Patent Publication Number: US-2021161712-A1

Title: Devices and methods for ocular surgery

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
     This application is a continuation of co-pending U.S. application Ser. No. 16/221,239, filed Dec. 14, 2018, which claims priority to U.S. Provisional Patent Application Serial Nos. 62/598,857, filed Dec. 14, 2017, entitled “Devices and Methods for Ocular Surgery”, and 62/696,769, filed Jul. 11, 2018, entitled “Devices and Methods for Ocular Surgery,” the disclosures of which are hereby incorporated by reference in their entireties for all purposes. 
    
    
     FIELD 
     The present technology relates generally to devices and methods for ocular surgery with one such procedure being removal of a lens from a human eye. More specifically, the technology relates to capturing, fragmenting and extracting of lenticular or other tissue in ophthalmic surgery. 
     BACKGROUND 
     Certain types of conventional ophthalmic surgery require breaking up lenticular tissue and solid intraocular objects, such as the intraocular lens into pieces so that it can be extracted from the eye. For example, extraction of lenses for cataract surgery is one of the most common outpatient surgical fields with more than 3 million cases performed annually in the United States alone. During cataract surgery a commonly used method for lens extraction is phacoemulsification, which incorporates using ultrasonic energy to break up the lens and then aspiration to remove the lens fragments through the instrument. Other methods of lens fragmentation and extraction may include the use of instruments such as hooks, knives, or laser to break up the lens into fragments and then extract through an incision in the cornea in an ab interno approach. Intraocular, ab interno fragmentation of the lenticular tissue is extremely important in cataract surgery in order to allow removal of cataracts from ocular incisions that are typically not exceeding 2.8-3.0 mm. 
     However, existing tools and techniques do not ensure full-thickness fragmentation of the lens. These techniques approach the lens from the anterior surface of the eye, and therefore the dissection forces exerted by mechanical instruments are limited such that they are often insufficient to accomplish a full-thickness segmentation. Further, due to the surgical approach through the incision at the edge of the cornea, a mechanical instrument is delivered at an angle substantially parallel to the plane defined by the capsulorhexis. As a result, a conventional surgical snare, loop or wire retrieval tool is not in an orientation in which that device could be looped around the lens to provide for fragmentation or extraction. Further, even if such a conventional tool could be looped around the lens, which it cannot, the wire of the snare would run the risk of applying excessive, damaging force to the capsular bag as it would be moved into position. 
     Energy-delivery instruments are limited in their ability to cut sections of the lens that are physically close to other delicate anatomical structures such as the capsular bag. For instance, a laser is generally not used to cut the posterior edge of the lens because it is in close proximity to the posterior edge of the capsular bag, leaving a lens that is not fully fragmented and must be fragmented carefully using secondary techniques. 
     For these reasons, phacoemulsification has become the most popular method of lens removal. However, phacoemulsification has its own drawbacks. As fluid and substances are aspirated from the capsular bag and the anterior chamber, other fluids such as saline are inspirated to maintain a constant volume or pressure. The flow of the fluids in the eye during inspiration and aspiration may create turbulent flow that may have a deleterious effect on the tissue within the eye, such as the corneal endothelium. The ultrasonic energy used in phacoemulsification can have its own negative consequences on ocular tissue. Further, phacoemulsification requires expensive and bulky capital equipment, limiting the locations in which phacoemulsification can be perform. 
     Additionally, certain aspiration and inspiration configurations require large pieces of capital equipment as in the case of phacoemulsification or may require certain resources such as wall vacuum that may not be available in all surgical settings, particularly in underdeveloped areas. A lower cost alternative with the same or better performance would also be desirable alternative such as one not requiring a costly control console and electronic control system. 
     SUMMARY 
     In an aspect, described is a surgical device for cutting a lens within a capsular bag of an eye. The device includes a shaft extending from a housing along a longitudinal axis of the device. The shaft has a lumen and a distal end. The device includes a cutting element movable through the lumen of the shaft. The cutting element includes a first sectioning element and a second sectioning element. Each of the first and second sectioning elements has a first end, a second end, and a distal loop formed between the first and second ends. The device includes an actuator operatively coupled to the cutting element. The cutting element is configured to transition from a first, retracted configuration towards a second, expanded configuration upon a first activation of the actuator. When in the second, expanded configuration, the distal loop of each of the first and second sectioning element defines an enlarged open area located outside the distal end of the shaft, the enlarged open area having a first leg advanced distally relative to the distal end of the shaft and a second leg positioned proximally to the distal end of the shaft. 
     When the cutting element is in the second, expanded configuration, the distal loops defining the enlarged open areas of each of the first and second sectioning elements can be aligned generally within a plane parallel to one another. A second activation of the actuator or a second, different actuator can cause the distal loop defining the enlarged open area of one of the first and second sectioning elements to move angularly relative to the plane transitioning the cutting element into a third, splayed configuration. A second activation of the actuator or a second, different actuator can cause the distal loop defining the enlarged open area of both of the first and second sectioning elements to move angularly away from one another transitioning the cutting element into a third, splayed configuration. 
     The device can further include an intermediate sectioning element positioned between the first and second sectioning elements. The intermediate sectioning element may also have a first end, a second end, and a distal loop formed between the first and second ends. When the cutting element is in the second, expanded configuration, the distal loop of the intermediate sectioning element can define an enlarged open area located outside the distal end of the shaft. The enlarged open area of the intermediate sectioning element can have a first leg advanced distally relative to the distal end of the shaft and a second leg positioned proximally to the distal end of the shaft. When the cutting element is in the second, expanded configuration, the distal loops defining the enlarged open areas of each of the first, second, and intermediate sectioning elements can be aligned generally within a plane parallel to one another. A second activation of the actuator or a second, different actuator can cause the distal loops defining the enlarged open areas of both the first and second sectioning elements to move angularly away from the intermediate sectioning element transitioning the cutting element into a third, splayed configuration. The first and second sectioning elements can move between about 15 degrees to about 45 degrees relative to the plane, the plane being a substantially vertical plane. 
     The first ends and the second ends of each of the first and second sectioning elements can be movable relative to the shaft. The first ends can be axially movable along the longitudinal axis of the device. The second ends can be angularly movable relative to the longitudinal axis of the device. The first ends of each of the first and second sectioning elements can be movable relative to the longitudinal axis of the device and the second ends of each of the first and second sectioning elements can be fixed relative to the longitudinal axis of the device. The first ends can be axially movable along the longitudinal axis of the device and angularly movable relative to the longitudinal axis of the device. 
     The actuator can be a slider movable along the longitudinal axis of the housing. The device can further include a sled positioned within the housing and coupled to move with the slider relative to the housing. The sled can include a first loop carrier coupled to the first sectioning element and a second loop carrier coupled to the second sectioning element. Movement of the slider a first distance in a distal direction relative to the housing can translate the sled distally causing the distal loops of the first and second sectioning elements to define the enlarged open areas and transition the cutting element towards the second, expanded configuration. Movement of the slider a second distance in the distal direction beyond the first distance can cause the distal loops defining the enlarged open areas of the first and second sectioning elements to move angularly away from one another transitioning the cutting element into a third, splayed configuration. The first loop carrier can be configured to rotate around a first axis of rotation in a first direction and the second loop carrier can be configured to rotate around a second axis of rotation in a second direction opposite the first direction. Rotation of the first loop carrier around the first axis of rotation can cause the distal loop of the first sectioning element to splay in the first direction and rotation of the second loop carrier around the second axis of rotation can cause the distal loop of the second sectioning element to splay in the second opposite direction. Movement of the slider a second distance in the distal direction beyond the first distance can rotate the first and second loop carriers around their axes of rotation transitioning the cutting element towards a third, splayed configuration. The device can further include a wedge positioned within a distal end region of the housing. Movement of the slider a second distance in the distal direction beyond the first distance can urge the first and second loop carriers against the wedge causing the first loop carrier to rotate around a first axis of rotation in a first direction and causing the second loop carrier to rotate around a second axis of rotation in a second, opposite direction resulting in the distal loops defining the enlarged open areas of the first and second sectioning elements to splay apart. The wedge can be immovable or can be movable in a proximal direction upon actuation of a second, different actuator. Movement of the wedge in a proximal direction can urge the wedge against the first and second loop carriers causing the first loop carrier to rotate around a first axis of rotation in a first direction and causing the second loop carrier to rotate around a second axis of rotation in a second, opposite direction resulting in the distal loops defining the enlarged open areas of the first and second sectioning elements to splay apart. The wedge can be movable in a proximal direction to cause splay of the first and second loop carriers independent of a relative location of the sled along the longitudinal axis of the device. 
     When the cutting element is in the second, enlarged configuration, the distal loops defining the enlarged open areas of the first and second sectioning element can be generally oval in shape and have a maximum width of about 4.0 mm to about 20 mm, and a maximum height of about 1.0 mm to about 15 mm. The distal loops defining the enlarged open areas of the first and second sectioning elements can be configured to splay angularly away from each other transitioning the cutting element into the third, splayed configuration independent of a size of the enlarged open areas. The size of the enlarged open areas of the first and second sectioning elements prior to splay can be selectable. The device can further include an adjustor configured to change a relative distance between the wedge and the sled. A shorter relative distance can achieve a smaller open area of the first and second sectioning elements in the second, expanded configuration prior to splay, and a longer relative distance can achieve a larger open area of the first and second sectioning elements prior to splay. 
     In an interrelated implementation, described is a surgical device for cutting a lens within a capsular bag of an eye that includes a shaft extending from a housing along a longitudinal axis of the device. The shaft has a lumen and a distal end. The device includes a cutting element movable through the lumen of the shaft. The cutting element includes at least a first sectioning element having a first end, a second end, and a distal loop formed between the first and second ends. The device includes a slider operatively coupled to the cutting element and movable along the longitudinal axis of the housing. The device includes a stroke counting mechanism coupled to the slider and contained within the housing. The cutting element is configured to transition from a first, retracted configuration towards a second, expanded configuration upon distal extension of the slider. When in the second, expanded configuration, the distal loop of the at least a first sectioning element defines an enlarged open area located outside the distal end of the shaft, the enlarged open area having a first leg advanced distally relative to the distal end of the shaft and a second leg positioned proximally to the distal end of the shaft. The stroke counting mechanism is configured to track distal extensions and/or proximal extensions of the slider. 
     The stroke counting mechanism can be configured to cause a lock-out event that prevents distal extension of the slider after the lock-out event. The stroke counting mechanism can include a cylindrical counting barrel having a plurality of ramp blocks; a hard stop; and a pair of slider ramps shaped and arranged to engage with the plurality of ramp blocks on the counting barrel causing the counting barrel to rotate around the longitudinal axis of the device. Each distal extension of the slider can turn the cylindrical counting barrel a fraction of a full revolution around the longitudinal axis of the device. The cylindrical counting barrel can be configured to turn up to about 24 fractions before the lock-out event occurs. The lock-out event can prevent distal extension of the slider and allows proximal retraction of the slider. The slider can be configured to extend about 3 to about 30 strokes in a distal direction before the lock-out event occurs and the slider is locked in a rearward position. 
     The device can include a lock-out warning feature. The lock-out warning feature can include a lock-out warning window extending through the housing providing a visible indication of a position of the counting barrel within the housing relative to the hard stop of the stroke counting mechanism. The counting barrel can be axially movable within the housing and have an outer surface having a color that contrasts with a color of the housing. When the counting barrel is positioned near the lock-out warning window, the color of the counting barrel can be visible through the lock-out warning window providing an indication of the distal extensions of the slider available before the lock-out event occurs. The counting barrel can have a series of markings on an outer surface and be fixed relative to the lock-out warning window. The series of markings can indicate a number of distal extensions performed by the slider. 
     The slider can further include a shutter window. When the slider is moved toward a distal end region of the housing, the shutter window of the slider and the lock-out warning window of the housing can align revealing the series of markings on the barrel. When the slider is moved proximally away from the distal end region of the housing, the shutter window of the slider and the lock-out warning window of the housing may not align and the series of markings on the barrel are not visible. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       These and other aspects will now be described in detail with reference to the following drawings. Generally speaking, the figures are not to scale in absolute terms or comparatively, but are intended to be illustrative. Also, relative placement of features and elements may be modified for the purpose of illustrative clarity. 
         FIG. 1  is a side schematic view of the ocular anatomy, showing the insertion of a shaft and sectioning element through an incision in the side of the cornea. 
         FIG. 2  is a top view of the sectioning element in a deployed position. 
         FIG. 3  is a perspective view of the capsular bag, with a completed capsulorhexis, with a sectioning element in a first, retracted configuration for insertion. 
         FIG. 4  is a perspective view of the capsular bag, with a completed capsulorhexis, with a sectioning element in a second, expanded configuration for capture. 
         FIG. 5  is a perspective view of the capsular bag, with a completed capsulorhexis, with a sectioning element in a third, fragmentation position. 
         FIG. 6  is a perspective view of the lens of  FIG. 5 , with the sectioning element not shown for clarity. 
         FIG. 7  is a perspective view of the lens of  FIG. 5 , with the sectioning element and capsular bag not shown for clarity. 
         FIG. 8  is perspective view of a surgical device including a handle, shaft and multiple sectioning elements. 
         FIG. 9  is a perspective view of the surgical device of  FIG. 8 , with the sectioning elements in the first, retracted configuration. 
         FIG. 10  is a perspective view of the surgical device of  FIG. 8 , with a left slider advanced to expand a left sectioning element toward the second, expanded configuration. 
         FIG. 11  is a perspective view of the surgical device of  FIG. 8 , with a left slider fully advanced to expand the left sectioning element to the second, expanded configuration. 
         FIG. 12  is a perspective view of the surgical device of  FIG. 8 , with a right slider advanced to expand a right sectioning element toward the second, expanded configuration. 
         FIG. 13  is a perspective view of the surgical device of  FIG. 8 , with a right slider fully advanced to expand the right sectioning element to the second, expanded configuration. 
         FIG. 14  is a perspective view of  FIG. 13 , showing the sectioning elements relative to the lens. 
         FIG. 15  is a detail perspective view of the distal end of the surgical device of  FIG. 8 . 
         FIG. 16  is a cutaway perspective view of the handle, with the right slider in its initial position. 
         FIG. 17  is a detail perspective view of part of the handle of  FIG. 16 . 
         FIG. 18  is a detail perspective view of a different part of the handle of  FIG. 16 . 
         FIG. 19  is a detail perspective view of the handle of  FIGS. 16-18 , with the right slider partially advanced. 
         FIG. 20  is a detail perspective view of the handle of  FIGS. 16-18 , with the right slider advanced further distally than its position in  FIG. 19 . 
         FIG. 21  is a detail perspective view of the handle of  FIGS. 16-18 , with the right slider returned toward its original position. 
         FIG. 22  is a detail perspective view of the handle of  FIGS. 16-18 , with the right slider returned to its original position. 
         FIG. 23  is a side view of another embodiment of two sectioning elements extending from a shaft to encircle a lens. 
         FIG. 24A  is a perspective view of another implementation of a surgical device including a handle, shaft and multiple sectioning elements prior to deployment. 
         FIG. 24B  is a perspective view of the device of  FIG. 24A  in a second, expanded configuration. 
         FIG. 24C  is a perspective view of the device of  FIG. 24B  in a third, splayed configuration. 
         FIG. 24D  is an exploded view of the device of  FIG. 24A  having three sectioning elements. 
         FIG. 24E  is an exploded view of another implementation of the device of  FIG. 24A  having two sectioning elements. 
         FIG. 25A  is a perspective, detail view of the device of  FIG. 24A  surrounding a lens. 
         FIGS. 25B-25C  are perspective, detail views of the device of  FIG. 25A  after tensioning and cutting through the lens. 
         FIG. 26A  is an exploded view of the device of  FIG. 24A  include a two-phase deployment mechanism. 
         FIG. 26B  is a partial, perspective view of the device of  FIG. 24A  illustrating the sled and loop carriers. 
         FIG. 26C  is a partial, end view of the device of  FIG. 24A . 
         FIG. 26D  is a partial, perspective view illustrating the loop carrier of the device of  FIG. 24A  prior to splay. 
         FIG. 26E  is a partial, perspective view illustrating the loop carrier of the device of  FIG. 24A  after splay. 
         FIG. 26F  is a top plan view of the wedge of the device of  FIG. 24A . 
         FIGS. 26G-26H  illustrates an expansion adjustment mechanism of the device of  FIG. 24A . 
         FIGS. 26I-26L  are various views of the expansion adjustment mechanism. 
         FIG. 26M  is a partial, perspective view illustrating the loop carrier of the device of  FIG. 24A  prior to splay illustrating an implementation of a user feedback element. 
