the treatment pattern to the lens of a patient's eye to create a plurality of cuts in the lens in the form of the treatment pattern, mechanically breaking the lens into a plurality of pieces along the cuts, and removing the lens pieces from the patient's eye.
Another embodiment is directed to a system that includes an imaging system configured to capture signals from a targeted tissue structure. The signals may be utilized to create an image of pertinent tissue structures, and may be utilized as an input to the controller in controlling the first and second laser sources and/or focal positions of the pertinent first and second laser beams. The first and second laser sources may comprise the same laser source.
Other objects and features of the present invention will become apparent by a review of the specification, claims and appended figures.



BRIEF DESCRIPTION OF THE DRAWINGS
FIG. 1 is a schematic diagram of the optical beam scanning system.
FIG. 2 is an optical diagram showing an alternative beam combining scheme.
FIG. 3 is a schematic diagram of the optical beam scanning system with an alternative OCT configuration.
FIG. 4 is a schematic diagram of the optical beam scanning system with another alternative OCT combining scheme.
FIGS. 5A-5C are side cross sectional views of the lens of the eye illustrating various treatment zones.
FIGS. 6A-6C are top views of an eye lens illustrating various configurations of line cuts.
FIG. 7 is a perspective three-dimensional view of the eye lens illustrating inclined plane cuts within the lens.
FIG. 8A is a side view of the eye lens illustrating non-inclined plane cuts within the lens.
FIG. 8B is a side view of the eye lens illustrating inclined plane cuts within the lens.
FIG. 9 is a perspective three-dimensional view of the eye lens illustrating inclined plane cuts within the lens forming a pyramid-shaped lens segment.
FIG. 10 is a top view of an eye lens illustrating a cross-shaped segmentation pattern.
FIGS. 11A-11B are top views of an eye lens illustrating different configurations of a combination of linear and circular cuts.
FIG. 12 is a top view of an eye lens illustrating a spiral shaped cut.
FIG. 13 is a top view of an eye lens illustrating an array of rectangular planar cuts.
FIG. 14 is a top view of an eye lens illustrating segmentation into quadrants.
FIG. 15 is a top view of an eye lens illustrating softening cuts made into a lens quadrant.
FIGS. 16-19 are top views of an eye lens illustrating various combinations of an array of rectangular planar cuts and one or more line cuts.
FIG. 20 illustrates a top view of an eye lens illustrating a treatment paradigm wherein a plurality of pulses is utilized to form orthogonal cuts.
FIG. 21 illustrates a top view of an eye lens illustrating a treatment paradigm wherein a plurality of pulses is utilized to form orthogonal cuts.
FIG. 22 illustrates a side view of an eye lens illustrating a treatment paradigm wherein pulses of varied energy are utilized in lens segmentation.
FIG. 23 illustrates a side view of an eye lens illustrating a treatment paradigm wherein pulses of varied energy are utilized in lens segmentation.