         FIG. 26N  is a top plan view of the user feedback element of  FIG. 26M . 
         FIGS. 27A-27C  illustrate an implementation of a stroke counting mechanism. 
         FIGS. 28A-28B  illustrate another implementation of a stroke counting mechanism. 
         FIGS. 29A-29B  illustrate another implementation of a stroke counting mechanism. 
         FIGS. 30A-30E  illustrate another implementation of a stroke counting mechanism. 
         FIG. 31A  is perspective view of another implementation of a device including a stroke counting mechanism. 
         FIG. 31B  is a partial cut-away view of the device of  FIG. 31A . 
         FIG. 31C  is an implementation of a counter barrel. 
         FIG. 31D  illustrates slider ramps configured to engage with the counter barrel of  FIG. 31C . 
         FIG. 31E  illustrates the counter barrel of  FIG. 31C  relative to the slider. 
         FIG. 31F  illustrates an implementation of a lock-out warning for the device of  FIG. 31A . 
         FIGS. 32A-32B  illustrate another implementation of a stroke counting mechanism. 
         FIGS. 33A-33C  illustrate implementations of sectioning elements formed of a long, narrow band of material. 
     
    
    
     It should be appreciated that the drawings are for example only and are not meant to be to scale. It is to be understood that devices described herein my include features not necessarily depicted in each figure. 
     DETAILED DESCRIPTION 
     Described herein are methods and devices for intraocular fragmentation and removal of the lens and other tissues during intraocular surgery. The devices described herein allow for extracting tissue from the anterior chamber without damaging other ocular structures. In various implementations, an ocular surgical device is described that uses cutting strings, loops, filaments, snares, and the like that are designed to engage and fragment the lenticular tissue and aid in its removal from the eye in a minimally-invasive, ab interno approach. In one aspect, provided is a hand-held device that can also be powered (manually) by the user and does not require electronic control. The devices described herein are configured for fully adjustable and customizable deployment that can occur in a two-step manner (i.e. expansion and rotation or expansion and splay) or a three-step manner (i.e. expansion, rotation, and splay). 
     Referring now to the figures,  FIG. 1  shows the normal anatomy of the eye  1  including a cornea  2 , capsular bag  6 , and a lens  8  within the capsular bag  6 . During a cataract procedure, an incision  4  can made in the edge of the cornea  2  to access the capsular bag  6 . The surgeon forms a capsulorhexis  10  on the anterior surface of the capsular bag  6 . The capsulorhexis  10  can be performed in any suitable manner, such as incising with a scalpel, applying energy with a femtosecond laser or other energy-based cutter, incising under robotic or automated control, or in any other suitable manner. The capsulorhexis  10  can be torn or cut in a diameter of approximately 2.0 mm to 8.0 mm. The capsulorhexis  10  may be made smaller in diameter than 2.0 mm, particularly where fragments of the lens  8  (as described in greater detail below) are small enough in size to be extracted through a smaller-diameter capsulorhexis  10 . The capsulorhexis  10  can be made with a separate set of instruments such as micro-forceps, as is commonly done. It is desirable to maintain the size of the corneal incision to a minimum. For example, corneal incisions that are self-sealing and require no stitches for closure are optimal for minimally-invasive surgery with the least risk for complications. The devices described herein are designed to minimize the size of incision needed to perform lens fragmentation and removal. 
     Referring also to  FIG. 3 , a shaft  12  is then inserted through the incision  4  in the cornea  2 . As seen in  FIG. 3 , the distal end of the shaft  12  is positioned above (i.e., anterior to) the capsulorhexis  10 , spaced apart from the capsulorhexis  10  but positioned within the circumference of the capsulorhexis  10  as viewed from outside the eye  1 . As seen in  FIG. 1 , the shaft  12  is generally parallel to the plane defined by the edges of the capsulorhexis  10  upon its insertion through the incision  4  in the cornea  2 . In some embodiments, the distal end of a sectioning element  16  extends out of an outlet  5  in a lumen  14  at the distal end of the shaft  12  in a first, retracted configuration. In such embodiments, the tight radius bend  24  may be positioned outside the shaft  12 , already bent at least partially toward the proximal direction. In this way, even in embodiments where the sectioning element  16  is fabricated from superelastic material, the angle through which portions of the sectioning element  16  are bent during transition from the first, retracted configuration to the second, expanded configuration is reduced. Further, less space is required within the lumen  14  of the shaft  12  to hold part of the sectioning element  16  than to hold all of it, allowing the shaft  12  to be made smaller in diameter. According to some embodiments, the shaft  12  is an ovular cross-section tube with a rounded tip. The ovular cross-section enhances the ability of the shaft  12  to be inserted into the eye  1  through the corneal incision  4 . Additionally, in the event that there are multiple sectioning elements, they may be arranged side-by-side more easily in the lumen  14  of an ovular cross-section shaft  12 . Alternately, the shaft  12  may have a circular cross-section or a cross-section of any other suitable shape. The proximal end of the sectioning element  16  extends through the lumen  14  of the shaft  12 . Alternately, the entirety of the sectioning element  16  is positioned within the lumen  14  of the shaft  12  in the first, retracted configuration. Alternately, more than one sectioning element  16  is utilized, where each sectioning element  16  is initially in the first, retracted configuration. While a single sectioning element  16  is described with regard to this particular embodiment for clarity, it will be apparent in light of the further disclosure below that any suitable number of sectioning elements  16  may be provided and used in a single lens removal procedure, and that the devices and methods herein are not limited to the use of any particular number of sectioning elements  16 . Related devices having sectioning elements as described herein are described in U.S. Pat. Nos. 9,775,743 and 9,629,747, which are each incorporated by reference herein in their entireties. 
     According to some embodiments, the sectioning element  16  includes a first end  18  and second end  20 . As described in greater detail below with regard to  FIGS. 16-22 , one of the ends  18 ,  20  of the sectioning element  16  may be movable relative to the shaft  12 , while the other of the ends  18 ,  20  of the sectioning element  16  may be fixed relative to the shaft  12 . For example, the second end  20  of the sectioning element  16  may be fixed relative to the shaft  12  and the first end  18  of the sectioning element  16  may be slideable relative to the shaft  12 . The second end  20  may be connected to the shaft  12  or to other structure by crimping, welding, adhesives, mechanical interlocks, or any other suitable structure or method. In some embodiments, the sectioning element  16  is a wire with a circular, oval or other atraumatic cross-section. In other embodiments, the sectioning element  16  is a strap. As used in this document, a strap is a structure that is wider than it is thick, as viewed longitudinally. 
     In the first, retracted configuration, where the distal end of the sectioning element  16  extends distally out of the shaft  12 , the sectioning element  16  is sized and shaped to pass through a standard corneal incision  4  without damaging the eye  1 . The corneal incision  4  is generally 3.5 mm or less in width and made with a small knife. Thus, the outer diameter of the shaft  12  advantageously is 3.5 mm or less. Where a differently-sized incision  4  is used, a different outer diameter of shaft  12  may be used, keeping in mind that it is most desirable to form the incision  4  as a line 5 mm or less in length. In other embodiments, the sectioning element  16  is positioned completely within the lumen  14  of the shaft  12  such that it is within the inner diameter of the shaft  12  as the shaft  12  is inserted through the incision  4 , and is then extended out of the shaft  12  once in the eye. Alternatively, additional components may be used to sheathe the sectioning element  16  during insertion through the corneal incision  4 . The device can include a thin-walled, retractable sleeve or sheath that restricts movement of the sectioning element  16  away from the longitudinal axis A of the device during certain times of use (i.e. during insertion, expansion and/or prior to splay of multiple sectioning elements relative to one another). In some implementations, a tapered piece may be positioned on the distal end of the shaft  12  that gradually tapers from the end of the shaft  12  down to a smaller cross section such that it can aid insertion through the corneal incision  4 . The tapered piece can also cover the sectioning element  16  to constrain it during insertion. The tapered piece can further have a slit in the front that the sectioning element  16  can extend through or tear open once it has passed through the incision  4 . 
     According to some embodiments, the sectioning element  16  is fabricated from of a flexible or superelastic material, such as nickel-titanium alloy, which allows the sectioning element  16  to bend and flex as it is inserted into the eye  1  through the corneal incision  4 . The sectioning element  16  can also be formed from other materials such as a polymer rather than metal. In these embodiments, the constricted shape of the sectioning element  16  may be larger in one or more dimensions than the corneal incision  4 , and flexes to pass through the incision  4  as the shaft  12  moves toward the capsulorhexis  10 . Alternatively, the sectioning element  16  may not have a first, retracted configuration, and may be inserted through the incision  4  in the same configuration that is later utilized to engage the lens  8 . In such embodiments, the sectioning element  16  compresses as it passes through the corneal incision  4  and then re-expands once it enters the eye  1 . In still other embodiments, the sectioning element  16  may not have a first, retracted configuration, and may be inserted through the incision  4  in a larger configuration than is later utilized to engage the lens  8 . In still other embodiments, the sectioning element  16  may be hooked, rotated, or otherwise inserted through the corneal incision  4  in any number of methods. 
     Referring to  FIG. 4 , the sectioning element  16  or elements are pushed distally relative to the lumen  14  of the shaft  12 . As set forth above, one end  20  of the sectioning element  16  may be fixed, such that the other end  18  of the section element  16  is pushed distally relative to the lumen  14  of the shaft  12 . As a result, the sectioning element  16  moves from a first, retracted configuration to a second, capture configuration. 
     The sectioning element  16  may be fabricated from any suitable material. For example, as discussed above, shape memory materials such as nickel-titanium alloy may be used to allow the sectioning element  16  to move to its predefined shape in the second, expanded configuration, with a high amount of elasticity. In one embodiment, the nickel-titanium alloy may be used in its superelastic condition, where the nickel-titanium alloy transforms its crystal structure to move from the first, retracted configuration to the second, expanded configuration. In other embodiments, the sectioning element  16  is fabricated from nickel-titanium alloy that is shape set to move from the first, retracted configuration to the second, capture configuration upon reaching a transition temperature that is above room temperature but below body temperature. The sectioning element  16  fabricated from nickel-titanium alloy thus may enter the eye at room temperature below its transition temperature such that it will hold a constricted shape. As the sectioning element  16  is placed into the eye  1  and allowed to warm to body temperature, the nickel-titanium alloy may become warmer than its transition temperature and begin to return to its predefined second, expanded configuration. This shape change may happen over a period of time that allows the surgeon to place the sectioning element into the capsular bag  6  and orient it while the shape changes such that the loop can define a sectioning plane through the lens. Alternatively, any other number of biocompatible materials may be considered such as stainless steel or non-metal polymer materials. In some embodiments, the nickel-titanium alloy may be warmed actively by the surgical device  40 , in which case the transition temperature of the sectioning element  16  may be selected to be greater than room temperature but less than a temperature that would damage the tissue of the capsular bag  6  or other tissue of the eye  1 . Other shape memory materials such as shape memory plastics may be utilized instead of nickel-titanium alloy. Alternatively, any other number of biocompatible materials may be considered such as stainless steel, titanium, silicone, polyimide, PEBAX® polyether block amide, nylon, polycarbonate, or any other suitable material. Furthermore, multiple materials joined end to end or in laminated layers or concentric tubes of material may be used. 
     Referring also to  FIGS. 1 and 4 , in the second, expanded configuration, the sectioning element  16  is specifically shaped for lens capture. According to some embodiments, the second, expanded configuration is a preset shape of the sectioning element  16 , such as through the use of elastic or superelastic materials to fabricate the sectioning element. 
     As seen most clearly in  FIG. 4 , in the second, expanded configuration, the sectioning element  16  approximates an irregular loop that is generally shaped like the cross-section of a lens  8 , and that is shaped and sized to surround the lens  8  within the capsular bag  6 . As set forth above, in some embodiments, the sectioning element  16  is fabricated from a length of round wire. The second, expanded configuration of the sectioning element  16  has a merging point  22  where the first end  18  and second end  20  of the sectioning element  16  merge back together, forming a shape with a perimeter so that the device  40  approximates a closed loop  21 . The “merging” refers to placing the first end  18  and second end  20  of the sectioning element  16  into proximity with one another. The merging point  22  may be located at or in proximity to the distal end of the shaft  12 . In the second, expanded configuration, the sectioning element includes a distal portion  28  that extends distal to the merging point  22  and a proximal portion  26  that extends proximally to the merging point  22 . The merging point  22  in this exemplary embodiment is at a point above the surface of the lens and within the circle defined by the capsulorhexis  10  at the top of the capsular bag  6 . In some embodiments, the proximal portion  26  of the sectioning element  16  may include a tight radius bend  24  as shown in  FIG. 1 . The tight radius bend  24  bends the second end  20  of the sectioning element  16  proximally such that the second end  20  extends proximally from the merging point  22 . Alternatively, the sectioning element  16  may take a different path to achieve this path transition without such a sharp radius bend. For example, paths that are outside of the normal plane of  FIG. 1  such as curves or oscillations may be incorporated to reduce the overall bend radius of the proximal portion  26  of the sectioning element  16 . This may improve the ability of the sectioning element  16  to change shape into other smaller constricted configurations as will be discussed below. 
     The first end  18  and/or second end  20  is pushed out of the lumen  14  of the shaft  12 , while the other end is fixed relative to the shaft  12 , as described above. Alternatively, both ends  18 ,  20  of the sectioning element  16  are movable relative to the shaft  12  and configured to slide relative to the lumen  14  of the shaft  12 . Alternatively, the shaft  12  may be the sliding component while the sectioning element  16  remains stationary. As the end or ends  18 ,  20  (sometimes referred to as “legs”) are pushed outward from the lumen  14 , the sectioning element  16  transitions to the second, expanded configuration. As the sectioning element  16  transitions, the tight radius bend  24  allows the proximal section of the sectioning element to extend proximally from the distal end of the shaft  12 , at a location spaced from and to one side of (i.e. off-set from) the longitudinal centerline of the lumen  12  in the direction toward the capsular bag  6 . In this way, the sectioning element  16  is able to extend downward through the capsulorhexis  10  and expand to a length within the capsular bag  6  that is greater than the diameter of the capsulorhexis  10 , as seen in  FIG. 1 . According to some embodiments, the tight radius bend  24  results in the second end  20  having an angle of at least 120 degrees relative to the longitudinal centerline of the shaft  12 , and relative to the distal direction, as seen in  FIG. 1 . Both the distal portion  28  and the proximal portion  26  of the sectioning element  16  in the second, expanded configuration are gently curved and generally approximate the size and shape of the lateral sides of the capsular bag  6 , in order to enter the capsular bag  6  without causing damage (e.g., such as a capsular tear or hole, over-stretching the capsular bag, or damaging the inner surface of the capsular bag tissue). 
     Referring also to  FIG. 2 , the shape of the sectioning element  16  in the second, expanded configuration forms a plane that is generally flat or horizontal with respect to the top lens surface, according to some embodiments. Referring back to  FIGS. 1 and 3 , with the correct orientation, the sectioning element  16  is held such that it opens through the capsulorhexis  10  into the capsular bag  6 . As the sectioning element  16  continues to expand, the plane formed by the sectioning element  16  can be rotated so that the sectioning element traverses a space between the capsular bag and the lens. The plane includes the longitudinal axis of the lumen  14  of the shaft  12 . Alternately, the shape of the sectioning element  16  in the second, expanded configuration is a more three-dimensional shape that does not lie in a single plane. For example, the sectioning element  16  may oscillate in and out of a flat plane, or may be substantially curved out of a flat plane in one direction or another. The rotation may be accomplished by manual rotation of the shaft  12  of surgical device  40  by the user, or may be accomplished by integrated mechanisms within the surgical device  40 , as described in greater detail below. Referring also to  FIG. 4 , the sectioning element  16  has proceeded most of the way from the first, retracted configuration to the second, expanded configuration, and has been rotated partially relative to the lens  8 . The sectioning element  16  may be rotated such that the shape plane is primarily vertical or to any number of other angles. Mechanisms and methods for producing such rotation are described in greater detail below. Additionally, multiple sectioning elements  16  may be used that rotate to a variety of angles. In other embodiments, the rotation does not occur until the sectioning element  16  transitions to the second, expanded configuration. According to some embodiments, rotation begins while the sectioning element  16  transitions to the second, expanded configuration. For example, rotation may begin once an open area  46  of the loop and within the sectioning element  16  expands to a size in which a 5-6 mm chord extends across the open area  46  between two points on the proximal portion  26  and the distal portion  28 . As another example, rotation may begin when the chord is longer than, or shorter than 5-6 mm. 