DETAILED DESCRIPTION OF THE ILLUSTRATED EMBODIMENTS
The present invention can be implemented by a system that projects or scans an optical beam into a patient's eye 68, such as system 2 shown in FIG. 1 which includes an ultrafast (UF) light source 4 (e.g. a femtosecond laser, or a dual purpose system capable of emitting pulses in a lower and in a higher range of pulse energies, perhaps with different pulse durations.). Using this system, a beam may be scanned in a patient's eye in three dimensions: X, Y, Z. In this embodiment, the UF wavelength can vary between 1010 nm to 1100 nm and the pulse width can vary from 100 fs to 10000 fs. The pulse repetition frequency can also vary from 10 kHz to 250 kHz. Safety limits with regard to unintended damage to non-targeted tissue bound the upper limit with regard to repetition rate and pulse energy; while threshold energy, time to complete the procedure and stability bound the lower limit for pulse energy and repetition rate. The peak power of the focused spot in the eye 68 and specifically within the crystalline lens 69 and anterior capsule of the eye is sufficient to produce optical breakdown and initiate a plasma-mediated ablation process. Near-infrared wavelengths are preferred because linear optical absorption and scattering in biological tissue is reduced across that spectral range. As an example, laser 4 may be a repetitively pulsed 1035 nm device that produces 500 fs pulses at a repetition rate of 100 kHz and an individual pulse energy in the ten microjoule range. Although not illustrated, UF Light Source 4 may be further configured to provide higher energy pulses with the same or longer pulse durations than those exiting the system after pulse compression. That is, the un-compressed beam may be extracted from UF Light Source 4 in order to provide those higher energy pulses. Regardless, the following system description details means to achieve the usage of higher and/or lower energy pulses.
The laser 4 is controlled by control electronics 300, via an input and output device 302, to create optical beam 6. Control electronics 300 may be a computer, microcontroller, etc. In this example, the entire system is controlled by the controller 300, and data moved through input/output device IO 302. A graphical user interface GUI 304 may be used to set system operating parameters, process user input (UI) 306 on the GUI 304, and display gathered information such as images of ocular structures.
The generated UF light beam 6 proceeds towards the patient eye 68 passing through half-wave plate, 8, and linear polarizer, 10. The polarization state of the beam can be adjusted so that the desired amount of light passes through half-wave plate 8 and linear polarizer 10, which together act as a variable attenuator for the UF beam 6. Additionally, the orientation of linear polarizer 10 determines the incident polarization state incident upon beamcombiner 34, thereby optimizing beamcombiner throughput.
The UF beam proceeds through a shutter 12, aperture 14, and a pickoff device 16. The system controlled shutter 12 ensures on/off control of the laser for procedural and safety reasons. The aperture sets an outer useful diameter for the laser beam and the pickoff monitors the output of the useful beam. The pickoff device 16 includes of a partially reflecting mirror 20 and a detector 18. Pulse energy, average power, or a combination may be measured using detector 18. The information can be used for feedback to the half-wave plate 8 for attenuation and to verify whether the shutter 12 is open or closed. In addition, the shutter 12 may have position sensors to provide a redundant state detection.
The beam passes through a beam conditioning stage 22, in which beam parameters such as beam diameter, divergence, circularity, and astigmatism can be modified. In this illustrative example, the beam conditioning stage 22 includes a 2 element beam expanding telescope comprised of spherical optics 24 and 26 in order to achieve the intended beam size and collimation. Although not illustrated here, an anamorphic or other optical system can be used to achieve the desired beam parameters. The factors used to determine these beam parameters include the output beam parameters of the laser, the overall magnification of the system, and the desired numerical aperture (NA) at the treatment location. In addition, the optical system 22 can be used to image aperture 14 to a desired location (e.g. the center location between the 2-axis scanning device 50 described below). In this way, the amount of light that makes it through the aperture 14 is assured to make it through the scanning system. Pickoff device 16 is then a reliable measure of the usable light.
After exiting conditioning stage 22, beam 6 reflects off of fold mirrors 28, 30, & 32. These mirrors can be adjustable for alignment purposes. The beam 6 is then incident upon beam combiner 34. Beamcombiner 34 reflects the UF beam 6 (and transmits both the OCT 114 and aim 202 beams described below). For efficient beamcombiner operation, the angle of incidence is preferably kept below 45 degrees and the polarization where possible of the beams is fixed. For the UF beam 6, the orientation of linear polarizer 10 provides fixed polarization.
Following the beam combiner 34, the beam 6 continues onto the z-adjust or Z scan device 40. In this illustrative example the z-adjust includes a Galilean telescope with two lens groups 42 and 44 (each lens group includes one or more lenses). Lens group 42 moves along the z-axis about the collimation position of the telescope. In this way, the focus position of the spot in the patient's eye 68 moves along the z-axis as indicated. In general there is a fixed linear relationship between the motion of lens 42 and the motion of the focus. In this case, the z-adjust telescope has an approximate 2× beam expansion ratio and a 1:1 relationship of the movement of lens 42 to the movement of the focus. Alternatively, lens group 44 could be moved along the z-axis to actuate the z-adjust, and scan. The z-adjust is the z-scan device for treatment in the eye 68. It can be controlled automatically and dynamically by the system and selected to be independent or to interplay with the X-Y scan device described next. Mirrors 36 and 38 can be used for aligning the optical axis with the axis of z-adjust device 40.
After passing through the z-adjust device 40, the beam 6 is directed to the x-y scan device by mirrors 46 & 48. Mirrors 46 & 48 can be adjustable for alignment purposes. X-Y scanning is achieved by the scanning device 50 preferably using two mirrors 52 & 54 under the control of control electronics 300, which rotate in orthogonal directions using motors, galvanometers, or any other well known optic moving device. Mirrors 52 & 54 are located near the telecentric position of the objective lens 58 and contact lens 66 combination described below. Tilting these mirrors 52/54 causes them to deflect beam 6, causing lateral displacements in the plane of UF focus located in the patient's eye 68. Objective lens 58 may be a complex multi-element lens element, as shown, and represented by lenses 60, 62, and 64. The complexity of the lens 58 will be dictated by the scan field size, the focused spot size, the available working distance on both the proximal and distal sides of objective 58, as well as the amount of aberration control. An f-theta lens 58 of focal length 60 mm generating a spot size of 10 μm, over a field of 10 mm, with an input beam size of 15 mm diameter is an example. Alternatively, X-Y scanning by scanner 50 may be achieved by using one or more moveable optical elements (e.g. lenses, gratings) which also may be controlled by control electronics 300, via input and output device 302.
The aiming and treatment scan patterns can be automatically generated by the scanner 50 under the control of controller 300. Such patterns may be comprised of a single spot of light, multiple spots of light, a continuous pattern of light, multiple continuous patterns of light, and/or any combination of these. In addition, the aiming pattern (using aim beam 202 described below) need not be identical to the treatment pattern (using light beam 6), but preferably at least defines its boundaries in order to assure that the treatment light is delivered only within the desired target area for patient safety. This may be done, for example, by having the aiming pattern provide an outline of the intended treatment pattern. This way the spatial extent of the treatment pattern may be made known to the user, if not the exact locations of the individual spots themselves, and the scanning thus optimized for speed, efficiency and accuracy. The aiming pattern may also be made to be perceived as blinking in order to further enhance its visibility to the user.
An optional contact lens 66, which can be any suitable ophthalmic lens, can be used to help further focus the optical beam 6 into the patient's eye 68 while helping to stabilize eye position. The positioning and character of optical beam 6 and/or the scan pattern the beam 6 forms on the eye 68 may be further controlled by use of an input device such as a joystick, or any other appropriate user input device (e.g. GUI 304) to position the patient and/or the optical system.
The UF laser 4 and controller 300 can be set to target the surfaces of the targeted structures in the eye 68 and ensure that the beam 6 will be focused where appropriate and not unintentionally damage non-targeted tissue. Imaging modalities and techniques described herein, such as for example, Optical Coherence Tomography (OCT), Purkinje imaging, Scheimpflug imaging, or ultrasound may be used to determine the location and measure the thickness of the lens and lens capsule to provide greater precision to the laser focusing methods, including 2D and 3D patterning. Laser focusing may also be accomplished using one or more methods including direct observation of an aiming beam, Optical Coherence Tomography (OCT), Purkinje imaging, Scheimpflug imaging, ultrasound, or other known ophthalmic or medical imaging modalities and/or combinations thereof. In the embodiment of FIG. 1, an OCT device 100 is described, although other modalities are within the scope of the present invention. An OCT scan of the eye will provide information about the axial location of the anterior and posterior lens capsule, the boundaries of the cataract nucleus, as well as the depth of the anterior chamber. This information is then be loaded into the control electronics 300, and used to program and control the subsequent laser-assisted surgical procedure. The information may also be used to determine a wide variety of parameters related to the procedure such as, for example, the upper and lower axial limits of the focal planes used for cutting the lens capsule and segmentation of the lens cortex and nucleus, and the thickness of the lens capsule among others.
The OCT device 100 in FIG. 1 includes a broadband or a swept light source 102 that is split by a fiber coupler 104 into a reference arm 106 and a sample arm 110. The reference arm 106 includes a module 108 containing a reference reflection along with suitable dispersion and path length compensation. The sample arm 110 of the OCT device 100 has an output connector 112 that serves as an interface to the rest of the UF laser system. The return signals from both the reference and sample arms 106, 110 are then directed by coupler 104 to a detection device 128, which employs either time domain, frequency or single point detection techniques. In FIG. 1, a frequency domain technique is used with an OCT wavelength of 920 nm and bandwidth of 100 nm.
Exiting connector 112, the OCT beam 114 is collimated using lens 116. The size of the collimated beam 114 is determined by the focal length of lens 116. The size of the beam 114 is dictated by the desired NA at the focus in the eye and the magnification of the beam train leading to the eye 68. Generally, OCT beam 114 does not require as high an NA as the UF beam 6 in the focal plane and therefore the OCT beam 114 is smaller in diameter than the UF beam 6 at the beamcombiner 34 location. Following collimating lens 116 is aperture 118 which further modifies the resultant NA of the OCT beam 114 at the eye. The diameter of aperture 118 is chosen to optimize OCT light incident on the target tissue and the strength of the return signal. Polarization control element 120, which may be active or dynamic, is used to compensate for polarization state changes which may be induced by individual differences in corneal birefringence, for example. Mirrors 122 & 124 are then used to direct the OCT beam 114 towards beamcombiners 126 & 34. Mirrors 122 & 124 may be adjustable for alignment purposes and in particular for overlaying of OCT beam 114 to UF beam 6 subsequent to beamcombiner 34. Similarly, beamcombiner 126 is used to combine the OCT beam 114 with the aim beam 202 described below.
Once combined with the UF beam 6 subsequent to beamcombiner 34, OCT beam 114 follows the same path as UF beam 6 through the rest of the system. In this way, OCT beam 114 is indicative of the location of UF beam 6. OCT beam 114 passes through the z-scan 40 and x-y scan 50 devices then the objective lens 58, contact lens 66 and on into the eye 68. Reflections and scatter off of structures within the eye provide return beams that retrace back through the optical system, into connector 112, through coupler 104, and to OCT detector 128. These return back reflections provide the OCT signals that are in turn interpreted by the system as to the location in X, Y Z of UF beam 6 focal location.
OCT device 100 works on the principle of measuring differences in optical path length between its reference and sample arms. Therefore, passing the OCT through z-adjust 40 does not extend the z-range of OCT system 100 because the optical path length does not change as a function of movement of 42. OCT system 100 has an inherent z-range that is related to the detection scheme, and in the case of frequency domain detection it is specifically related to the spectrometer and the location of the reference aim 106. In the case of OCT system 100 used in FIG. 1, the z-range is approximately 1-2 mm in an aqueous environment. Extending this range to at least 4 mm involves the adjustment of the path length of the reference arm within OCT system 100. Passing the OCT beam 114 in the sample arm through the z-scan of z-adjust 40 allows for optimization of the OCT signal strength. This is accomplished by focusing the OCT beam 114 onto the targeted structure while accommodating the extended optical path length by commensurately increasing the path within the reference aim 106 of OCT system 100.
Because of the fundamental differences in the OCT measurement with respect to the UF focus device due to influences such as immersion index, refraction, and aberration, both chromatic and monochromatic, care must be taken in analyzing the OCT signal with respect to the UF beam focal location. A calibration or registration procedure as a function of X, Y Z should be conducted in order to match the OCT signal information to the UF focus location and also to the relate to absolute dimensional quantities.
Observation of an aim beam may also be used to assist the user to directing the UF laser focus. Additionally, an aim beam visible to the unaided eye in lieu of the infrared OCT and UF beams can be helpful with alignment provided the aim beam accurately represents the infrared beam parameters. An aim subsystem 200 is employed in the configuration shown in FIG. 1. The aim beam 202 is generated by a an aim beam light source 201, such as a helium-neon laser operating at a wavelength of 633 nm. Alternatively a laser diode in the 630-650 nm range could be used. The advantage of using the helium neon 633 nm beam is its long coherence length, which would enable the use of the aim path as a laser unequal path interferometer (LUPI) to measure the optical quality of the beam train, for example.
Once the aim beam light source generates aim beam 202, the aim beam 202 is collimated using lens 204. The size of the collimated beam is determined by the focal length of lens 204. The size of the aim beam 202 is dictated by the desired NA at the focus in the eye and the magnification of the beam train leading to the eye 68. Generally, aim beam 202 should have close to the same NA as UF beam 6 in the focal plane and therefore aim beam 202 is of similar diameter to the UF beam at the beamcombiner 34 location. Because the aim beam is meant to stand-in for the UF beam 6 during system alignment to the target tissue of the eye, much of the aim path mimics the UF path as described previously. The aim beam 202 proceeds through a half-wave plate 206 and linear polarizer 208. The polarization state of the aim beam 202 can be adjusted so that the desired amount of light passes through polarizer 208. Elements 206 & 208 therefore act as a variable attenuator for the aim beam 202. Additionally, the orientation of polarizer 208 determines the incident polarization state incident upon beamcombiners 126 and 34, thereby fixing the polarization state and allowing for optimization of the beamcombiners' throughput. Of course, if a semiconductor laser is used as aim beam light source 200, the drive current can be varied to adjust the optical power.