     The second, expanded configuration of the sectioning element  16  may be generally ovular in shape, referring to  FIG. 1 , with a width 7.0 mm-15 mm and a height of 3.0-10 mm, according to some embodiments. According to other embodiments, the width of the sectioning element  16  may be 4.0-20 mm with a height of 1.0-15 mm. In some embodiments the size of the second, expanded configuration of the sectioning element  16  may be intentionally smaller than the size of the lens at certain areas or along the entire profile. This may improve the ability of the sectioning element  16  to remain close to the lens  8  and reduce interaction with the capsular bag  6 . For example, the second, expanded configuration of the sectioning element  16  may be 12 mm wide and 4.0 mm high. This may allow clearance between the sectioning element  16  and the lens  8  at the width of the oval while maintaining interference along the height of the oval that may reduce the likelihood of damaging the posterior surface of the capsular bag  6 . That is, by configuring the second, expanded configuration of the sectioning element  16  to engage a portion of lens  8 , rather than move to a position in which it encircles the thickest part of the lens  8 , the sectioning element  16  is sized smaller, and engages less of the capsular bag  6 , than a configuration in which the second, expanded configuration of the sectioning element  16  is able to encircle the thickest part of the lens  8 . In other embodiments, the second, expanded configuration of the sectioning element  16  is predefined to have a generally specific clearance around the lens  8 . According to some embodiments, the second, expanded configuration of the sectioning element  16  has a different shape than generally oval. 
     The sectioning element  16  may have features or geometry that further prevents the element from damaging the capsular bag. For example, the sectioning element  16  is a round wire of sufficient diameter to reduce the likelihood of tearing or damaging the capsular bag  6 , according to some embodiments. The diameter of that round wire may be 0.004″-0.012″ but may also be any size that prevents excessive stress from being placed on the capsular bag  6 , such as 0.001″-0.030″ diameter. Alternatively, the profile of the sectioning element  16  may be ovular with a larger width or height, or may be a strap, to further distribute the force of the sectioning element  16  on the capsular bag  6  over a larger surface area, thereby reducing or eliminating areas of high pressure exerted on the capsular bag  6  by the sectioning element. 
     In some embodiments, portions of the outer surface of the sectioning element  16  may be coated to improve certain aspects of the device. For example, as discussed in greater detail below, the sectioning element  16  traverses a space between the capsular bag  6  and the lens  8 . As the sectioning element  16  moves between these anatomical structures it may be advantageous to have a more hydrophilic or hydrophobic surface so the sectioning element  16  rotates and moves more freely. In one embodiment, the sectioning element  16  may be coated with a hydrophobic material such as a fluoropolymer; for example, PTFE. A coating can be added through dip coating, plasma vapor deposition process, heat shrink sleeves, or any other suitable method. The coating can reduce the friction between the sectioning element  16 , and the lens  8  and/or capsular bag  6 , to allow the sectioning element  16  to move more freely. Other methods of reducing the friction may include using mechanical abrasion, plasma treatments, or any other suitable method. Alternatively, the sectioning element  16  may be coated with other materials such as active pharmaceutical agents that are configured to release into they during the procedure. For example, a steroid like triamcinolone may be added to the surface of the sectioning element  16  such that during the procedure it releases into the eye. Any other number of coatings and drugs may be contemplated. 
     The sectioning element  16  may be constructed with any other suitable geometries or materials. In an exemplary embodiment, the sectioning element  16  is a round wire. The wire is configured to bluntly traverse a space between the lens  8  and the capsular bag  6 . The wire can have various sizes or diameters along the length of the sectioning element  16 . Alternatively, the sectioning element  16  may be any number of other profiles. For example, the sectioning element  16  could be a tube, a ribbon, a strap, a wire with a hexagonal profile, or any other number of suitable shapes. In addition, the profile of the sectioning element  16  could change along its length. For example, the sectioning element  16  may include one or more padded areas along its profile where damage to the capsular bag  4  is of particular concern. The padded areas may include different materials, such as but not limited to soft elastomeric materials like silicone that are bonded or coated onto appropriate areas of the sectioning element  16 . The padded areas may distribute the force over a larger area, and provide a softer and more atraumatic interface against the capsular bag  6 . In other embodiments, the padded areas are geometry profile changes of the sectioning element in certain areas. For example, areas that are flared out or broadened, even if comprised of the same material, distribute the force over a larger area. Additionally, the stiffness or flexibility of the sectioning element may vary over the sectioning element  16  by changing the material thickness or wire diameter in certain areas. Alternatively, sleeves or other materials may be added to the sectioning element  16  to increase stiffness locally in certain areas. In still other embodiments, the sectioning element  16  may have cuts or ribs along its length that change its flexibility or stiffness in certain areas. 
     In other embodiments, the shape of the sectioning element  16  in the second, expanded configuration is not predetermined. Instead shape of the sectioning element  16  in the second, expanded configuration is defined by the material or geometric properties of the sectioning element  16 , engaged with the lens  8 . The sectioning element  16  may be sufficiently flexible, elastic, soft, or blunt along its length, while maintaining sufficient stiffness to allow for rotation to engage the lens  8 , such that minimal force is applied to the capsular bag  6  even when the sectioning element  16  is within the capsular bag  4  and fully opened. In other embodiments, the sectioning element  16  may be a soft elastomer such as silicone that may be sufficiently soft and large enough in diameter so that the sectioning element  16  does not place excessive force onto the capsular bag  6 . In still other embodiments, the sectioning element  16  may be sufficiently blunt along certain portions and edges such that the force applied to the capsular bag  6  is distributed over a larger area and therefore the tearing pressure may be reduced. In still other embodiments, the sectioning element  16  may be comprised of a linkage of multiple elements, for example a chain-like structure, allowing for flexible movement between the multiple elements. In still other embodiments, the sectioning element  16  may have slits along portions of its length that locally may increase its flexibility. For example, the sectioning element  16  may include a tube with cutouts along its length at areas where the capsular bag  6  may come in contact with the sectioning element  16  such that these areas are more flexible and therefore are less prone to putting excessive force onto the capsular bag  6 . In still other embodiments, portions of the sectioning element  16  in the second, expanded configuration are not predetermined in shape, while other portions of the sectioning element  16  are predetermined in shape. For instance, a portion of the sectioning element  16  anterior to the lens may be fabricated from a shape memory round wire that is shape-set to a predefined shape that aids in guiding the sectioning element  16  into the eye. For example, such a portion can include the tight radius bend  24  of the proximal portion  26 . A portion of the sectioning element  16  posterior to the lens  8  may be fabricated from a different, more-flexible material that more easily conforms to the shape of the eye. In this way, the portion of the sectioning element  16  in the second, expanded configuration that allows for insertion of the sectioning element through the capsulorhexis, including the tight radius bend, are anterior to the lens  8 , and the portion of the sectioning element  16  in the second, expanded configuration that contacts the capsular bag  6  is composed of more-flexible material even less likely to damage the capsular bag  6 . 
     According to some embodiments, additional guide tubes or components may align or direct the path of the sectioning element  16  through the capsulorhexis  10  and/or around the lens  8 . For example, in embodiments where the sectioning element  16  in the second, expanded configuration does not have a predefined shape, a guiding element may exist along areas of the distal portion  28  or proximal portion  26  of the sectioning element  16  to constrain it into a particular shape. A tube may extend from the merging point  22  in the direction of the distal portion  28 , and the tube may concentrically constrain the flexible sectioning element  16  such that it more or less follows a desired path during insertion into the capsular bag  6  and placement around the lens  8 . The guiding tube may then be retracted, leaving the flexible sectioning element  16  in place around the lens  8 . 
     In still other embodiments, the predefined shape of the sectioning element  16  in the second, expanded configuration may be created during any part of the surgical procedure. For example, the surgeon may use imaging techniques to measure anatomical features of the eye such as the lens  8  or capsular bag  6 . The surgeon may then use this information to or change a shape of the sectioning element  16 . Alternatively, a piece of equipment such as a forming die or an automated wire forming machined may be used in conjunction with the measured data to change the shape of the sectioning element  16  in the second, expanded configuration. In one embodiment, the surgeon uses an imaging modality such as OCT to perform a measurement of the lens  8 , and then this information is provided to an automated wire forming station that creates a custom sectioning element  16  for the patient. In still other embodiments, the surgeon may add or change a shape of the sectioning element  16  while at least a portion of the sectioning element  16  is within the eye. For example, the surgeon may begin to place the sectioning element  16  into the capsular bag  6  and determine that its shape may be improved. The surgeon may then insert a separate tool such as forceps into the eye or use an integrated tool associated with the shaft  12  to add or change a shape of the sectioning element  16 . 
     According to some embodiments, a fluid is introduced between the capsular bag  6  after the capsulorhexis  10  is made, such that a space is created between the lens  8  and capsular bag  6  in at least some areas. This may be referred to as fluid dissection, hydro dissection or space creation. According to some embodiments, the fluid creates a space for the sectioning element  16  in the second, expanded configuration to be rotated within the capsular bag  6  and surround the lens  8 . In an exemplary embodiment, fluids such as viscoelastic hyaluronic acid or saline may be injected since these materials are commonly used during ocular surgery, well-tolerated within the eye, and readily available. One or more other or additional fluids may be introduced, such as dyed fluids, pharmaceutical liquids like steroids, drug loaded fluids, bio absorbable fluids, lubricants, hydro gels, microspheres, powdered substances, fluorescent contrast, liquid foams, or any other suitable fluid. Additionally, one or more gases additionally or instead may be introduced, such as air, oxygen, argon, nitrogen, or the like. Alternatively, in other embodiments a fluid space may not be required between the lens  8  and the capsular bag  6 , and the sectioning element  16  may perform a mechanical dissection or blunt dissection of the lens  8  and capsular bag  6  as it is rotated about the lens  8 . Fluid dissection and blunt dissection may be done in combination with one another or separately. The fluid may be injected through a cannula or a needle into the capsular bag  6  using a separate instrument. According to other embodiments, provisions for fluid dissection may be incorporated into elements of the surgical device  40 , such as the sectioning element  16 . For example, the sectioning element  16  may be fabricated as a flexible tube with a plurality of holes along its length that allow for the passage of fluid therethrough. In such an embodiment, fluid may be introduced into the lumen of the sectioning element  16  and then flow out of the plurality of holes. This may improve the ability of the sectioning element  16  to pass between the capsular bag  6  and the lens  8  because the fluid may be introduced through the sectioning element  16  continuously or at discrete points in time when dissection is needed. In still other embodiments, the fluid injection may be incorporated in other aspects of the surgical device  40 . For example, fluid may be delivered via the lumen  14  of the shaft  12 . Alternatively, a component separate from the shaft  12 , such as a telescoping tube or other tube, may be connected to the shaft  12  to provide for fluid introduction. In some embodiments, the fluid that is infused through a component of the device, such as the shaft  12  or the sectioning element  16 , may be used for other surgical purposes. For example, fluid may be infused through the shaft  12  to maintain the chamber of the eye  1  without the need for a separate cannula or without the need for a viscoelastic substance. Irrigation and aspiration may be accomplished through a single component or through multiple separate components. For example, fluids such as saline may be irrigated into the eye through a lumen of an embodiment of the sectioning element  16 , as described above, and aspirated through the lumen of the shaft  12 . Other irrigation or aspiration techniques may be performed, according to some embodiments. 
     Referring to  FIG. 5 , the sectioning element  16  has been fully extended to the second, expanded configuration, and has been rotated about the longitudinal axis of the shaft  12  and/or otherwise rotated or moved to an orientation within the capsular bag  6  in which the sectioning element  16  surrounds the lens  8  without exerting excessive force onto the capsular bag  6 . The sectioning element  16  is then used to cut the lens  8  by tensioning one or both ends  18 ,  20  of the sectioning element  16 , such as by retracting one or both ends  18 ,  20  through the lumen  14  of the shaft  12 . The sectioning element  16  may be moved in the opposite manner as set forth above for expanding the sectioning element  16  from the first to the second configuration, in order to compress and cut the lens  8 . As the sectioning element  16  is tensioned, it exerts an inward force on the lens  8  and begins cutting and/or fragmenting it due to the force applied to the lens  8  across the small surface area of the thin diameter sectioning element  16 . The sectioning element  16  continues to be tensioned until the lens  8  is partially or fully sectioned. In some embodiments the sectioning element  16  is tensioned until the lens  8  is fully sectioned. In other embodiments, tensioning of the sectioning element  16  only partially fragments the lens  8 , and the remainder of the lens  8  can be fragmented by repeating the use of the sectioning element, or with additional tools. Referring to  FIG. 6 , the fragmented lens  8  is shown within the capsular bag  6 . The section plane is primarily vertical, but it should be appreciated that any number of angles and orientations may exist for the cutting path of the sectioning element  16 . Referring to  FIG. 7 , the lens is shown with the capsular bag removed. 
     In some embodiments, the surgical device  40  may incorporate multiple sectioning elements  16 , as described below, to create multiple lens fragments at one time. For example, the multiple sectioning elements  16  may form a mesh that is capable of cutting the lens  8  into a multitude of fragments; the sectioning elements  16  may be at oblique or acute angles relative to one another such that they form a crisscross pattern. In other embodiments, the surgical device  40  may be used successively on the lens  8 . For example, after a single section is created the lens  8  (or the sectioning element  16 ) can be rotated 90 degrees such that the first section plane is now perpendicular to the delivery device plane. The sectioning element  16  can then be reinserted into the capsular bag  6  as described above, and used to create a new section across the two lens fragments that creates four fragments in total. The process may be repeated for as many times as necessary to create any number of lens fragments of any desired size. The final desired size of the lens fragments may depend on method of extraction from the eye  1 . In some embodiments, phacoemulsification additionally may be used in the capsular bag  6  to remove the lens fragments. This may be particularly useful in difficult or hard cataracts, where full lens fragmentation increases the surface area and decreases the size of fragments that are to be emulsified by phacoemulsification. In other embodiments, the lens fragments may be extracted as described below. 
     In some embodiments, the lens fragments may be pushed out of the capsular bag  6  by introducing fluid into the capsular bag  6  under slight pressure. The fluid flow and/or pressure may move the lens fragments into the anterior chamber of the eye  1 , such that other tools and methods for extracting the lens may be utilized. For example, forceps or grasping tools may be used to grab the lens fragments and pull them out of the eye  1  through the corneal incision  4 . In some embodiments, the sectioning element  16  may be used to snare the lens fragments and pull them out of the eye  1 . The sectioning element  16  may be returned to the second, expanded configuration and placed around a lens fragment. The sectioning element  16  may then be tensioned or otherwise closed until the lens  8  is held within of the sectioning element but the lens fragment is not cut. The lens fragment can then be pulled out of the eye  1  with the sectioning element  16 . To ensure that the lens  8  is not cut by the sectioning element  16 , additional components may be used such as pads, straps, or strips with a larger surface area that grip the lens fragment rather than cutting it. These components can be extended from the shaft  12 , or may be separate components that are inserted into the eye  1  through the incision  4  and attached to the sectioning element  16 . 
     Referring to  FIGS. 8-9 , one embodiment of the surgical device  40  includes two sectioning elements  16  extending from the distal end of a shaft  12 , with a handle mechanism  42  attached to the proximal end of the shaft  12 . Referring also to  FIG. 15 , two sectioning elements  16  are shown in the first, retracted configuration at the distal end of the shaft  12 . The handle  42  has two sliders  44   a ,  44   b  slideable longitudinally, which are connected to the two sectioning elements  16  as described below. The sliders  44   a ,  44   b  in this initial configuration are in their retracted proximal location. The shaft  12  and sectioning elements  16  in the first, retracted configuration are inserted through an incision  4  in the cornea  2  toward a capsulorhexis  10 , as described above. As used in this document, the term “handle” includes both handles configured for manual gripping and actuation by a surgeon, as well as a robotic handle that is coupled to a surgical robot and configured for robotic control and actuation. 