The aim beam 202 proceeds through a shutter 210 and aperture 212. The system controlled shutter 210 provides on/off control of the aim beam 202. The aperture 212 sets an outer useful diameter for the aim beam 202 and can be adjusted appropriately. A calibration procedure measuring the output of the aim beam 202 at the eye can be used to set the attenuation of aim beam 202 via control of polarizer 206.
The aim beam 202 next passes through a beam conditioning device 214. Beam parameters such as beam diameter, divergence, circularity, and astigmatism can be modified using one or more well known beaming conditioning optical elements. In the case of an aim beam 202 emerging from an optical fiber, the beam conditioning device 214 can simply include a beam expanding telescope with two optical elements 216 and 218 in order to achieve the intended beam size and collimation. The final factors used to determine the aim beam parameters such as degree of collimation are dictated by what is necessary to match the UF beam 6 and aim beam 202 at the location of the eye 68. Chromatic differences can be taken into account by appropriate adjustments of beam conditioning device 214. In addition, the optical system 214 is used to image aperture 212 to a desired location such as a conjugate location of aperture 14.
The aim beam 202 next reflects off of fold mirrors 222 & 220, which are preferably adjustable for alignment registration to UF beam 6 subsequent to beam combiner 34. The aim beam 202 is then incident upon beam combiner 126 where the aim beam 202 is combined with OCT beam 114. Beamcombiner 126 reflects the aim beam 202 and transmits the OCT beam 114, which allows for efficient operation of the beamcombining functions at both wavelength ranges. Alternatively, the transmit and reflect functions of beamcombiner 126 can be reversed and the configuration inverted. Subsequent to beamcombiner 126, aim beam 202 along with OCT beam 114 is combined with UF beam 6 by beamcombiner 34.
A device for imaging the target tissue on or within the eye 68 is shown schematically in FIG. 1 as imaging system 71. Imaging system includes a camera 74 and an illumination light source 86 for creating an image of the target tissue. The imaging system 71 gathers images which may be used by the system controller 300 for providing pattern centering about or within a predefined structure. The illumination light source 86 for the viewing is generally broadband and incoherent. For example, light source 86 can include multiple LEDs as shown. The wavelength of the viewing light source 86 is preferably in the range of 700 nm to 750 nm, but can be anything that is accommodated by the beamcombiner 56, which combines the viewing light with the beam path for UF beam 6 and aim beam 202 (beamcombiner 56 reflects the viewing wavelengths while transmitting the OCT and UF wavelengths). The beamcombiner 56 may partially transmit the aim wavelength so that the aim beam 202 can be visible to the viewing camera 74. Optional polarization element 84 in front of light source 86 can be a linear polarizer, a quarter wave plate, a half-wave plate or any combination, and is used to optimize signal. A false color image as generated by the near infrared wavelength is acceptable.
The illumination light from light source 86 is directed down towards the eye using the same objective lens 58 and contact lens 66 as the UF and aim beam 6, 202. The light reflected and scattered off of various structures in the eye 68 are collected by the same lenses 58 & 66 and directed back towards beamcombiner 56. There, the return light is directed back into the viewing path via beam combiner and mirror 82, and on to camera 74. Camera 74 can be, for example but not limited to, any silicon based detector array of the appropriately sized format. Video lens 76 forms an image onto the camera's detector array while optical elements 80 & 78 provide polarization control and wavelength filtering respectively. Aperture or iris 81 provides control of imaging NA and therefore depth of focus and depth of field. A small aperture provides the advantage of large depth of field which aids in the patient docking procedure. Alternatively, the illumination and camera paths can be switched. Furthermore, aim light source 200 can be made to emit in the infrared which would not directly visible, but could be captured and displayed using imaging system 71.
Coarse adjust registration is usually needed so that when the contact lens 66 comes into contact with the cornea, the targeted structures are in the capture range of the X, Y scan of the system. Therefore a docking procedure is preferred, which preferably takes in account patient motion as the system approaches the contact condition (i.e. contact between the patient's eye 68 and the contact lens 66. The viewing system 71 is configured so that the depth of focus is large enough such that the patient's eye 68 and other salient features may be seen before the contact lens 66 makes contact with eye 68.
Preferably, a motion control system 70 is integrated into the overall control system 2, and may move the patient, the system 2 or elements thereof, or both, to achieve accurate and reliable contact between contact lens 66 and eye 68. Furthermore, a vacuum suction subsystem and flange may be incorporated into system 2, and used to stabilize eye 68. The alignment of eye 68 to system 2 via contact lens 66 may be accomplished while monitoring the output of imaging system 71, and performed manually or automatically by analyzing the images produced by imaging system 71 electronically by means of control electronics 300 via IO 302. Force and/or pressure sensor feedback may also be used to discern contact, as well as to initiate the vacuum subsystem.
An alternative beamcombining configuration is shown in the alternate embodiment of FIG. 2. For example, the passive beamcombiner 34 in FIG. 1 can be replaced with an active combiner 140 in FIG. 2. The active beamcombiner 34 can be a moving or dynamically controlled element such as a galvanometric scanning mirror, as shown. Active combiner 140 changes it angular orientation in order to direct either the UF beam 6 or the combined aim and OCT beams 202,114 towards the scanner 50 and eventually eye 68 one at a time. The advantage of the active combining technique is that it avoids the difficulty of combining beams with similar wavelength ranges or polarization states using a passive beam combiner. This ability is traded off against the ability to have simultaneous beams in time and potentially less accuracy and precision due to positional tolerances of active beam combiner 140.
Another alternate embodiment is shown in FIG. 3 which is similar to that of FIG. 1 but utilizes an alternate approach to OCT 100. In FIG. 3, OCT 101 is the same as OCT 100 in FIG. 1, except that the reference arm 106 has been replaced by reference aim 132. This free-space OCT reference arm 132 is realized by including beamsplitter 130 after lens 116. The reference beam 132 then proceeds through polarization controlling element 134 and then onto the reference return module 136. The reference return module 136 contains the appropriate dispersion and path length adjusting and compensating elements and generates an appropriate reference signal for interference with the sample signal. The sample arm of OCT 101 now originates subsequent to beamsplitter 130. The potential advantages of this free space configuration include separate polarization control and maintenance of the reference and sample arms. The fiber based beam splitter 104 of OCT 101 can also be replaced by a fiber based circulator. Alternately, both OCT detector 128 and beamsplitter 130 might be moved together as opposed to reference arm 136.
FIG. 4 shows another alternative embodiment for combining OCT beam 114 and UF beam 6. In FIG. 4, OCT 156 (which can include either of the configurations of OCT 100 or 101) is configured such that its OCT beam 154 is coupled to UF beam 6 after the z-scan 40 using beamcombiner 152. In this way, OCT beam 154 avoids using the z-adjust. This allows the OCT 156 to possibly be folded into the beam more easily and shortening the path length for more stable operation. This OCT configuration is at the expense of an optimized signal return strength as discussed with respect to FIG. 1. There are many possibilities for the configuration of the OCT interferometer, including time and frequency domain approaches, single and dual beam methods, swept source, etc, as described in U.S. Pat. Nos. 5,748,898; 5,748,352; 5,459,570; 6,111,645; and 6,053,613 (which are incorporated herein by reference.)
FIGS. 5 through 15 illustrate the various embodiments of the present invention. Specifically, they describe possible scanned 3-dimensional patterns within lens 69 of the patient's eye 68. These patterns have been specifically designed to provide more convenient splitting of lens 69 into segments that are easy to aspirate using existing technology and devices. Phacoemulsification is particularly well suited for this. Several such aspiration devices are commercially available and well known in the art.
FIG. 5A to 5C illustrate a side views of lens 69 and the depth profiles of the patterns of FIGS. 6 to 15. Specifically, in FIGS. 5A to 5C, treatment zone 500 denotes the internal volume of lens 69 where beam 6 is used for softening the cataractous material within lens 69. Treatment zone 500 has a high density of laser exposures, but a distinct safety zone 502 in the lens 69 between the treatment zone 500 and the posterior capsular bag surface 514 is preferably maintained, to insure that the surface 514 is not damaged by beam 6. The inner boundary of safety zone 502 ranges between 10 μm to 1000 μm away from surface 514, but is typically 300 μm, and may be determined by use of OCT device 100 within system 2. Safety zone 502 may also comprise the softer portions of lens 69, the cortex and epi-nucleus. Safety zone 502 may also be a function of the numerical aperture (NA) used for beams 6, 114 & 202 in system 2. The higher the NA used, the closer the focus of beam 6 from system 2 can be to surface 514 without risk of incidental damage due to the increased divergence of beam 6. Damage to posterior surface 514 may cause surgical complications, and retinal damage.
As shown in FIG. 5A, safety zone 502 is maintained throughout lens 69 except opening 504 in anterior surface 512 of the capsule, as that portion of the capsule will ultimately be removed.
FIG. 5B shows the example where treatment zone 500 extends in a cylindrical shape of circular projection from the front (top) of lens 69, with the addition of safety zone 503 adjacent to surface 512 in addition to safety zone 502 for posterior surface 514.
FIG. 5C shows an alternate embodiment where treatment zone 500 extends in a cylindrical shape and only safety zone 502 is used. This represents the case where area 504 of anterior surface 512 will be incised and ultimately removed, so safety zone 503 is not required.
In both FIGS. 5B and 5C, the diameter of the cylindrical treatment zone 500 can be the same size as the capsular opening but also smaller or bigger than capsular opening 504. The safety zone 502 is used for “lens-in-the-bag” IOL implants. In the alternate case of a “bag-in-the-lens” approach, where the posterior capsule will also be incised and ultimately removed, incisions will be made by the system in posterior surface 514 and the safety zone 502 need not be used, similarly to the case of FIG. 5C.
In nearly all previously described ultrasonic phacoemulsification techniques, lens 69 is split into several smaller pieces to enable easier handling of the single segments. Using optical segmentation patterns enables pre-segmentation of the lens 69 into smaller pieces more reliably and with better control than prior ultrasonic techniques. Exemplary optical segmentation patterns are shown in FIG. 6A to 6C, as seen from the front of the lens 69. Depending on its hardness, lens 69 may be split into a variable number of segments, the number of segments typically, but not always, increasing with hardness. In the pattern of FIG. 6A, the optical beam 6 is scanned in a pattern of two crossing cuts 520, will is ideal for cataract grades 1-3 in order to split lens 69 into four sections, or quadrants. For cataracts of grade 3+ and higher, a scanned pattern as shown in FIG. 6B having three crossing cuts 522 to form sextants is ideal. For the hardest cataracts of grade 4-4+, a scanned pattern of four crossing cuts 524 implementing octant splitting as shown in FIG. 6C would be ideal.
System 2 can also be configured to laterally shift the center point of the splitting patterns of FIG. 6A to 6C over depth, creating inclined planes of laser induced damage via beam 6. This is shown in FIG. 7, where the two laser cut planes 526 shift their crossing point 528 throughout the depth of lens 69. This enables three dimensional inclined plane cuts within the lens 69 that promote easier removal of the quadrants from the anterior side 527 of the lens 69, as the problem of interference of the posterior edges 529 is avoided. Furthermore, the same benefits apply to the general case of any number of multiple axi-symmetric intersecting cuts within the lens 69.
The difficulty of extracting lens segments 530 through the limiting aperture of the iris 532 without an inclined plane is depicted in FIG. 8A. Without the ability to move laterally, the lens segment 530 will be blocked by the iris 532 due to anterior 527 and posterior 529 interference with the remaining lens segments 533. FIG. 8B is a side view of the inclined plane cuts described in FIG. 7. The inclined plane segment 536 can be removed through the iris 532 by sliding along the contact plane 535 with the remaining inclined plane lens segments 537.
Another embodiment of lens segmentation is shown in FIG. 9 which consists of four inclined laser cut planes 536 merging in a manner to create a segment within lens 69 that is shaped similar to an inverted pyramid. This segment has its anterior portion 527 larger than its posterior portion 529, thus allowing it to be more easily removed. This simplifies the removal of the remaining lens sections 537 which allows faster progress of the surgeon. Furthermore, the same benefits apply to the general case of any number of multiple axi-symmetric intersecting cuts inclined in the same manner within the lens 69.
FIG. 10 illustrates a cross-shaped optical segmentation pattern 540 which includes four cross bar quadrants 542. This pattern enables pre-formed channels which are used in the “divide and conquer” technique of phacoemulsification. This also allows easier splitting of the lens with phacoemulsification by direct mechanical means. The width of the cross bar quadrants 542 is preferably selected to correspond to the outer width of the phacoemulsification tip 541 used by the surgeon. A typically but not limiting example of tip widths includes 0.5 mm to 1.5 mm. The small quadrant width can be chosen to be smaller than the inner diameter of the phacoemulsification tip 541, such as between 0.3 mm and 1.3 mm, for easier insertion of the tip and aspiration of lens material.
FIG. 11A illustrates another optical segmentation pattern similar to that of FIGS. 5 & 6, which is especially useful in conditioning harder lens nuclei. FIG. 11A illustrates an optical segmentation pattern similar to that of FIG. 6B, but with the addition of concentric circular scans/cuts 604 that serve to further divide the nucleus 600 of lens 69 into segments small enough to be aspirated through a small probe and commensurately small capsular incision. In this example, the crossed cuts 522 extend beyond the nucleus 600 of lens 69, passing through nuclear boundary 601, and extending into the softer cortex and/or epi-nucleus of lens 69 that are inherently easy to remove via aspiration alone. Thus, by extending the laser segmentation pattern into the softer material surrounding nucleus 600, lens removal is further facilitated. The boundary 601 between nucleus 600 and the epi-nucleus or cortex of lens 69 may be determined via OCT device 100, and/or imaging system 71 by mapping the target tissues and discerning changes in the optical properties of the tissue. More opaque material will be readily apparent to both imaging system 71 and OCT device 100. The spatial map of their responses may be used by CPU 300 to generate a boundary for nucleus 600, and guide the patterning to include all of nucleus 600 and the peripheral softer material.
FIG. 11B shows an optical segmentation pattern similar to that of FIG. 11A, except that crossed cuts 522 do not pass through nucleus center 602, as it's already small enough to be easily aspirated. This may save time and cumulative energy delivered during a procedure, making it safer and more efficient.