     Referring also to  FIGS. 16-17 , one embodiment of a handle  42  of the surgical device  40  is shown in cutaway in a configuration corresponding to the first, retracted configuration of the sectioning elements  16 . A slider  44  is slideable along the top surface of the handle  42 . A finger  48  extends from the slider  44  into the handle  42  through a slot in the top surface of the handle  42 . The finger  48  is coupled to a helical cam  50  or other cam structure, located proximal to the finger  48 , that is longitudinally fixed to the finger  48  but that is free to rotate axially relative to the finger  48 . This may be accomplished mechanically through an engagement pin, collar, or other suitable mechanism. A cam path  52  is defined in the surface of the helical cam  50 . The helical cam  50  is confined within a chamber inside the handle  42  that allows the helical cam  50  to slide longitudinally but not move substantially radially. A nose  56  extends distally from the finger  48  and is rotatable relative to the finger  48 . Advantageously the nose  56  is rotationally fixed to the helical cam  50 . In some embodiments, the nose  56  is simply the distal end of the helical cam  50 . A retraction spring  58  is positioned between the finger  48  and the front passage  60  out of the handle  42 , acting to push the finger  48  toward the first, retracted configuration. The proximal end of the retraction spring  58  may be centered on and engage the nose  56 . The proximal end of the first end  18  of the sectioning element  16  may be fixed to the nose  56  in any suitable manner, such as by wrapping around the nose, friction fitting, welding, soldering, or by pressure fitting. Alternately, the proximal end of the first end  18  may be fixed to the finger  48 . A cam post  62  is defined in and/or fixed relative to the handle  42 , and engages the cam path  52 . As the helical cam  50  translates relative to a remainder of the handle  42 , the cam post  62  remains in the same place on the handle  42 . Where two sectioning elements  16  are used, two such assemblies as described above (the slider  44 , finger  48 , cam  50 , nose  56 , retraction spring  58  and connection to the first end  18  of the sectioning element  16 ) are utilized side-by-side within the handle  42 . Such assemblies may be identical to one another, may be lateral mirror-images of one another, or may vary from one another in other ways that allow substantially the same assembly to operate two separate sectioning elements  16  in the manner described below. The description of the motion of the sliders  44   a ,  44   b  and the sectioning elements  16  are the same for both sliders  44  and sectioning elements  16  unless otherwise noted, and the descriptions of the two are interchangeable unless otherwise noted. 
     Referring to  FIG. 10 , one of the sectioning elements  16  is transitioned to the second, expanded configuration by sliding the corresponding slider  44   b  distally. One end  20  of the sectioning element  16  may be connected to the shaft  12 , handle  42 , or other structure fixed relative to the handle  42 , and maintained in a fixed position while the first end  18  is configured to translate and rotate with the moving elements within the handle  42 . As set forth above, the first end  18  is attached to the nose  56 . Referring also to  FIG. 18 , as the slider  44  translates distally, the finger  48  compresses the retraction spring  58 , moves the nose  56  distally, and pulls the helical cam  50  distally. The retraction spring  58  is compressed and imparts a proximal force on the finger  48 . If the user releases the slider  44 , the slider  44 , finger  48 , and mechanisms translationally fixed to the finger  48  are pushed distally toward the initial position of the slider  44 . As the slider  44  advances distally, the helical cam  50  translates within the handle  42 . The cam path  52  may be substantially longitudinal during this first segment of motion of the slider  44 , such that engagement between the cam path  52  and cam post  62  does not cause rotation of the helical cam  50 . Therefore, the sectioning element  16  remains in substantially the same rotational orientation relative to the longitudinal axis of the shaft  12 . As the slider  44  advances distally, it pushes the first end  18  of the sectioning element  16  distally. As a result, the sectioning element  16  changes shape to the second, expanded configuration, in the same manner as described above with regard to  FIGS. 1-4 . 
     Referring also to  FIG. 11 , the slider  44  may be further advanced distally after the sectioning element  16  changes shape to the second, expanded configuration. The cam path  52  engages the cam post  62  to rotate the helical cam  50 , as seen in  FIGS. 18-20 . The amount of distal motion of the slider  44  controls the amount of rotation of the helical cam  50 . In this way, linear motion of the slider  44  is converted to rotary motion of the sectioning element  16 . Because the helical cam  50  and the nose  56  are rotationally fixed to one another, rotation of the helical cam  50  causes rotation of the nose  56 , and thus rotation of the sectioning element  16  in the second, expanded configuration. The sectioning element  16  rotates, and the plane defined by the shape of the sectioning element  16  correspondingly rotates. The sectioning element  16  is rotated from its initial position, which may be substantially parallel to a plane defined by the edges of the capsulorhexis  10 , to a position that is approximately within 0-40 degrees from a vertical orientation. During this rotation, the sectioning element  16  moves between the capsular bag  6  and the lens  8 , capturing the lens  8  in the open area  46  within the perimeter of the sectioning element  16 . The sectioning element  16  may not engage the capsular bag  6  and/or lens  8  substantially, or may be configured to engage either the lens  8  or the capsular bag  6 . Alternately, the sectioning element  16  may cause a blunt dissection between the capsular bag  6  and the lens  8 . 
     Referring also to  FIG. 20 , the slider  44  is moved fully forward and the rotation of the helical cam  50  and sectioning element  16  is complete. The sectioning element  16  surrounds the lens  8  within the capsular bag  6 , and is configured to apply an inward cutting force relative to the lens  8 , in the manner described above with regard to  FIGS. 4-5 . 
     Referring also to  FIGS. 12-13 , a second sectioning element  16  then may be deployed to a second, expanded configuration, and rotated into position to surround the lens  8 , in the same manner as described above with regard to  FIGS. 9-11 and 16-20 . Referring also to  FIG. 14 , both sectioning elements  16  engage the lens  8 , such that when the sectioning elements  16  are tensioned or otherwise closed, the sectioning elements  16  will cut the lens  8  into three partially- or fully-separate fragments. Referring also to  FIG. 21 , the tensioning may be provided by sliding the sliders  44  proximally, thereby pulling the first end  18  of each sectioning element  16  proximally and tensioning it. In some embodiments, the proximal force exerted on the finger  48  by the retraction spring  58  may be sufficiently large to cut the lens  8  without the application of additional force by the user. In other embodiments, the user provides additional force that fragments the lens  8 . This may be necessary especially for hard or difficult cataracts. Each sectioning element  16  engages the posterior surface of the lens  8  along a line spaced apart from the other sectioning element  16 , and engages the anterior surface of the lens  8  along substantially the same line, according to some embodiments. 
     In  FIG. 22 , the slider  44  is moved proximally to return to the original position. The sectioning element  16  is rotated back to its original plane of insertion, and then retracted toward the shaft  12 . Referring also to  FIG. 15 , the sectioning elements  16  may return substantially to their initial configuration after sectioning the lens. The cam path  52  of the helical cam  50  may be a closed loop as shown. Alternately, the cam path  52  may be a one-way path wherein the slider  44  must be translated fully distally and then proximally to move it to the original position. In some embodiments, one-way latches or levers may be incorporated into the cam path  52  that prevent the helical cam  50  from rotating or moving in certain directions, and may be included at discrete positions of the cam path  52  or along the entire cam path  52 . 
     According to some embodiments, the sectioning elements  16  may be configured to move synchronously with the actuation of a single slider  44 , rather than each sectioning element  16  being coupled to a different slider  44   a ,  44   b  as described above. If so, the sectioning elements  16  may be configured to expand, open and/or rotate at the same time. Alternately, the rotation of the sectioning elements  16  may be staggered such that one sectioning element  16  opens first and rotates first before the other sectioning element  16 . This may be accomplished by associating a different cam path  52  and cam post  62  with each sectioning element  16 . In still other embodiments, two sliders  44   a ,  44   b  can be configured such that a left slider  44   b  will move both sliders  44  forward, but the right slider  44   a  will only move the right slider  44   a  forward (or vice versa). The right slider  44   a  may be configured to move both sliders  44   a ,  44   b  backward and the left slider to move only the left slider  44   b  backward. Thus, the user may decide whether to move the sliders  44   a ,  44   b  independently or synchronously. 
     According to some elements, the sectioning elements  16  are rotated in the same direction. For example, the first sectioning element  16  opens and is then rotated into the capsular bag  6  in a clockwise direction. The second sectioning element then opens and is also rotated into the capsular bag  6  in a clockwise direction. In this embodiment, the first sectioning element  16  may rotate to an angle 10-40 degree beyond a vertical plane, and the second sectioning element  16  may rotate to an angle 10-40 degree less than a vertical plane. 
     In still other embodiments, one or more additional or different mechanisms may be used to deploy the sectioning elements  16 . For example, a scroll wheel advancing mechanism or other rotating mechanism could be used to deploy one or both sectioning elements  16 . In some embodiments, the movement by the user is geared up or down to the movement of the sectioning element  16  such that moving a given amount of the user interface components moves the sectioning element  16  a greater or lesser amount through the use of gears, scaled pulleys or any other number of components. In some embodiments, certain parts of the surgical device  40  may be mechanically powered through components such as motors, linear motors, pneumatics, hydraulics, magnets, or the like. The surgical device  40  may be incorporated as a part of one or more larger robotic assemblies. For example, a robotic device that is configured to perform a cataract procedure may include an embodiment of the surgical device  40 . This may allow surgeons to perform parts of the described method robotically. In some embodiments this may allow for alternate techniques and methods such as approaching the capsular bag  4  through the sclera. According to some embodiments, at least inserting a shaft  12  having a lumen  14  therethrough, through the corneal incision  4  toward the capsulorhexis  10 , and extending a sectioning element  16  out of the distal end of the lumen  14 , to cause the sectioning element  16  to bend away from the axis of the shaft  12  through the capsulorhexis  10 , expand to a size greater than the capsulorhexis  10 , and capture at least a part of the lens  8 , are performed under robotic control. 
     In some embodiments, the sectioning element  16  need not approximate a loop initially as it is placed into the capsular bag  6 . For example, the sectioning element  16  may be a single piece of round wire that is fed into the capsular bag  6  from the shaft  12 , without doubling back on itself to form a loop. In such an embodiment, the distal tip of the sectioning element  16  is blunt to prevent puncture or damage to tissue within the eye  1 . As the distal tip of the sectioning element  16  reaches the wall of the capsular bag  6 , it may be configured to bend with either a predefined bend in its structure, or by tracking along the inner surface of the capsular bag  6 . The sectioning element  16  may then traverse a space between the lens  8  and the capsular bag  6  such that it goes around a circumference of the lens  8 . The sectioning element  16  may then come back into the view of the user into the top portion of the capsular bag  6  where the user can grab the sectioning element  16  with features on the handle  42  such as grippers, or with a separate tool entirely. At this point, the sectioning element  16  surrounds the lens  8  within the capsular bag  6  and approximates a loop. As one or both ends of the sectioning element  16  are tensioned and/or pulled, an inward cutting force is applied to the lens  8  such that it is fragmented. The sectioning element  16  of this embodiment may have a cross-section that allows it to bend preferentially in certain directions more easily than others, such that the sectioning element  16  can bend as necessary to track around the lens  8  but still follow a suitable path around the lens  8  without going off track into tissue. This may include the use of a preferred bending moment cross-section like an “I” beam that bends preferentially about certain planes. Alternatively, a tube with cutouts to allow bending may be configured to bend in certain planes by placing the cuts in this plane. Therefore, the sectioning element  16  may bend around the lens  8 , primarily in a distal-to-proximal manner. This may improve the ability of the sectioning element  16  to traverse a desired general path relative to capsular bag  6  and lens  8 . In some embodiments, the sectioning element  16  may be entirely flexible such that its distal tip is unconstrained to travel in any predefined path. The distal tip may be configured to include a magnet or electromagnetic components to which a force can be applied to with an external electromagnetic field. An external device may then be used to control the location of the distal tip of the sectioning element  16  such that it may be guided around the capsular bag  6  along a desired path. Any number of different paths or fragmentation planes may be contemplated with this embodiment. The surgical device  40  may incorporate various imaging modalities in order to create a desired path for the distal tip of the sectioning element  16  that does not damage the capsular bag  6 . 
     In some embodiments, the sectioning element  16  may bifurcate into multiple portions and/or multiple loops. For example, in the initial configuration, the sectioning element  16  may have a shape and profile as described above. However, when transitioned to the second, expanded configuration, the sectioning element  16  may bifurcate along its length into two elements that may have the same or similar shapes, or different shapes, each surrounding the lens  8  in whole or in part. This may allow the sectioning element  16  to cut the lens  8  into multiple fragments without using two separate sectioning elements  16 . 
     In some embodiments, one or both of the sectioning elements  16  may be configured to apply one or more types of energy to aid in the blunt dissection or fragmentation of the lens  8 . For example, one or both of the sectioning elements  16  may include one or more portions configured to be heated through the use of electrically resistive wire that becomes hot as current is run through it. The increased temperature may improve the separation of the capsular bag  6  and the lens  8  as well as aid in sectioning the lens  8 . Alternatively, any number of other modalities may be used such as radio frequency ablation, electric cautery, ultrasonic vibratory energy, or the like. 
     Ultraviolet (UV) energy can kill cells that can contribute to secondary opacification of the capsule after primary cataract surgery. Treating the capsule with UV energy while the lens is being separated and sectioned from the lens capsule can reduce the rate of incident secondary opacification. UV energy can be applied via one or more sectioning elements  16  of the device. In some implementations, the sectioning element  16  can be a non-metal filament that can be used to transmit UV light through the sectioning element  16 . For example, the sectioning element  16  can be formed of a transparent, flexible polymer or other material that can transmit the UV light therethrough. Thus, the sectioning element  16  can act as a sort of light pipe to transmit the UV energy during capture and sectioning of the lens  8 . In other implementations, the sectioning elements  16  can be formed of metal such as Nitinol wire and be sheathed in a transparent polymer material that can be used as a light pipe to allow the UV energy to be transmitted through the sheathe to treat the capsule. 
     In some embodiments, the handle  42  may incorporate fluid delivery features. For example, as described above, the sectioning element  16  or the shaft  12  may allow the injection of fluids through the respective components. The handle  42  may include fluid passageways and paths that connect these components to external fluid sources through tubes, integrated connectors, or the like. Alternatively, the handle  42  may include internal pressure injection systems that push fluid through the shaft  12 . The fluid may be stored in a cylinder with a piston wherein the piston is pressed forward by actuation components in the handle  42 . For example, a separate slider or button may be connected to the piston and arranged such that as the slider is moved by the user, the piston is translated and expels a fluid from the cylinder into the injection system. This may allow the user to control the delivery of fluid through the sectioning element  16 , the shaft  12 , or any other handle  42  component at certain times during the procedure such as creating space between the capsular bag  6  and the lens  8 . Alternatively, the surgical device  40  may be configured such that the fluid is injected automatically by the surgical device  40  during certain periods within the normal actuation of the device. For example, a spring may be configured to place a force on the piston such that as the helical cam  50  moves through its path, the piston is configured to expel an amount of fluid. 
     Referring to  FIG. 23 , an alternate embodiment of sectioning elements  16  is shown as a side view. Two sectioning elements  16  extend from the distal end of the shaft  12 . In this embodiment, the sectioning elements  16  are arranged to loop around the lens  8  starting at the distal end  8   a  of the lens  8 , rather than around the sides of the lens  8  as described above. The sectioning elements  16  may be extended one at a time from the distal end of the shaft  12  distally toward the distal end  8   a  of the lens  8  and into the capsular bag. The sectioning element  16  may approximate a loop of wire that is configured to have a predefined shape and curves to allow it go around the lens  8  without placing excessive force on the capsular bag. This may include side-to-side bends as wells as forward-and-back curves that form various three-dimensional geometries as the sectioning element  16  is extended from the delivery device. In order to enter the capsular bag and capture the lens  8 , the sectioning elements  16  are configured to be shaped differently as they expand. Rather than being planar, these sectioning elements  16  are curved downward from the shaft  12  in the second configuration, as seen in  FIG. 23 . Where multiple sectioning elements  16  are used, each may be configured to curve to a different degree than the other or others. One end of the sectioning element  16  may be extended while the other remains relatively fixed to the delivery device, or both ends may be extended at the same time, as described above. As described above, the sectioning element may have various profiles, materials, or flexibilities along its length. 
     One of the sectioning elements  16  may be extended to traverse the space between the capsular bag and the lens  8 , and then may be moved downward and proximally around the lens  8 . A second sectioning element  16  may be extended as shown, and any number of other sectioning elements  16  may be used. In some embodiments, a forward extending sectioning element  16  may be used in conjunction with a side extending sectioning element  16  as described above, in order to create intersecting fragmentation planes such that two sectioning elements  16  can slice the lens into 4 discrete pieces. Furthermore, the fragmentation planes can be at any number of angles to each other, and the sectioning elements  16  can extend around the lens  8  from any number of directions such as a combination of the forward extending and side extending embodiments. 
       FIGS. 24A-24E ,  FIGS. 25A-25C ,  FIGS. 26A-26N ,  FIGS. 27A-27C ,  FIGS. 28A-28B ,  FIGS. 29A-29B ,  FIGS. 30A-30E ,  FIGS. 31A-31F  illustrate interrelated implementations of a device  2440  for fragmentation of a lens  8  within the capsular bag  6  and for removal of the lenticular tissue from the eye  1 . The same or similar reference numbers may refer to the same or similar structures. Aspects described with respect to the same or similar structures may be equally applicable to the structures described elsewhere herein. Features, aspects, and methods of using each of the devices and methods described herein may be equally applicable to the implementations of devices and methods described below. 