FIG. 12 shows an alternate optical segmentation pattern in the form of a “carousel pattern.” The spiral shaped cut 608 of the “carousel” pattern allows for the increased ease of aspiration by causing the hardened nucleus 600 of lens 69 to unroll when aspirated by phacoemulsification tip 541, as indicated by direction R. The spiral spacing of the carousel pattern may be chosen to fit easily within phacoemulsification tip 541. Should the nucleus 600 be too stiff to easily unfurl along the spiral cut 608 of the carousel pattern, a series of sub-segment cuts 610 may be employed to cause the hardened nucleus to break into segments small enough to be easily aspirated by phacoemulsification tip 541. The width of a single section should be made to be smaller than the inner-diameter of the phacoemulsification tip 541, typically but not limited to inner-diameters between 1.1 mm and 0.25 mm. Alternate, orthogonal planes may also be cut into lens 69 to create smaller still segments of nucleus 600 to assist with its removal, especially with very hard nuclei.
FIG. 13 shows an alternate optical segmentation pattern, with an array of rectangular planar cuts 520 (i.e. crossing array of rows and columns of cuts) creating pattern 620 to facilitate removal of lens 69 by segmenting it into rectangular sub-elements 618. This is shown as extending beyond the boundary 601 of the nucleus 600 (not explicitly shown). As described above with respect to FIGS. 11A and B, the width of a single section 618 should be made to be smaller than the inner-diameter of the phacoemulsification tip 541, typically but not limited to inner-diameters between 1.1 mm and 0.25 mm. Orthogonal planes (i.e. cuts parallel to the anterior surface 512 of the capsule) may also be cut into lens 69 to create smaller still segments and further assist with lens removal, especially with very hard nuclei.
FIG. 14 depicts lens segmentation into quadrants 622 by creating planar crossed cuts 520 in the lens 69, together with softening cuts 618 within each quadrant to better facilitate removal of the lens by phacoemulsification. This technique combines segmenting cuts 520 that are larger (i.e. deeper, longer and/or generated with greater pulse energy), with softening cuts 618 that are smaller (shallower, shorter and/or generated with less pulse energy). The distance between the splitting and softening cuts are selected based on the hardness of the lens. The central plane cuts 520 allow the lens splitting forces to penetrate all the way out to the lens cortex, better assuring the reliable propagation of cracks along cuts 520. The spacing 624 between the splitting cuts 520 and the softening pattern of cuts 618 may be variable, but is typically but not limited to be between 0.1 mm to 1 mm.
FIG. 15 shows an another example of softening cuts, where each quadrant 622 is filled with a regular array of single laser spots 626 that are distributed throughout quadrant 622. Single laser spots 626 serve to soften the material of the lens in order to facilitate its removal. The patterning of laser spots 626 need not be regular, as shown. It may be a randomized distribution of spots throughout the volume subtended by quadrant 622.
FIG. 16 depicts lens segmentation similar to that of FIGS. 13 & 14 with the addition of pattern 620 of softening cuts being confined to the center of the lens and segmenting cuts 520 being provided to facilitate the “bowl and chop” technique of phacoemsulification. The boundary of pattern 620 is shown as circular, but may be any shape. The central plane cuts 520 allow the lens splitting forces to penetrate all the way out to the lens cortex, better assuring the reliable propagation of cracks along cuts 520.
FIGS. 17 & 18 depict similar patterns to facilitate the “stop and chop” technique of phacoemsulification. The thickness of pattern 620 may be variable, but is typically but not limited to be between 0.1 mm to 1 mm. The central plane cuts 520 allow the lens splitting forces to penetrate all the way out to the lens cortex, better assuring the reliable propagation of cracks along cuts 520.
FIG. 19 depicts lens segmentation including central pattern 620 of softening cuts and segmenting cuts 520 to facilitate the combined “divide and conquer” and “pre-chopping” techniques of phacoemsulifcation. The meridonal thickness of pattern 620 may be variable, but is typically but not limited to be between 0.1 mm to 1 mm. The central plane cuts 520 allow the lens splitting forces to penetrate all the way out to the lens cortex, better assuring the reliable propagation of cracks along cuts 520.
For any pattern described above, the system 2 may also be made to deliver additional laser pulses or cuts to the incisions previously created in the lens material. These pulses can create bubbles that may serve to further separate the material for easier aspiration. Because it requires less energy density to cause a bubble to form at an interface, these later pulses can be attenuated as compared to the initial segmentation pulses. Furthermore, the laser beam may be made to linger at a location for a time sufficient to produce a large bubble, forcing the material to further separate. This can be done in a number of different ways. The system 2 may be configured to perform these separation pulses before, during and/or after a scan.
Preferably, the cataract lens is segmented into quadrants for removal. If the surgeon just starts to remove the central hard lens nucleus, they are left with an annulus of lens material within the lens capsule. This annulus is extremely hard to remove due to the fact that it is located right under the iris that impairs or even inhibits the surgeon to visualize it on the surgical microscope.
Conventionally, the surgical technique of divide-and-conquer technique has been developed to minimize surgical complications and to avoid the creation of the lens annulus. After the manual capsulorhexis, the surgeon uses the phacoemulsification system to sculpture two perpendicular grooves centrally in the lens. The sculpt depth varies between 60% in normal cataracts and about 80% in extremely brunescent cataracts. The sculpture length is held within the boundaries given by the capsulorhexis. As the next step, either the phaco tip and an additional hook are used to separate the lens into quadrants or specific cracking forceps are used. This separation is then propagated all they way out to the edge of the lens. Then, the single quadrants are phacoemulsified and simultaneously pulled out of their location. Little or no tissue is left behind in the outer rims of the lens.
In laser cataract surgery, the lens is preconditioned by the laser so the separation of the lens into quadrants is simplified. But the access of the laser is limited and apertured to the opening size of the iris plus an additional safety margin. So the laser actually cannot completely place cutting lines across the entire length of the lens. Therefore, there is still the need for the surgeon to manually break the remaining uncut areas and separate the lens into the quadrants. Additionally, because the laser cuts are so narrow in width, it can be difficult for the surgeon to insert a surgical instrument into the cuts for splitting the lens.
The pulse energies used to enable laser facilitated cataract surgery is typically twice the optical breakdown threshold of the laser pulse used. For femtosecond lasers this is typically in the range of 1 to 20 micro Joules. This allows the efficient generation of cuts within the lens. The mechanical side effects which are caused by the cavitation bubbles generated by the laser pulses are a function of the pulse energy, and the magnitude of this effect is driven by the pulse energy. For 1-20 μJ pulses, the size of the bubbles is limited to about 10-200 μm. This limited damage range of the cavitation bubbles enables the highly precise micromachining of the lens tissue.
Nanosecond laser pulse induced cavitation has been used in ophthalmology for the removal of posterior secondary cataracts after lens implantation. The pulse energies used are typically 1-2 mJ, so about a factor of 100 to 1000 higher than the femtosecond laser pulse energies used for cataract surgeries. The size of the induced cavitation bubbles are in the order of 1-2 mm. In early in-vitro studies, the nanosecond laser was also used within the lens in an attempt to emulsify cataract within the crystalline lens. (Intraocular photodisruption with picosecond and nanosecond laser pulses: tissue effects in cornea, lens, and retina. Vogel A, Capon M R, Asiyo-Vogel M N, Bimgruber R., Invest Ophthalmol Vis Sci. 1994 June; 35(7):3032-4) It was evident that huge mechanical side effects of the nanosecond laser pulses made this approach impractical for cataract emulsification.