     As with other implementations described elsewhere herein and as shown in  FIGS. 24A-24E , the device  2440  can include a housing  2442  having a nose cone  2443 . A distal shaft  2412  can extend from the housing  2442  along a longitudinal axis of the device, the shaft  2412  having a lumen and a distal end. The device can include a cutting element  2416  movable through the lumen of the shaft  2412 . The cutting element and the shaft  2412  are configured to be inserted through an incision  4  in the cornea  2 . For example, the distal shaft  2412  can have an outer diameter sized to extend through a self-sealing incision in a cornea  2 . The shaft  2412  can have an outer diameter configured to insert within the anterior chamber that is between about 0.5 mm and about 2.5 mm. In some implementations, the shaft  2412  may have a uniform outer diameter along its length from the nose cone  2443  to the distal tip of the shaft  2412 . The outer diameter of the shaft  2412  may also have a non-uniform outer diameter along its length. For example, in some implementations, the shaft  2412  may taper towards the distal outlet  2405  such that the outer diameter near the distal tip is smaller than an outer diameter near the nose cone  2443 . In still further implementations, the shaft  2412  may have a beveled edge near the distal outlet  2405 . A bellows  2445  (see  FIG. 24E ) can be coupled to a forward-facing, distal end of the housing  2442 . The bellows  2445  can be cylindrical in shape and surround a proximal end of the distal shaft  2412  extending through nose cone  2443 . The bellows  2445  can be a relatively soft element. A distal end of the bellows  2445  is configured to engage and seal with an outer surface of the eye surrounding the incision  4  upon insertion of the shaft  2412  through the incision  4 . The bellows  2445  can provide a visual indication of depth of penetration. The shaft  2412  has reached a proper depth of penetration once the distal end of the bellows  2445  contacts an outer surface of the eye. The bellows  2445  can thereby additionally prevent over-insertion of the shaft  2412  in the eye beyond a certain desirable depth. In some implementations, a plurality of grooves  2447  can be formed in an outer surface of the bellows  2445  giving it a ringed appearance. The grooves  2447  allow for the bellows  2445  to compress along a longitudinal axis upon application of a force and to expand along the longitudinal axis to be longer upon release of the force. 
     The cutting element of the device  2440  includes one or more sectioning elements  2416  moveably extendable through a lumen of the distal shaft  2412 . Each sectioning element  2416  can include a first end, a second end, and a distal loop formed between the first and second ends, as will be described in more detail below. At least a portion of each of the sectioning elements  2416  can be housed within corresponding one or more secondary tubular elements or sheathes or sleeves  2415  (see  FIG. 24E or 26A ) that are, in turn, housed within the lumen of the distal shaft  2412 . The cutting element is configured to transition from a first, retracted configuration towards a second, expanded configuration upon activation of an actuator on the device  2440 . When in the second, expanded configuration, the distal loop of each of the sectioning elements defines an enlarged open area. The enlarged open areas may be located outside the distal end of the shaft  2412  and have a first leg advanced distally relative to the distal end of the shaft and a second leg positioned proximally to the distal end of the shaft. The distal loops defining the enlarged open areas of each of the sectioning elements  2416  can be aligned generally parallel to one another within a plane (such as a vertical plane) when the cutting element is in the second, expanded configuration. A second activation of the actuator or a second, different actuator may cause the distal loops defining the enlarged open areas of at least one or more of the sectioning elements to move angularly relative to the plane thereby transitioning the cutting element into a third, splayed configuration. The second activation of the actuator or a second, different actuator may cause the distal loops of the enlarged open areas of each sectioning element to move angularly away from one another, for example, two sectioning elements moving angularly away from each other, thereby transitioning the cutting element into the third, splayed configuration. 
     The sectioning elements  2416  are configured to be deployed within the eye such that loops or open areas are enlarged at a distal end of the sectioning elements  2416  that are sized to surround at least a portion of a lens  8  positioned within a capsular bag  6 . The open areas defined by the distal loops of the sectioning elements  2416  are configured to expand from the first, retracted configuration for insertion ( FIG. 24A ) to the second, expanded configuration ( FIG. 24B ) and to the third, splayed configuration ( FIG. 24C ). When moved from the collapsed position ( FIG. 24A ) toward the unbiased shape of the expanded position ( FIG. 24B ), each of the one or more sectioning elements  2416  can form a distal loop having an unbiased (unconstrained) shape that bounds an open area  2446  defined in an orientation that maximizes the open area  2446 . It should be appreciated that use of the term “loop” when referring to the cutting end of the unbiased, unconstrained shape of the sectioning elements  2416  does not limit the open area  2446  to having a particular shape, such as a circle. The shape of the loop can be oval, elliptical, or another irregular, non-geometrical shape. The loop also need not be fully closed. 
     The devices are described as useful for cutting a whole lens within the capsular bag, but may be used for other purposes without departing from various aspects of the device and methods described. The sectioning elements described herein may be positioned and extended between the capsular bag and the anterior side of the lens due to natural expansion of the loops toward the expanded shape. When cutting the lens, the loops may extend around the posterior and anterior surfaces to form a full cut of the lens. The loops may also be moved between the posterior surface of the lens and the capsular bag to dissect the lens from the capsular bag before cutting the lens into fragments. The devices described herein are particularly useful in advancing atraumatically between the bag and lens while the lens is still whole. 
     In an implementation, the sectioning element  2416  can include three sectioning elements  2416   a ,  2416   b ,  2416   c  in which an intermediate loop or sectioning element  2416   b  is positioned generally between the first and second sectioning elements  2416   a ,  2416   c  (see  FIG. 24D ). The intermediate sectioning element can likewise include a first end, a second, end, and a distal loop formed between the first and second ends. When the cutting element is transitioned towards the second, expanded configuration, the distal loop of the intermediate sectioning element may define an enlarged open area located outside the distal end of the shaft  2412 . The enlarged open area may have a first leg advanced distally relative to the distal end of the shaft and a second leg positioned proximally to the distal end of the shaft. In this implementation, the sectioning elements  2416   a ,  2416   b ,  2416   c  are configured to expand from the first, retracted configuration ( FIG. 24A ) to the second, expanded configuration ( FIG. 24B ) and to the third, splayed configuration ( FIG. 24C ). The enlarged open areas of each of the first, second, and intermediate sectioning elements may be aligned generally parallel to one another within a plane when in the second, expanded configuration. In the third, splayed configuration the outer two sectioning elements  2416   a ,  2416   c  can be moved angularly away from the intermediate sectioning element  2416   b . A second activation of an actuator or a second, different actuator may cause the enlarged open areas of both the first and second sectioning elements to move angularly away from the intermediate sectioning element transitioning the cutting element into a third, splayed configuration. The sectioning elements  2416   a ,  2416   b ,  2416   c  can be actuated to move from the collapsed position toward the unbiased shape of the expanded position, for example via a slider  2444  or other actuation mechanism positioned on the housing  2442 . The sectioning elements  2416   a ,  2416   b ,  2416   c  can also be actuated to move toward the third, splayed configuration via the slider  2444  and/or another actuation mechanism positioned on the housing  2442 . As will be described in more detail below, the device  2440  can include a two-phase deployment in which expansion of the loops to the second, expanded configuration can be performed independently of the splay in the third, splayed configuration. 
     As described elsewhere herein, the sectioning elements  2416  can be formed of a superelastic metal and/or polymer material. The housing  2442  of the device  2440  can be formed of a relatively rigid, lightweight material(s). The shaft  2412  coupled to a distal end region of the housing  2442  can have a lumen extending through it to a distal outlet  2405 . The shaft  2412  can be oval in cross-section with a rounded tip. The oval cross-section enhances the ability of the shaft  2412  to be inserted into the eye  1  through the corneal incision  4 . The oval cross-section also allows for a side-by-side arrangement of the plurality of sectioning elements  2416   a ,  2416   b ,  2416   c  within the lumen. Alternately, the shaft  2412  may have a circular cross-section or a cross-section of any other suitable shape. 
     The distal end of the sectioning elements  2416  can extend out of the outlet  2405  from the lumen when in the first, retracted configuration (see  FIG. 24A ). In such embodiments, the tight radius bend  2424  may be positioned outside the shaft  2412 , already bent at least partially toward the proximal direction (see  FIG. 24B ). In this way, even in implementations where the sectioning element  2416  is fabricated from superelastic material, the angle through which a portion of the sectioning element  2416  is bent during transition from the first, retracted configuration to the second, expanded configuration is reduced. Further, less space may be required within the lumen of the shaft  2412  to hold part of the sectioning element  2416  than to hold all of it, allowing the shaft  2412  to be made smaller in diameter. Alternately, the entirety of the sectioning elements  2416  can be positioned within the lumen of the shaft  2412  when in the first, retracted configuration. The distal end of the sectioning element  2416 , whether inside or outside the lumen in the first, retracted configuration, is sized and shaped to pass through a clear corneal incision  4  without damaging the eye  1 . Generally, clear corneal incisions  4  are less than about 3.5 mm, although this size can vary. The maximum outer diameter of the distal end region of the shaft  2412  including the sectioning elements  2416  in the first, retracted configuration can be less than about 3.5 mm such that they may be inserted through a clear corneal incision, for example, between about 1.5 mm and 3.5 mm. 
     As described elsewhere herein and as shown in  FIG. 26A , each of the sectioning elements  2416  can include a first end  2418  and a second end  2420 , at least one of which is moveable relative to the shaft  2412 . For example, one end (e.g. the first end  2418 ) of the sectioning elements  2416  may be fixed relative to the shaft  2412  and another end (e.g. the second end  2420 ) of the sectioning elements  2416  may be movable relative to the shaft  2412 . When the movable end is pushed distally (i.e. axially along the longitudinal axis of the device), the sectioning elements  2416  translate from the first, retracted configuration toward the second, expanded configuration. When the movable end is withdrawn proximally, if allowed, the sectioning elements  2416  translate from the second, expanded configuration toward the first, retracted configuration. It should be appreciated that both ends  2418 ,  2420  can be movable relative to the shaft  2412  as described elsewhere herein and as will be described in more detail below. Use of the terms “first,” “second,” or “third” are not intended to be limiting and may be interchangeable herein, except where explicitly described as otherwise. 
     The sectioning elements  2416  upon extension out of the lumen of the shaft  2412  can have a distal end region or a distal loop that approximates or defines an open area generally in the shape of an irregular loop having a cross-section of a native lens  8 . This allows the enlarged open area  2446  of the sectioning elements  2416  to surround the lens  8  within the capsular bag  6 . As the end or ends  2418 ,  2420  are pushed distally out from the lumen, the sectioning elements  2416  transition to the second, expanded configuration. As the sectioning elements  2416  transition out of the shaft  2412 , the tight radius bend  2424  allows the proximal section of the sectioning elements  2416  to extend proximally from the distal end of the shaft  2412 , at a location spaced from and to one side of the longitudinal centerline of the lumen  2412  (i.e. longitudinal axis A of the device  2440 ) in the direction toward the capsular bag  6 . In this way, the sectioning elements  2416  are able to extend downward through the capsulorhexis  10  and expand to a length within the capsular bag  6  that is greater than the diameter of the capsulorhexis  10 . For example, the sectioning elements  2416  can be movable relative to the shaft  2412  from the first, retracted configuration toward a second, expanded configuration in which the larger portion of each sectioning element  2416  extends out of the distal end of the lumen  2450 . At least a portion of the sectioning elements  2416  are positioned within the lumen when in the first, retracted configuration. It should be appreciated that some of the sectioning elements  2416  can extend outside the lumen, but that the sectioning elements  2416  and the shaft  2412  are still sized for insertion into an anterior chamber of an eye through a small corneal incision (e.g. a clear corneal incision). Motion from the first, retracted configuration toward the second, expanded configuration can cause at least one of the ends  2418 ,  2420  to advance distally relative to the distal end of the shaft  2412  to form the open area  2446 , the open areas  2446  bounded by their respective sectioning elements  2416  and the distal end  2405  of the shaft  2412 . At least a portion of the sectioning elements  2416  bounding the open area  2446  extends proximally relative to the distal end  2405  of the shaft  2412 . The second, expanded configuration of the sectioning elements  2416  is sized and shaped to permit advancement of the sectioning elements  2416  between the capsular bag  6  and the lens  8  of the eye while the lens remains in the capsular bag  6  to capture a portion of the lens  8  within the open area  2446 . As the sectioning elements  2416  continue to expand, the plane formed by the sectioning elements  2416  can be rotated so that the sectioning elements traverse a space between the capsular bag  6  and the lens  8 . The shape plane can be rotated to be primarily vertical or to any number of other angles relative to vertical. The rotation may be accomplished by manual rotation of the shaft  2412  of surgical device  2440  by the user. The rotation may be accomplished by integrated mechanisms within the surgical device  2440 , as described elsewhere herein. 
     As mentioned above, the device  2440  includes an actuator to tension the sectioning elements  2416  to reduce the size of the open areas  2446  and cut the lens  8 . The actuator can be a slider  2444  movable relative to the housing  2442  such as along the longitudinal axis of the housing. The slider  2444  can be slideable along the top surface of the housing  2442 . It should be appreciated that use of the term “slider” is not intended to be limiting and other configurations of actuator are considered here. For example, the actuation mechanism can be a button, switch, knob, or other interface element. As best shown in  FIG. 26A-26C , the slider  2444  can be operatively coupled to a sled  2472  located within an interior of the housing  2442  via one or more fingers  2448  that extend upwards through a slot  2474  in the top surface of the housing  2442 . The finger(s)  2448  can couple to an undersurface of the slider  2444 . The slider  2444  and sled  2472  are movable within the interior of the housing  2442  along the longitudinal axis A of the housing  2442 . As shown in  FIG. 26A , a plurality of loop carriers  2476  can be coupled to the sled  2472  having an arm  2482  and a proximal post  2478 . The arm  2482  can extend outward from the proximal post  2478 . The proximal post  2478  can be generally cylindrical and configured to be received through a corresponding bore  2480  of the sled  2472  (see  FIG. 26B ) and configured to rotate around its respective axis of rotation within the bore  2480 . 
     As mentioned, the proximal post  2478  is configured to rotate around its respective axis of rotation within its respective bore  2480 . The sled  2472  can be coupled to first and second loop carriers  2476   a ,  2476   c  positioned on either side of the longitudinal axis A of the device  2440  (see  FIG. 26C-26E ). The rotation of the loop carriers  2476   a ,  2476   c  around their respective axes of rotation R 1 , R 2  and thus, the rotational movement of the arms  2482   a ,  2482   c  can be mirror image.  FIG. 26D  illustrates the loop carriers  2476   a ,  2476   c  prior to splay. The arms  2482   a ,  2482   c  of the loop carriers  2476   a ,  2476   c  are positioned in a substantially vertical position such that they are arranged substantially parallel to one another. During splay, the loop carrier  2476   a  positioned on a first side of the longitudinal axis A rotates a first direction around its axis of rotation R 1  (e.g. clockwise) and the loop carrier  2476   c  positioned on the opposite side of the longitudinal axis A rotates a second direction around its axis of rotation R 2  (e.g. counter-clockwise). The arms  2482   a ,  2482   c  splay outward away from the substantially vertical starting position (e.g. orthogonal to the longitudinal axis A) to a substantially non-vertical position. The amount of rotation achieved by each of the arms  2482   a ,  2482   c  can vary, but is generally between about 15 degrees to about 45 degrees relative to the vertical starting position. 