It has been discovered that combining low power pulses to generate cuts in the lens, followed by higher power pulses directed to the previously formed cuts (using co-registered patterns for both), provides an improved technique and device for preconditioning and completely separating the lens segments without further manual surgeon intervention. The low energy pattern of pulses (on the order of 1 to 20 micro Joules per pulse) cuts (scribes) the lens to divide it into (still attached) segments, and the high energy pattern of pulses (on the order of 100 μJ to 3 mJ per pulse, generated by example from a Q-switched YAG laser), which are registered to the first pattern of low energy pulses, drives the precut areas apart even though the co-registered patterns do not reach the edge of the lens.
In the preferred non-limiting embodiment, the low energy pulses are positioned close together or even partially overlapping to effectively create cuts (scribe lines) deep but not all the way through the thickness of the lens to divide it into segments (in this case, 4 quadrants). Then, high energy pulses (preferably spaced further apart from each other than the low energy “cutting” pulses) are applied to the same scribe lines (i.e. the patterns for the low and high energy pulses are co-registered to each other using the pattern laser control system described above) to separate the segments from each other.
FIG. 20 illustrates the application of low power pulses (depicted as small circles, 700, in FIG. 20) applied to the lens (69) in a pattern of two orthogonal lines (710, 712), which results in two cuts that divide the lens into four quadrants (702, 704, 706, 708). Similarly, FIG. 21 illustrates the application of high power pulses (depicted as larger circles, 714, in FIG. 21) applied in a similar orthogonal line (716, 718) pattern (i.e., similar to the cuts formed by the low power pulses), which separates the four quadrant segments (720, 722, 724, 726) of the lens (69) from each other. The high power pulses (714) are shown with greater separation than the lower power pulses (element 700 of FIG. 20), which is preferable but not necessary. The high power pulses (714) are also shown in FIG. 21 with greater size, to reflect their greater pulse energy (and commensurately larger cavitation bubble dimension) relative to the low power pulses (element 700 of FIG. 20). The physical size of the high power pulses on the lens can match that of the low power pulses, and can vary. Lower and higher, as well as low and high energy pulses as used herein describes not a fixed pulse energy for a set of pulses, but the distinction between the nominal energies of the two sets of pulses. This further distinguishes their purpose.
It is also important to note that the underlying pattern of lower energy pulses leaves behind a layer of opacity that provides further shielding of the retina from the higher energy pulses delivered afterwards. This shielding offers an increased margin of patient safety. Using lower energy pulses to create a nominally contiguous segmentation pattern within the lens, but not completely throughout the lens volume provides the ideal basis for the present invention.
Referring to FIGS. 22 and 23, two treatment paradigms are illustrated using a side view of a lens (69) to facilitate the depiction of depth dimensions within the lens (69). Referring to FIG. 22, in one embodiment, the majority of the lens (69) is segmented using the finer and less mechanically intrusive lower energy pulses (700), while the uppermost portion (i.e., most anterior to the face of the patient) of the cataractous lens is left untreated. Following that, the higher energy pulses (714) may be brought to bear on that uppermost portion of the lens segmentation and force the segments to further divide. The same convention described above for illustrating relative pulse energy (i.e., in FIGS. 20 and 21) is applicable in FIGS. 22 and 23.
Similarly, higher energy pulses (714) may be used at selected points in the lens (69) segmentation process/pattern to provide piecewise enhanced separation, such as is shown in the embodiment of FIG. 23.
This makes the segments easier to remove without requiring too many high energy pulses, thus attempting to minimize the overall energy required to effectively segment a lens while also commensurately limiting the amount of gas liberated during the photoablation process. To further limit the possible iatrogenic effects of such gas, the lens may be segmented using higher energy pulses only after the anterior capsule has been incised to provide a means for the otherwise trapped gases to escape. This limits the chances of capsular rupture.
Furthermore, imaging system 71 and/or OCT system 100 of FIG. 1 may be employed to provide feedback on the segmentation process by monitoring bubble creation and tissue displacement. In this way the signals provided by the imaging system may be used as input to Control Electronics 300 via IO 302 to determine the extent of the bubble created and/or the amount of actual tissue separation. As an example of a non-limiting embodiment, Control Electronics 300 may be configured to discontinue the use of higher energy pulses once the prescribed level of tissue separation has been detected. Likewise, tit may continue the use of higher energy pulses until said level is achieved. The use of higher energy pulses may not be required if the system detects adequate separation through the use of lower energy pulses alone. Alternatively, the pulse energy may be increased if the abovementioned system(s) do not detect sufficient tissue segmentation. Alternate methods of assessing the tissue separation may also be employed, such as a confocal back-reflectance configuration using the treatment beam itself, or a probe beam such as that provided by aim beam 202.
The laser system that provides the higher pulses may be the same as that providing the lower energy pulses, but could also be a different and distinct source that is interleaved into the scanning system. As such, it should have its own beam train (at least to a common point) and safety shutter to provide for safe operation. Although this configuration is not shown the attached drawings, the concepts are nevertheless identical. For example, a non-limiting embodiment may be described by referring to FIG. 1 with the added functionality of UF Light Source 4 providing both high and low energy pulses. This may be accomplished by commanding those energies from UF Light Source 4, or alternately by actively controlling the level of attenuation using Controller 300 of fixed output using half-wave plate 8 and polarizer 10 via IO 302. Alternately, a pattern may be completed at a lower energy setting and then repeated at a higher energy setting to provide for the initial incision and the subsequent segment separation. This optomechanical segment separation provides for easier target tissue segment separation, which in turn makes surgical manipulation simpler and material removal more time and energy efficient. An alternate embodiment of comprises the use of a second pulsed light source. It may be combined using the same scheme as described in FIG. 1 regarding the combination of OCT beam 114 and UF beam 6 and/or aim beam 202 using beamcombiners 34 and 126, respectively. Alternately, independently directing them into the scanning assembly, and interleaving them may combine these separate beams. This is similar to the optical multiplexing described in U.S. patent application Ser. No. 11/523,159, which is incorporated herein by reference. A system further configured to accommodate an independent higher pulse energy light source, such as a Q-Switched Nd:YAG laser, may be added to that of FIGS. 1, 3 and 4, as described above.
It is to be understood that the present invention is not limited to the embodiment(s) described above and illustrated herein, but encompasses any and all variations explicitly and implicitly derived therefrom. For example, the lens conditioning may be made in multiple steps, with the capsulotomy occurring between them to accomplish the intended goal. Although not shown in the figures, multiple imaging steps can also be employed in between treatment steps to account for any changes in position and/or size due to treatment and further insure the accurate disposition of laser energy in the target tissue.

## Claims

1. A method for cataract surgery on an eye of a patient, comprising:
scanning a first focus position of a first pulsed laser beam at a first pulse energy of between one-half microjoule and 50 microjoules in a first scanning pattern to photodisrupt a first tissue structure portion with a plurality of pulses of the first laser beam to form an incised surface; and
after scanning first focus position of the first laser beam in the first scanning pattern, scanning a second focus position of a second pulsed laser beam having a second pulse energy being between 50 microjoules and 5,000 microjoules in a second scanning pattern that is co-registered to the first scanning pattern to dispose the second focal position on the incised surface for a plurality of pulses of the second laser beam to further photodisrupt the same first tissue structure portion with the second laser beam to further separate segments of the first tissue structure along the incised surface,
wherein the pulses of the first laser beam scanned in the first scanning pattern have a first pulse duration between 100 femtoseconds and 10 picoseconds, and the pulses of the second laser beam scanned in the second scanning pattern have a second pulse duration between 10 picoseconds and 10 nanoseconds and is longer than the first pulse duration.

2. The method of claim 1, wherein the first tissue structure portion is a portion of a crystalline lens of the eye.

3. The method of claim 1, wherein the controller is operatively coupled to the first and second laser sources, and configured to control the first and second pulse energies.

4. The method of claim 1, wherein the first scanning pattern is configured to divide the lens into two or more discrete segments.

5. The method of claim 1, wherein the first scanning pattern comprises a three-dimensional pattern wherein two or more pulses are targeted for two or more different depths within the targeted tissue structure portion.

6. The method of claim 1, wherein the pulses of the first laser beam scanned in the first scanning pattern have a substantially distinct range of pulse energies relative to the pulses of the second laser beam scanned in the second scanning pattern.

7. The method of claim 6, wherein the pulses of the first laser beam scanned in the first scanning pattern have a pulse energy of 1 microjoule to 20 microjoules and the pulses of the second laser beam scanned in the second scanning pattern have a pulse energy of 100 microjoules to 3 millijoules.

8. The method of claim 7, wherein the pulses of the first laser beam scanned in the first scanning pattern are directed to a deeper portion of the targeted tissue structure portion than the pulses of the second laser beam scanned in the second scanning pattern.

9. The method of claim 1, wherein the second scanning pattern comprises increased spacing between the focus position of adjacent pulses of the second laser beam relative to spacing between the focus position of adjacent pulses of the first laser beam in the first scanning pattern.

10. A method for cataract surgery on an eye of a patient, comprising:
scanning a focus position of a first pulsed laser beam having a first pulse energy of between one-half microjoule and 50 microjoules in a first pattern so as to photodisrupt tissue with a plurality of pulses of the first laser beam to incise a plurality of intersecting cut planes within a lens; and
after scanning the focus position of the first laser in the first pattern, scan the focus position of a second pulsed laser beam having a second pulse energy being between 50 microjoules and 5,000 microjoules in a second pattern that is co-registered with the first pattern to dispose the focus position of the second laser on at least one of the cut planes for a plurality of pulses of the second laser beam so as to further photodisrupt tissue along at least one of the cut planes incised by the scanning of the first laser to further separate segments of the tissue along at least one of the cut planes incised by the first laser,
wherein the pulses of the first laser beam scanned in the first scanning pattern have a first pulse duration between 100 femtoseconds and 10 picoseconds, and the pulses of the second laser beam scanned in the second scanning pattern have a second pulse duration between 10 picoseconds and 10 nanoseconds that is longer than the first pulse duration.

11. The method of claim 10, wherein the laser light source includes a first laser source configured to deliver the first laser beam and a second laser source configured to deliver the second laser beam.

12. The method of claim 10, wherein the second pattern comprises increased spacing between the focus positions of adjacent pulses of the second laser beam relative to spacing between the focus positions of adjacent pulses of the first laser beam in the first pattern.

13. The method of claim 10, wherein the pulses of the first laser beam scanned in the first scanning pattern are directed to a deeper portion of the targeted tissue structure portion than the pulses of the second laser beam scanned in the second scanning pattern.

14. A method for cataract surgery on an eye of a patient, comprising:
scanning a focus position of a first pulsed laser beam having a first pulse energy of between one-half microjoule and 50 microjoules in a first pattern so as to photodisrupt tissue with a plurality of pulses of the first laser beam to incise a plurality of intersecting cut planes within a lens; and
after scanning the focus position of the first laser beam in the first pattern, scanning a focus position of a second pulsed laser beam, for a plurality of pulses of the second laser beam having a second pulse energy greater than the first pulse energy of between 50 microjoules and 5,000 microjoules in a second pattern that is co-registered with the first pattern so as to further photodisrupt tissue along at least one of the cut planes incised by the scanning of the first laser beam to further separate segments of the tissue along at least one of the cut planes incised by the scanning of the first laser beam,
wherein the pulses of the first laser beam scanned in the first scanning pattern have a first pulse duration between 100 femtoseconds and 10 picoseconds, and the pulses of the second laser beam scanned in the second scanning pattern have a second pulse duration between 10 picoseconds and 10 nanoseconds and is different than the first pulse duration.

15. The method of claim 14, wherein the laser light source includes a first laser source configured to deliver the first laser beam and a second laser source configured to deliver the second laser beam.

16. The method of claim 14, wherein the second pattern comprises increased spacing between the focus positions of adjacent pulses of the second laser beam relative to spacing between the focus positions of adjacent pulses of the first laser beam in the first pattern.