     The rotation of the loop carriers  2476  causes a corresponding rotation in the distal loops defining the enlarged open areas  2446  of the sectioning elements  2416  and thereby transitions the cutting element into the splayed configuration. The splayed configuration of the cutting element can vary. As described throughout, the distal loops defining the enlarged open areas may move angularly away from one another transitioning the cutting element into the splayed configuration, the angular movement being relative to a plane of the longitudinal axis of the device (or the longitudinal axis of the shaft or the longitudinal axis of the lumen through which the cutting element extends). When the cutting element is in an expanded configuration such that the open areas defined by the distal loops are expanded or otherwise enlarged away from their initial insertion configuration (typically referred to herein as a retracted configuration), the distal loops defining the open areas can be arranged generally parallel to one another within a plane, such as a vertical plane, relative to the longitudinal axis of the shaft. It should be appreciated that when the distal loops and their enlarged opening areas are generally aligned with the plane parallel with each other one or more portions of that distal loop may extend outside the plane. Meaning, that the enlarged open areas defined by the distal loops may take on a shape that is not flat (see, e.g., sectioning element  16  shown in  FIG. 2 ), but the enlarged open areas of the sectioning elements may be arranged substantially parallel to one another and substantially within a plane relative to the device when in the second, expanded configuration. It should also be appreciated that the enlarged open areas need not be fully enlarged in order to be splayed relative to one another. Thus, where the second, expanded configuration is referred to herein it need not require the distal loops be expanded to their maximally expanded configuration. The second, expanded configuration can include an enlarged configuration in which the enlarged open areas defined by the distal loops are expanded to less than a maximal expansion before they are splayed relative to one another.  FIG. 24B  shows sectioning elements  2416  having enlarged open areas  2446  that have expanded in generally two directions (i.e. along an X and Y axis) and are not yet splayed such that they are still generally compressed against each other (i.e. along the Z axis).  FIG. 24C  shows the sectioning elements  2416  in the splayed configuration where the one or more of the distal loops defining the enlarged open areas have moved angularly away from one another (e.g. along the Z axis). In some implementations, the cutting element has two sectioning elements and the distal loops defining the enlarged open areas of the two sectioning elements splay apart a distance in the Z axis. One region of the enlarged open area of each distal loop (i.e. a region aligned with the longitudinal axis of the lumen of the shaft  2412 ) can remain generally compressed against a neighboring distal loop while another region of the enlarged open area (i.e. a region below the longitudinal axis of the lumen of the shaft  2412 ) can splay apart from the neighboring distal loop. This region of the loop that rotated and is thus splayed apart can be positioned at an angle relative to a plane of the longitudinal axis of the shaft. The angle can vary, for example, between about 15 degrees relative to the plane up to about 45 degrees relative to the plane. 
     One or more of the sectioning elements  2416  can have a fixed, first end  2418  and a movable, second end  2420 . For example, the movable, second ends  2420  of sectioning elements  2416   a ,  2416   c  are capable of movement along the longitudinal axis A of the device  2440  such that they may be deployed into the second, expanded configuration (see  FIGS. 26B-26C ). The movable, second ends  2420   a ,  2420   c  of the outer two sectioning elements  2416   a ,  2416   c  are additionally capable of angular movement with respect to the longitudinal axis A. The second end  2420   b  of the intermediate sectioning element  2416   b  (shown in  FIG. 24D ) may be fixed such that it does not rotate or move angularly relative to the longitudinal axis A. For example, the fixed, first end  2418   a  of a first sectioning element  2416   a  may be fixed such that it remains stationary during actuation and the movable, second end  2420   a  of the first sectioning element  2416   a  may be configured to be moved relative to the longitudinal axis A of the device  2440  along at least two planes. Similarly, the fixed, first end  2418   c  of a second sectioning element  2416   c  may be fixed such that it remains stationary during actuation and the movable, second end  2420   c  of the second sectioning element  2416   c  may be configured to be moved relative to the longitudinal axis A of the device  2440  along at least two planes. The fixed, first end  2418   b  of the intermediate sectioning element  2416   b  may be fixed such that it remains stationary during actuation and the moveable, second end  2420   b  of the intermediate sectioning element  2416   b  may be configured to be moved relative to the longitudinal axis A of the device  2440 . However, the intermediate sectioning element  2416   b  may be configured to move along a single plane and may not be capable of rotational or angular movement relative to the longitudinal axis A. As such, all three sectioning elements  2416   a ,  2416   b ,  2416   c  can be configured to expand upon actuation of the slider  2444 , for example, by movement of their respective movable, second ends  2420   a ,  2420   b ,  2420   c  along the longitudinal axis A of the device  2440 . The outer two sectioning elements  2416   a ,  2416   c  may have movable, second ends  2420   a ,  2420   c  additionally capable of angular rotation relative to the longitudinal axis A. The movable, second end  2420   b  of the intermediate sectioning element  2416   b  can be fixed such that it does not move. It should be appreciated that the relative splaying movements of the plurality of sectioning elements  2416  can vary and this is an example of how splay may occur. Each of the plurality of sectioning elements  2416  can have an end capable of translation along the longitudinal axis A of the device as well as rotational and/or angular movements relative to the longitudinal axis A. 
     With respect to  FIGS. 26B-26E , the rotational movement of the loop carriers  2476  around their respective axes of rotation R 1 , R 2  provides the rotational angular displacement that causes the outer sectioning elements  2416   a ,  2416   c  to splay apart from the intermediate sectioning element  2416   b . One or more of the sectioning elements may not be shown in the figures for clarity. In an implementation, the fixed, first ends  2418   a ,  2418   b ,  2418   c  of each of the three sectioning elements  2416   a ,  2416   b ,  2416   c  can be coupled to a region of the housing  2442  or other non-moving component of the device  2440 . The movable, second ends  2420   a ,  2420   c  of the outer two sectioning elements  2416   a ,  2416   c  can be coupled to distal-facing surfaces of their respective loop carriers  2476 . For example, a first of the loop carriers  2476   a  can couple to the movable, second end  2420   a  of the first sectioning element  2416   a  and the second of the loop carrier  2476   c  can couple to the movable, second end  2420   c  of the second sectioning element  2416   c  (see  FIG. 26C ). As the loop carriers  2476   a ,  2476   c  rotate around their rotational axes R 1 , R 2 , the ends  2420   a ,  2420   c  translate along with them around the rotational axes R 1 , R 2  towards the third, splayed configuration.  FIG. 26C  illustrates the third, splayed configuration in which the first loop carrier  2476   a  has rotated clockwise (arrow C) such that the arm  2482   a  splays to the left away from vertical and the second loop carrier  2476   c  has rotated counter-clockwise (arrow CC) such that the arm  2482   c  splays to the right away from vertical. The movable ends  2420   a ,  2420   c  of the sectioning elements  2416   a ,  2416   c  travel along with the loop carriers  2476   a ,  2476   c  towards the longitudinal axis A of the device  2440  causing the loops to splay outward away from the longitudinal axis A. The movable, second end  2420   b  of the intermediate sectioning element  2416   b  (not shown in  FIG. 26C ) can be coupled to the sled  2472  such that movements of the loop carriers  2476  do not impact its position relative to the longitudinal axis A. 
     In some implementations, the device  2440  can further include a small diameter, thin-walled sleeve  2415  that is configured to move relative to the longitudinal axis of the device (see  FIG. 24E ). At least a portion of the plurality of sectioning elements  2416  can extend through the sleeve  2415 . When the sleeve  2415  is advanced distally over a greater length of the sectioning elements  2416 , the sleeve  2415  prevents the sectioning elements  2416  from splaying away from one another and/or away from the longitudinal axis A of the device  2440  even when their loops are expanded. When the sleeve  2415  is retracted towards a proximal end of the device  2440 , the sectioning elements  2416  are free to splay. The retraction of the sleeve  2415  can be performed manually by a user. Alternatively, the retraction of the sleeve  2415  can occur automatically during the phases of deployment of the sectioning elements  2416 . The sectioning elements  2416  are configured to expand from the first, retracted configuration to a second, expanded configuration. The sleeve  2415  can be positioned around a length of the sectioning elements  2416  in a manner that allows for their respective loops to achieve the enlarged state, but prevents splaying or angular movement of the sectioning elements  2416  relative to the longitudinal axis. Actuation of the sectioning elements  2416  from the second, expanded configuration towards the third, splayed configuration can also retract the sleeve  2415 . Retraction of the sleeve  2415  can occur in a step-wise manner (retract, then splay) such that splay of the sectioning elements  2416  relative to the longitudinal axis is possible. Each sectioning element  2416  may be rigidly coupled to its respective sleeve  2415 . Where the device includes a single sectioning element  2416 , a single sleeve  2415  may be incorporated. Where the device includes two sectioning elements  2416 , two sleeves  2415  may be incorporated, one for each sectioning element  2416  and so on. Each sleeve  2415  allows for longitudinal, lateral, and rotational motion of its sectioning element  2416 . Longitudinal motion allows for extension and expansion of the distal loops beyond the distal opening  2405  of the shaft  2412 . Lateral and rotational motion allows for splay or fanning of the distal loops. The sleeves  2415  for each sectioning element  2416  aid in preventing “wind up” of the wires when the sectioning elements  2416  are manipulated and provide sufficient torsional stiffness for extension and splay. 
     The arms  2482  of the loop carriers  2476  can be urged into the splayed configuration by a wedge  2490  positioned on a wedge sled  2492 . The wedge  2490  can be positioned in a distal end region of the housing and have a ramped surface  2494  facing towards a proximal end of the device  2440 . Movement of the arms  2482  against the wedge  2490  causes the arms  2482  to be urged away from one another and splay outward (see  FIGS. 26D-26F ). As discussed above, the loop carriers  2476  can be coupled to the sled  2472  that can slide along the longitudinal axis A of the device  2440  with the slider  2444 . Distal movement of the sled  2472  can force the arms  2482  of the loop carriers  2476  to abut against the wedge  2490  and slide along the ramped surface  2494 . The arms  2482  can rotate around their respective rotational axes such that they splay away from one another as they slide along the ramped surface  2494  in a distal direction towards the thicker portion of the wedge  2490 . In some implementations, the wedge  2490  is movable in a proximal direction and can be moved against the sled  2472  to play the arms  2482  of the loop carriers  2476 . 
     The deployment can be a step-wise deployment including an expansion step followed by a splay step. The deployment can also be a step-wise deployment including an expansion step followed by a rotation step followed by a splay step. If the device includes the retractable sleeve  2415  controlling splay of the sectioning elements, the step-wise deployment can further include a sleeve retraction step prior to or in combination with the splay step. Sliding movement of the slider  2444  relative to the housing  2442  moves the sled  2472  a first distance to achieve expansion of the loops from the first, retracted configuration towards the second, expansion configuration. Sliding movement of the slider  2444  relative to the housing  2442  moves the sled  2472  a second distance beyond the first distance to achieve splay of the loops (i.e. the third, splayed configuration). Rotation of the expanded loops is described elsewhere herein as involving a mechanical element within the device itself or performed can be performed by a user. 
     The splay mechanism can further include an element configured to provide user feedback regarding where in the first deployment phase the slider  2444  is positioned. For example, as best shown in  FIGS. 26M and 26N , the user feedback element  2493  can be a splay detent spring configured to contact the loop carriers  2476  immediately before the arms  2482  start to splay. The user feedback element  2493  can be coupled near the distal end region of the housing  2442  just proximal to the ramped surface  2494  facing towards the proximal end of the device  2440 . The user feedback element  2493  can include two springs  2491  biased towards a centerline of the wedge sled  2492 , the distal ends of the springs  2491  located just proximal to the ramped surface  2494  of the wedge  2490 . As the slider sled  2472  moves axially in a distal direction relative to the wedge sled  2492 , the arms  2482  of the slider sled  2472  slide between the springs  2491 . The distal ends of the springs  2491  may be positioned closer to one another than the proximal ends of the springs  2491  such that the springs  2491  flex away from the centerline of the wedge sled  2492  and from each other as the arms  2482  past between them in a distal direction. Each spring  2491  may include a detent  2501  near an inner surface of its distal end region. The detent  2501  forms a concavity sized and shaped to receive an outer diameter of its respective arm  2482 . Upon reaching the location of the detent  2501 , the arms  2482  snap into its detent  2501  providing tactile and/or audible feedback that indicates to a user that the arms  2482  are about to contact the ramped surfaces  2494  of the wedge  2490  if the slider  2444  is extended further distally. Upon further distal extension of the slider  2444 , the arms  2482  pass beyond the detents  2501  of the springs  2491  and abut against the proximally facing ramped surfaces  2494  of the wedge  2490  to begin their rotation 
     In some configurations, an initial, long distally-directed movement of the slider  2444  achieves the second, expanded configuration and a final, short distally-directed movement of the slider  2444  beyond this achieves the third, splayed configuration. This step-wise deployment can expand the loops upon a first actuation (i.e. sliding the slider  2444  a first distance) and can splay the loops upon a second actuation (i.e. sliding the slider  2444  a second distance beyond the first distance). In some configurations, the third, splayed configuration is achieved by proximally-directed movement of the wedge  2490  towards the arms  2482 . In this configuration, the relative position of the slider sled  2472  and thus, the arms  2482  of the loop carriers  2476  can remain fixed along the longitudinal axis A and the wedge  2490  on the wedge sled  2492  can be moved in a proximal direction towards the arms  2482 . For example, the loops or open areas  2446  can be expanded upon a first actuation (i.e. sliding the slider  2444  a first distance in the distal direction) and the loops or open areas  2446  can be splayed upon a second actuation (i.e. withdrawing the wedge  2490  in the proximal direction). It should be appreciated that the second actuation can be performed using the slider  2444  or an actuator independent of the slider  2444 , as will be described in more detail below. This allows for the splayed configuration to be achieved regardless of the overall expansion of the loops while still providing the step-wise, two phase deployment. As such, even when the size of expansion is limited to a size smaller than a maximum expansion, the individual loops of the sectioning elements  2416  may still be splayed from one another. Thus, the distal loops of the sectioning elements are configured to splay angularly away from each other transitioning the cutting element into the third, splayed configuration independent of the size of the enlarged open areas. 
     The device  2440  allows for a user to fully adjust and select at what point during wire extension the loops will begin to separate angularly from one another. As described elsewhere herein, the second, expanded configuration of the sectioning elements  2416  can be generally oval in shape with a maximum width of about 4.0 mm to about 20 mm, and a height of about 1.0 mm to about 15 mm. In some implementations, the second, expanded configuration of the sectioning elements  2416  can be manually adjustable by a user such that the size of the open area  2446  that can be achieved upon full deployment is less than a maximum size of the open area  2446  when the sectioning element  2416  is unconstrained. The second, expanded configuration of the sectioning elements  2416  may be limited to an intentionally smaller size than the lens  8  at certain areas or along the entire profile. This may improve the ability of the sectioning elements  2416  to remain close to the lens  8  and reduce interaction with the capsular bag  6 . Limiting the size of the open area  2446  of the sectioning elements  2416  to one that is less than a maximum dimension allows for the sectioning elements  2416  to also be used as tissue manipulators to capture small fragments of lens material to remove them from the capsular bag. This may eliminate the need for a second removal device to be used. 
     The maximum size of open space  2446  achievable from the sectioning elements  2416  upon actuation of the slider  2444  and prior to splay can be manually adjusted by a user.  FIGS. 26G-26L  illustrate an expansion adjustment mechanism including an adjustor  2470  positioned on the housing  2442 . In some implementations, the adjustor  2470  can be a rotatable knob, push button, switch, slider, or other feature configured to be actuated by a user. It should be appreciated, use of the terms “knob” or “slider” are not intended to be limiting and that any of a variety of user inputs are considered herein that can be actuated by a user to achieve extension and/or splay of the sectioning elements  2416 . The size of the enlarged open areas of the sectioning elements prior to splay may be selectable by a user, for example, by using an adjustor configured to change a relative distance between the wedge and the sled. A shorter relative distance between the wedge and the sled can result in a smaller open area of the sectioning elements when urged into the second, expanded configuration prior to splay and a longer relative distance between the wedge and the sled can result in a larger open area of the sectioning elements when urged into the second, expanded configuration prior to splay. 
     In an implementation, the adjustor  2470  is rotatably coupled to a proximal end of a cam  2495  such that rotation of the adjustor  2470  causes the cam  2495  to rotate. The adjustor  2470  can be coupled directly to the proximal end of the cam  2495  or to a dowel  2499  extending through the cam  2495  (see  FIG. 26J ). The proximal end of the cam  2495  can include a mechanism that provides a step-wise rotation providing a series of tactile or audible clicks providing user feedback as to the degree of rotation achieved. In some implementations, the mechanism can include a plurality of detents  2484  positioned near a proximal end of the cam  2495  arranged to interface with a spring  2486 , such as a leaf spring. The spring  2486  can have an end configured to flex upward away from the longitudinal axis such that it slides over the proximal end of the rotating cam  2495  and the flex downward to insert within each detent  2484 . The spring  2486  can provide a detent force as a user turns the thread. The cam  2495  can have a helical cam path  2496  on an outer surface that is configured to engage with a cam post  2497  located at a proximal end of the wedge sled  2492 . As the adjustor  2470  is rotated a first direction the cam post  2497  of the wedge sled  2492  travels along the helical cam path  2496  around the cam  2495  thereby sliding the wedge sled  2492  along the longitudinal axis A of the device  2440 . The wedge  2490  at a distal end of the wedge sled  2492  is moved towards the proximal end of the device  2440 . As the wedge  2490  is withdrawn in a more proximal location along the longitudinal axis A of the device, the loops or open areas  2446  of the sectioning elements  2416  will splay earlier in the expansion stroke. Meaning, the open area  2446  of the respective sectioning elements  2416  will be smaller at the time of splay. The opposite movement can occur as the adjustor  2470  is rotated a second, opposite direction. The wedge  2490  can be advanced to a more distal location along the longitudinal axis A of the device such that the loops of the sectioning elements  2416  will splay later in the expansion stroke resulting in a larger open area  2446  at the time of splay. The slider sled  2472  can additionally include an expansion stop  2498  configured to abut the wedge  2490  thereby preventing further relative sliding movement between the sled  2472  and the wedge  2490  (see  FIG. 26K ). Thus, the position of the wedge  2490  can ultimately limit the total expansion achieved because it is incapable of moving beyond the expansion stop  2498 . 
     As described above, one or more retractable sleeves  2415  (see  FIG. 24E ) can be incorporated that maintain the sectioning elements  2416  in a constrained configuration such that they do not splay away from the longitudinal axis of the device before a user desires splay to occur. A retractable sleeve  2415  may be rigidly coupled to each sectioning element  2416  as discussed elsewhere herein and aid in the longitudinal and rotational motion of the elements  2416 . The retractable sleeve  2415  in this way prevents the multiple wires from creating unnecessary drag on the lens during positioning. The retractable sleeve  2415  can be used in conjunction with a separate spreading element (e.g. the wedge  2490 ) to provide adjustability of the degree of splay, as described in more detail above. Alternatively, the retractable sleeve  2415  can be used in conjunction with a plurality of sectioning elements  2416  that are pre-shaped to splay upon withdrawal of the sleeve  2415  and release of the constraining force. In this implementation, no separate spreading element (e.g. the wedge  2490 ) is incorporated. Each of the plurality of sectioning elements  2416  can be pre-shaped into the third, splayed configuration. During expansion of the loops towards the second, expanded configuration, the sleeve  2415  can be positioned in a distally extended position in order to keep the plurality of sectioning elements  2416  constrained toward the longitudinal axis A of the device. The sleeve  2415  can then be retracted to allow the plurality of sectioning elements  2416  to automatically splay towards their unbiased splayed configuration. 
     As described elsewhere herein, the sectioning elements  2416  can be a wire having a round or oval cross-section. For example, the device can include a plurality of sectioning elements  2416  formed of three discrete wires (e.g.  0 . 006 ″ Nitinol wire). The sectioning elements  2416  also can be a strap or long, narrow sheet of material. For example, the device can include a plurality of sectioning elements  2416  formed from a band  2905  of material (see  FIGS. 33A-33C ). In an implementation as shown in  FIG. 33A , the distal end region of the band  2905  can have the plurality of struts  2910  formed into it, each of which are shaped to form a cutting loop when unconstrained, as described elsewhere herein. The proximal end region of the band  2905  can remain as a singular band of material. In another implementation as shown in  FIGS. 33B-33C , the plurality of struts  2910  can be formed into a middle region of the band  2905  such that both the proximal end region and the distal end region are flat, contiguous bands of material interspersed by the struts  2810  extend therebetween. The band of material mitigates the discrete wires tangling during deployment movements. The band  2905  can be formed of Nitinol or other biocompatible material capable of shape memory. The implementation of  FIGS. 33A-33C , the band  2905  has two cuts  2915  creating three struts  2910 . The band  2905  have a thickness of about 0.006″ and can be about 0.022″ wide. The band  2905  can be laser cut to form the two cuts  2915  resulting in the three struts  2910 . The two cuts  2915  can be about 0.002″ leaving three struts  2910  that are each about 0.006″ wide. The three struts  2910  can then be electro polished to remove corners reshaping the struts  2910  into the plurality of sectioning elements  2416 . The cutting and electro polishing can transform the 0.006″×0.006″ struts  2910  into 0.006″ sectioning elements  2416  that approximate a 0.006″ diameter Nitinol wire. It should be appreciated that the number of struts  2910  created can vary as can their dimensions depending on the number of sectioning elements  2416  ultimately desired for the device. For example, the width of the band  2905  can depend on the number of sectioning elements  2416  to be formed. In some implementations, the band  2905  can be formed into two, three, four, or more struts  2910 . It should also be appreciated that the width and thickness of the band  2905  can, but need not be uniform and can vary over its length. 
     Again with respect to  FIGS. 25A-25C  and also  FIGS. 26A-26D , once the sectioning elements  2416  have been extended to the second, expanded configuration (which as described above can be a fully expanded maximum open space dimension or a dimension that is less than maximum), rotated and/or splayed to the third, splayed configuration within the capsular bag  6  in which the sectioning elements  2416  surround at least a portion of the lens  8 , the sectioning elements  2416  are then used to cut the lens  8  by tensioning the movable ends  2420  of the sectioning elements  2416 . The ends  2420  can be retracted through the lumen of the shaft  2412  in the opposite manner as set forth above for expanding the sectioning elements  2416  from the second, expanded configuration back toward the first configuration in order to compress and cut the lens  8 . As the sectioning elements  2416  are tensioned, they exert an inward force on the lens  8  and begin cutting and/or fragmenting it due to the force applied to the lens  8  across the small surface are of the thin diameter sectioning elements  2416 . The tensioning may be provided by movement of the slider  2444  proximally, thereby pulling the movable ends of each sectioning element  2416  proximally and tensioning it. Tensioning may also be provided at least in part by the user providing additional force as described elsewhere herein. 
     With a single tensioning procedure, the lens  8  can be divided into two, three, or more fragments depending on the number of sectioning elements  2416  incorporated. The process can be repeated along a different rotational angle (i.e. 90 degrees to create a crisscross pattern relative to the first fragmentation) and expansion and tensioning performed again to fragment the lens  8  into even smaller fragments (e.g. four, six, or more). The section plane is shown in  FIG. 25C  as primarily vertical, but it should be appreciated that any number of angles and orientations may exist for the cutting path of the sectioning elements  2416 . The process may be repeated for as many times as necessary to create any number of lens fragments of any desired size. The final desired size of the lens fragments may depend on method of extraction from the eye  1 . In some embodiments, phacoemulsification additionally may be used in the capsular bag  6  to remove the lens fragments. This may be particularly useful in difficult or hard cataracts, where full lens fragmentation increases the surface area and decreases the size of fragments that are to be emulsified by phacoemulsification. In other embodiments, the lens fragments may be extracted as described herein. In some embodiments, the lens fragments by be extracted as described in U.S. Publication No. 2018/0318132, entitled “Devices and Methods for Ocular Surgery,” published Nov. 8, 2018, which is incorporated by reference herein. 
     Upon proximal movement of the slider  2444 , the sled can be returned to the original position for safe removal of the sectioning elements  2416  from the eye. The sectioning elements  2416  can be rotated back to their original plane of insertion, and then retracted into the shaft  2412 . When the slider  2444  is fully withdrawn in a proximal direction, the sectioning elements  2416  can be placed in an over-strained position that over time can be detrimental to the shape memory properties of the sectioning elements  2416 . The device can include a spring  2458  that, when the loops of the sectioning elements  2416  are retracted back into the lumen of the shaft  2412 , causes the loops to not be retracted to such a small size that the shape memory of the Nitinol is affected. For example, a spring  2458  (see  FIG. 24D ) can be placed over a proximally-facing nose  2456  and extend proximally from the sled  2472  such that the slider  2444  and sled  2472  are urged into a slightly more distal position relative to the housing  2442  upon release of the slider  2444  (see  FIG. 26A-26B ). If the user retracts the sectioning elements  2416  too far using the slider  2444 , the spring  2458  can urge the sled  2472  a short distance in the distal direction after the slider  2444  is released by the user. This allows the loops of the sectioning elements  2416  to extend slightly out the distal end  2405  of the shaft  2412  and maintain a slightly enlarged open area  2446  when in a resting state compared to the fully retracted state (see  FIG. 24A ). The size of the distal end  2405  of the shaft  2412  and the slightly enlarged open areas  2446  positioned outside the distal end  2405  of the shaft  2412  may be small enough to be inserted through a clear corneal incision (i.e. maximum outer diameter being less than about 3.5 mm) such that the distal loops of the sectioning elements  2416  need not ever be fully retracted inside the lumen of the shaft  2412  in order to be inserted into the anterior chamber of the eye. 
     Slider actuation can be restricted such that the device is prevented from being used more than for a single medical procedure. For example, one-way latches, levers, ratchets, pawls, racks, and other mechanical elements can be incorporated within the housing to engage with the slider preventing extension of the cutting element via distal movements of the slider and sled attached to the slider. The stroke counting mechanisms described herein may limit the device to being a single-use device or limited-use device. “Single-use” or “limited-use” as referred to herein means the devices described herein are intended to be used in a single patient and not intended to be re-sterilized and used on another patient. The stroke counting mechanisms described herein may provide a low-cost method for limiting the use of the device, which can be manufactured as a low-cost, disposable device. It should be appreciated the stroke counting mechanisms configured to track distal extensions and/or proximal extensions of the slider can be used with a device having any number of sectioning elements, including 1, 2, 3, or more sectioning elements. 
     Even with a single-use device, it is preferable to allow the slider  2444  (or other extension/retraction mechanism) to be actuated more than a single back-and-forth stroke. For example, a user may want to slide the slider  2444  back and forth a few times to get the feel for the device prior to using it on a patient. In some implementations, the device  2440  can incorporate a stroke counting mechanism that allows for multiple actuations or distal extensions/proximal extensions of the slider (or other input configured to extend and retract the sectioning elements  2416 ) a discrete number of times prior to preventing extension of the slider  2444 , sled  2472  and/or sectioning elements  2416 . The stroke counting mechanism thereby may limit the utility of the device after clinical use in a single patient. The stroke counting mechanism can track distal extensions and/or proximal extensions of the slider and cause a lock-out event that prevents further distal extensions of the slider after the lock-out event occurs. It should be appreciated that use of the term “slider” is not intended to be limited and other types of inputs configured to extend/retract the sectioning elements  2416  are considered herein. 
     In some implementations, the slider  2444  can be coupled to a stroke counting mechanism  2701 .  FIGS. 27A-27C  shows a stroke counting mechanism  2701  that can incorporate a counting pawl system. A ratchet or cogwheel  2705  positioned within the handle  2442  can have a plurality of teeth  2710  in operable engagement with a main sprag  2715  and a secondary sprag  2720 . The main sprag  2715  can be coupled to an inner region of the housing  2442  and the secondary sprag  2720  can be coupled to the slider  2444 . During forward movement of the slider  2444  (i.e. towards a distal end of the housing  2442  along the direction of arrow A), a tooth  2710  of the cogwheel  2705  is urged against the main sprag  2715  causing the cogwheel  2705  to rotate forward one tooth  2710  around arrow B. On the backstroke as the slider  2444  is moved towards a proximal end of the housing  2442 , the secondary sprag  2720  prevents the cogwheel  2705  from back-driving in the opposite direction as the teeth  2710  slide back over the main sprag  2715 . The cogwheel  2705  also includes a stop tooth  2725  configured to lock against a stop  2730 . After the cogwheel  2705  has been advanced through a number of strokes, which can be defined by the number of teeth  2710  on the cogwheel  2705 , the stop tooth  2725  locks against the stop  2730  preventing further turning of the cogwheel  2705  in either direction (see  FIG. 27C ). This prevents the slider  2444  from entering the distal end of its travel and thereby prevents the sectioning elements  2416  from being fully expanded. Movement of the sectioning elements  2416  is prevented by the lockout rendering the device  2440  unusable after a certain number of extensions. The number of teeth  2710  can vary, including 2, 3, 4, 5, 6, 7, 8, 9, 10, or more teeth. After lockout, the slider  2444  is still able to move freely in the proximal portion of its travel, allowing further constriction of the distal loop and safe removal of the sectioning elements  2416  from the eye. The main sprag  2715  can be formed of sheet metal material having a shape that will bend upwards if a user attempts to over-power the main sprag  2715  by urging the slider forward. Similarly, the secondary sprag  2720  can be formed of a sheet metal material. Alternatively, one or both of the sprags  2715 ,  2720  can be formed by a flexible piece of molded plastic that can be deflected out of the way when the cogwheel  2705  spins in a direction B, but will not move out of the way when the cogwheel  2705  spins in the opposite direction. 
     The stroke counting mechanisms described herein can be configured to count the number of distal extensions, proximal extensions (i.e. retractions), or both the distal extensions and proximal extensions of the slider. The stroke counting mechanisms described herein can prevent distal extensions after a certain number of actuations of the slider have been performed. Generally, the stroke counting mechanisms described herein do not prevent proximal movement of the slider such that the device is prevented from being stuck in an extended configuration with the expanded loops trapped outside of the shaft. 
     The configuration of the stroke counting mechanism can vary.  FIGS. 28A-28B  illustrate another implementation of a stroke counting mechanism  2701 . The stroke counting mechanism  2701  can incorporate a counting pawl system. A cogwheel  2705  positioned within the handle or housing  2442  can have a plurality of teeth  2710  in operable engagement with a main sprag  2715  and a secondary sprag  2720 . In this implementation, the cogwheel  2705  can be attached to the device housing  2442  such that it remains stationary along the longitudinal axis of the device during movement of the slider  2444 . The slider  2444  can have a proximally-extending arm  2735  having the main sprag  2715  on its proximal end. In contrast to the implementation of  FIGS. 27A-27C  in which the cogwheel  2705  is advanced during each forward stroke of the slider  2444 , the cogwheel  2705  in this implementation is advanced one tooth  2710  at a proximal end of each backstroke of the slider  2444  (arrow A of  FIG. 28A ). The main sprag  2715  on the proximal-extending arm  2735  engages with a tooth  2710  of the cogwheel  2705  and rotates the cogwheel  2705  in a backward direction one tooth  2710  (arrow B of  FIG. 28A ). The cogwheel  2705  is prevented from rotating in the opposite direction due to the presence of the secondary sprag  2720  engaging with a tooth  2710  on the cogwheel  2705 . The secondary sprag  2720  can be positioned on an interior of the housing  2442 . After the cogwheel  2705  has been advanced through a discrete number of strokes defined by the number of teeth  2710  on the cogwheel  2705 , a catch tooth  2740  becomes entrapped with the main sprag  2715  on the arm  2730 , which in turn cannot be advanced forward because the cogwheel  2705  is prevented from rotating in the forward direction due to the secondary sprag  2720  (see  FIG. 28B ). This locks the slider  2444  in the proximal-most position and the sectioning elements  2416  in their most constricted shape. The counting pawl system can have any of a variety of configurations that allow for a limited number of retraction/extension cycles of the slider before mechanical locking occurs. 
       FIGS. 29A-29B  illustrate another configuration of a stroke counting mechanism  2701 . As with implementations described above, a cogwheel  2705  is positioned within the handle having a plurality of teeth  2710  in operable engagement with a main sprag  2715  and a secondary sprag  2720 . The cogwheel  2705  can be attached to an interior of the device housing  2442  and configured to rotate around an axis arranged perpendicular to the longitudinal axis of the housing  2442  extending from distal end to proximal end. The cogwheel  2705  is fixed along the longitudinal axis such that as the slider  2444  extends and retracts axially along the longitudinal axis of the housing  2442 , it engages with the teeth  2710  of the cogwheel  2705 . The slider  2444  can have a proximally-extending arm  2735  having the main sprag  2715  on its proximal end region. The main sprag  2715  extends from the proximal end region of the arm  2735  such that an end of the main sprag  2715  faces towards a distal end of the housing  2442 . The teeth  2710  of the cogwheel  2705  project towards a proximal end of the housing  2442 . This relative arrangement of the main sprag  2715  and the teeth  2710  allows for the cogwheel  2705  to be advanced during each forward stroke of the slider  2444  (i.e. towards a distal end of the housing  2442 ) and to remain stationary during each backward stroke of the slider  2444  (i.e. towards the proximal end of the housing  2442 ) as the main sprag  2715  passes over the teeth  2710  of the cogwheel  2705 . During forward movement of the slider  2444 , a tooth  2710  of the cogwheel  2705  is urged against the main sprag  2715  causing the cogwheel  2705  to rotate forward one tooth  2710  around arrow B. On the backward stroke as the slider  2444  is moved towards the proximal end of the housing  2442 , the secondary sprag  2720  prevents the cogwheel  2705  from back-driving in the opposite direction as the teeth  2710  slide back over the main sprag  2715 . The cogwheel  2705  can also include a stop tooth (like  2725  shown in  FIG. 27A-27C ) configured to lock against a stop as described elsewhere herein. 
     The implementations of the counting mechanisms described above involve rotation of a cogwheel around an axis that is perpendicular to the longitudinal axis A of the housing  2442 . The counting mechanism  2701  can also include an element configured to rotate around the longitudinal axis A of the housing  2442 .  FIGS. 30A-30D  illustrate another implementation of a stroke counting mechanism  2701  including a cylindrical counting barrel  3005  positioned within the housing  2442  such that a central axis of the barrel  3005  is aligned coaxially with the longitudinal axis A of the housing  2442 . The counting barrel  3005  can include a plurality of ramp blocks  3010  projecting upward from and arranged radially around its outer surface. An underneath side of the slider  2444  can have a first slider ramp  3025  and a second slider ramp  3030  (see  FIG. 30D ) shaped and arranged to engage with the ramp blocks  3010  upon retraction and extension of the slider  2444 , respectively. The shape of each ramp block  3010  and the shape of the slider ramps  3025 ,  3030  can vary, but are generally complementary to one another. A complementary shape of the ramp blocks  3010  and the slider ramps  3025 ,  3030  allows the slider ramps  3025 ,  3030  to abut and slide past the ramp blocks  3010 . The axial movement of the ramps  3025 ,  3030  along the longitudinal axis A results in rotary motion of the barrel  3005  in a direction around arrow B due to interaction with the ramp blocks  3010  (see  FIG. 30A ). Each distal extension of the slider can turn the cylindrical counting barrel a fraction of a full revolution of the barrel as will be described in more detail below. The barrel is configured to turn up to a certain number of fractions before the lock-out event occurs. The lock-out event can prevent distal extensions of the slider while allowing proximal retraction of the slider to avoid locking the slider when the cutting element is in the expanded configuration within a patient&#39;s eye. 
     In some implementations, the ramp blocks  3010  can have a polygonal shape with at least two ramped surfaces relative to the longitudinal axis of the barrel  3005 , including a front ramp  3015  configured to engage with a complementary ramped surface on the first slider ramp  3025  and a back ramp  3020  configured to engagement with a complementary ramped surface of the second slider ramp  3030 . In some implementations, the front ramp  3015  faces towards the distal end of the housing  2442  and the back ramp  3020  faces towards the proximal end of the housing  2442 . As such, the first slider ramp  3025  configured to engage with the front ramp  3015  faces towards the proximal end of the housing  2442  and the second slider ramp  3025  configured to engage with the back ramp  3020  faces towards the distal end of the housing  2442  (see  FIG. 30B ). On the backward stroke (i.e. towards a proximal end of the housing  2442 ), the first slider ramp  3025  abuts the front ramp  3015  of a first ramp block  3010   a  of the barrel  3005 . The barrel  3005 , in turn, is rotated around the longitudinal axis A of the device in a first direction around arrow B. The barrel  3005  rotates a fraction of a complete revolution of the barrel  3005 . After the barrel  3005  has completed its fraction of a rotation and the slider  2444  continues to move backwards, the barrel  3005  is prevented from rotating by an extension  3027  of the second slider ramp  3030  (see  FIG. 30E ). The extension  3027  is positioned between two of the ramp blocks  3010   a ,  3010   b  on the barrel  3005  such that the barrel  3005  is prevented from rotating even, for example, if the device is shaken or dropped. The slider  2444  can prevent the barrel  3005  from rotating when the slider ramps are not aligned with the ramp blocks  3010  on the barrel  3005 . On the forward stroke of the slider  2444 , the second slider ramp  3030  abuts the back ramp  3020  of the next ramp block  3010   b  and rotates the barrel  3005  around the longitudinal axis A of the housing  2442  another fraction of a complete revolution of the barrel  3005  around arrow B. For example, the barrel  3005  can rotate 1/24 of a complete revolution on the backward stroke and another 1/24 of a complete revolution on the forward stroke. Thus, for every forward and backward cycle of the slider  2444 , the barrel  3005  can rotate 1/12 of a complete revolution. 
     The number of ramp blocks  3010  can vary depending on how many cycles of actuation of the slider  2444  is desired (e.g. 3, 4, 5, 6, up to about 19, 20, or more). The slider can extend distally about 3 to about 30 strokes before the lock-out event occurs and the slider is locked in the rearward position. Each barrel  3005  can additionally include a stop block  3032  (see  FIG. 30C ). The stop block  3032  can be positioned on the outer surface of the barrel  3005  after than last ramp block  3010 . The stop block  3032  may include a front ramp  3015 . However, the stop block  3032  may have no back ramp  3020 . Instead, the stop block  3032  may include a groove  3034  arranged to prevent forward or distal translation of the slider  2444  (see  FIG. 30C ). The stop block  3032  can limit the barrel  3005  to a certain number of turns. The stop block  3032  can be positioned such that it engages with the slider ramps when the slider  2444  is moving forward or when the slider  2444  is moving backward. 
     The position of the slider  2444  when it engages with the stop block  3032  can be anywhere along its range of motion. For example, the slider  2444  can engage with the stop block  3032  when the slider  2444  is in the most forward position, the most backward position, or at any point between the two. In some implementations, the slider  2444  engages with the stop block  3032  about mid-way through its range of motion on a forward stroke. There are several potential advantages to this configuration related to the shape of the sectioning element  2416  at the front of the device. For example, the sectioning element  2416  is able to be transitioned into its smallest configuration even if the stroke counting mechanism has reached its limit and a lock-out event has occurred. This is useful so that the device can always be removed from the eye through the corneal incision by retracting the slider fully. 
     In some implementations, the counting barrel  3005  includes a plurality of ramp blocks  3010  within an internal passage  3035  (shown in  FIGS. 31C and 31E ). The plurality of ramp blocks  3010  may be arranged radially around the inner surface of the internal passage  3035 . As with the implementation described above, each ramp block  3010  can include a front ramp  3015  and a back ramp  3020  configured to be placed in operable engagement with a first slider ramp  3025  and a second slider ramp  3030  upon retraction and extension of the slider  2444 . In this implementation, a proximal end region of the slider  2444  can extend through the internal passage  3035  of the counting barrel  3005  such that the slider ramps  3025 ,  3030  can come into engagement with the ramp blocks  3010 . The outer surface of the barrel  3005  can include a helical thread  3040  (visible in  FIG. 31B ) configured to engage a corresponding female thread on an inner surface of the housing  2442 . As the barrel  3005  turns, the barrel  3005  threads down a length of the housing  2442  in an axial direction. Eventually, the barrel  3005  reaches a hard-stop that prevents the barrel  3005  from moving any further in an axial direction and the device is locked out. Thus, the barrel  3005  can go through multiple revolutions before a lock-out event occurs and it reaches the hard-stop. The hard-stop can include a termination of the female thread on the inner surface of the housing  2442 . The helical thread  3040  can limit the barrel  3005  to a certain number of turns, for example, 2.5 turns of travel. The barrel  3005  can rotate through 2.5 turns×12 strokes/turn or a total of 30 strokes before hitting the hard-stop. At the hard-stop, the slider  2444  can get trapped in the rearward part of the travel and the device is prevented from being used again. 
     In some implementations, the device can include mechanism to provide a warning before lock-out of actuation occurs (see  FIG. 31F ). The lock-out warning feature can be mechanical, for example, a window  3042  extending through the housing  2442  providing a visible sign or indication of the position of the barrel  3005  within the housing  2442 , for example, relative to the hard-stop. The window  3042  can be arranged near where a user can easily view it during use (e.g. on the top of the device near where a user might be holding the device). The window  3042  allows a user to see a contrasting color as the indexing barrel  3005  translates rearward. When the barrel  3005  is positioned near the window  3042  of the housing  2442 , the color of the barrel  3005  may be visible through the window  3042  providing an indication of the number of distal extensions still available before a lock-out event occurs. For example, the outer surface of the barrel  3005  can be viewed through the window  3042  during use. When the barrel  3005  is in a more distal position within the housing  2442  and still has quite a few strokes available, the barrel  3005  can be positioned distal to the window  3042  such that it is not visible through the window  3042  and the window  3042  appears dark or a first color. The barrel  3005  can remain distal to the window  3042  for a number of strokes until the barrel  3005  approaches the stop (e.g. the stop block  3032  or other stop as described elsewhere herein). At this stage when only a few more strokes are available, the outer surface of the barrel  3005  can be visible through the window  3042 . The color of the outer surface of the barrel  3005  can be easily identifiable through the window  3042 . The barrel  3005  may be a distinct color that is readily identifiable compared to a color of the handle  2442  (e.g. orange or red where the handle  2442  is white or gray) alerting the user to the position of the barrel  3005  before lock-out occurs. Alternatively, the outer surface of the barrel  3005  can be visible through the window  3042  prior to and during use. The outer surface of the barrel  3005  can have at least two contrasting colors that notifies the user where the barrel  3005  is in its travel. For example, a proximal end region of the barrel  3005  can be viewed through the window  3042  prior to use. The outer surface of the proximal end region of the barrel  3005  can be a first color (e.g. black or blue). With each translation cycle of the slider  2444 , the barrel  3005  is urged in a proximal direction within the housing  2442  until a distal end region of the outer surface of the barrel  3005  is visible through the window  3042 . The outer surface of the distal end region of the barrel  3005  can be a different color (e.g. orange or red). Thus, as the barrel  3005  approaches its stop within the housing  2442 , the different color can be visible through the window  3042  alerting the user the barrel  3005  is near the end of its life. 
     In some implementations, the barrel  3005  has a series of markings  3007  on its outer surface. For example,  FIG. 30A-30E  shows the barrel  3005  has the numbers ‘1’ through ‘20’ marked on the outer surface. The markings  3007  can line up with the window  3042  in the top housing such that the markings  3007  on the barrel  3005  aligned with the window  3042  are visible to the user. The markings  3007  may be numbers corresponding to the number of cycles remaining, the number of cycles used, etc. such that the user is made aware of the status of the stroke counting mechanism. Further, the slider  2444  may also have a window  3009  along its length (see  FIG. 30D ). The window  3009  of the slider  2444  may line up with the window  3042  through the top housing  2442  such that the marking(s)  3007  on the barrel  3005  at a particular position of the slider  2444  aligns with the windows  3009 ,  3042  and is visible to the user. For example, when the slider  2444  is advanced fully distally forward and the sectioning element  2416  of the device is fully open, then the window  3009  of the slider  2444  may line up with the window  3042  of the top housing so that the user can see the corresponding number at this time. As the slider  2444  is retracted proximally, the window  3009  of the slider  2444  moves and the slider  2444  blocks the view of the markings  3007  on the barrel  3005  through the top housing  2442 . In this way, the slider  2444  can act like a shutter that is only open at a given slider position. This may be beneficial in some embodiments of the device to prevent users from tampering with the barrel  3005  or trying to rotate it backwards to ‘reset’ the stroke counting mechanism  2701 . Such a shutter mechanism can be incorporated into any of the implementations described herein and any number of other shutter designs are contemplated. 
     In still further implementations, the counting mechanism  2701  need not involve rotation of a barrel or cogwheel as in the implementations described above and can instead involve linear actuators.  FIGS. 32A-32B  illustrate an implementation of a counting mechanism  2701  that includes an axially sliding rack  3050 . The rack  3050  can include a plurality of teeth  2710  configured to engage with a corresponding element such as camming bumps  3052  on a proximally-extending arm  2735  of the slider  2444 . The proximally-extending arm  2735  is configured such that it is generally not in contact with the rack  3050  for the majority of its stroke. As best shown in  FIG. 32A , the proximally-extending arm  2735  in an unstressed, straight position can be aligned with longitudinal axis A. As the slider  2444  is retracted proximally, the proximally-extending arm  2735  can flex away from the longitudinal axis A in a downward direction away from the teeth  2710  of the rack  3050 . As the slider  2444  is advanced distally, the proximally-extending arm  2735  can relax back toward the longitudinal axis A in an upward direction toward the teeth  2710  of the rack  3050 . The one or more camming bumps  3052  on a proximal-most end of the arm  2735  are configured to engage with one or more camming profiles  3054  on the interior of housing  2442  as the slider  2444  is moved proximally and distally. As the slider  2444  is retracted proximally, the camming bumps  3052  on the proximally-extending arm  2735  engage with the camming profile  3054  on the housing  2442  causing the proximally-extending arm  2735  to be urged downward (see arrow A of  FIG. 32A ). The proximally-extending arm  2735  elastically flexes downward relative to the slider  2444  and the housing  2442 . Once the camming bumps  3054  slide proximally past the camming profile  3054 , the proximally-extending arm  2735  can return upward back to its unstressed, straight position aligned with longitudinal axis A. As the slider  2444  is advanced distally, for example, to extend the sectioning element once again, the camming bumps  3052  engage with the camming profile  3054  on the housing  2442 . The proximally-extending arm  2735  is urged upward and flexes toward the rack  3050  away from the longitudinal axis A. A feature  3056  on the slider  2444  engages with the teeth  2710  on the rack  3050  causing the rack  3050  to advance forward with the slider  2444  while the proximally-extending arm  2735  is flexed upward. Once the camming bumps  3052  advance distally past the camming profile  3054 , the proximally-extending arm  2735  relaxes downward away from the teeth  2710  and to its neutral unstressed state aligned with longitudinal axis A. With each cycle backward and forward of the slider  2444 , the camming bumps  3052  move around the camming profiles  3054  and the rack  3050  is advanced a given distance. During proximal travel of the slider  2444 , the camming bumps  3052  travel down below the camming profile  3054  and the feature  3056  moved away from the teeth  2710  of the rack  3050 . During distal travel of the of the slider  2444 , the camming bumps  3052  travel back up above the camming profile  3054  and the feature  3056  is urged against the teeth  2710  of the rack  3050  thereby causing the rack  3050  to travel a distance forward. After a given number of cycles, the rack  3050  is configured to engage with a hard-stop on the housing such that it cannot be advanced any further. In this state, the slider  2444  is prevented from moving forward. 
     The devices and methods may be described in relation to preferred embodiments and it is understood that numerous modifications could be made to the preferred embodiments. For example, the tissue manipulators may have additional filaments or cross-filaments without departing from numerous aspects described. 
     In various implementations, description is made with reference to the figures. However, certain implementations may be practiced without one or more of these specific details, or in combination with other known methods and configurations. In the description, numerous specific details are set forth, such as specific configurations, dimensions, and processes, in order to provide a thorough understanding of the implementations. In other instances, well-known processes and manufacturing techniques have not been described in particular detail in order to not unnecessarily obscure the description. Reference throughout this specification to “one embodiment,” “an embodiment,” “one implementation, “an implementation,” or the like, means that a particular feature, structure, configuration, or characteristic described is included in at least one embodiment or implementation. Thus, the appearance of the phrase “one embodiment,” “an embodiment,” “one implementation, “an implementation,” or the like, in various places throughout this specification are not necessarily referring to the same embodiment or implementation. Furthermore, the particular features, structures, configurations, or characteristics may be combined in any suitable manner in one or more implementations. 
     The use of relative terms throughout the description may denote a relative position or direction. For example, “distal” may indicate a first direction away from a reference point. Similarly, “proximal” may indicate a location in a second direction opposite to the first direction. However, such terms are provided to establish relative frames of reference, and are not intended to limit the use or orientation of an anchoring delivery system to a specific configuration described in the various implementations. 
     While this specification contains many specifics, these should not be construed as limitations on the scope of what is claimed or of what may be claimed, but rather as descriptions of features specific to particular embodiments. Certain features that are described in this specification in the context of separate embodiments can also be implemented in combination in a single embodiment. Conversely, various features that are described in the context of a single embodiment can also be implemented in multiple embodiments separately or in any suitable sub-combination. Moreover, although features may be described above as acting in certain combinations and even initially claimed as such, one or more features from a claimed combination can in some cases be excised from the combination, and the claimed combination may be directed to a sub-combination or a variation of a sub-combination. Similarly, while operations are depicted in the drawings in a particular order, this should not be understood as requiring that such operations be performed in the particular order shown or in sequential order, or that all illustrated operations be performed, to achieve desirable results. Only a few examples and implementations are disclosed. Variations, modifications and enhancements to the described examples and implementations and other implementations may be made based on what is disclosed. 
     In the descriptions above and in the claims, phrases such as “at least one of” or “one or more of” may occur followed by a conjunctive list of elements or features. The term “and/or” may also occur in a list of two or more elements or features. Unless otherwise implicitly or explicitly contradicted by the context in which it is used, such a phrase is intended to mean any of the listed elements or features individually or any of the recited elements or features in combination with any of the other recited elements or features. For example, the phrases “at least one of A and B;” “one or more of A and B;” and “A and/or B” are each intended to mean “A alone, B alone, or A and B together.” A similar interpretation is also intended for lists including three or more items. For example, the phrases “at least one of A, B, and C;” “one or more of A, B, and C;” and “A, B, and/or C” are each intended to mean “A alone, B alone, C alone, A and B together, A and C together, B and C together, or A and B and C together.” 
     Use of the term “based on,” above and in the claims is intended to mean, “based at least in part on,” such that an unrecited feature or element is also permissible.