JP2023500829A - Surgical system and procedure for treatment of trabecular meshwork and Schlemm's canal with a femtosecond laser - Google Patents

Abstract

An ocular tissue target volume characterized by a distal extent, a proximal extent, and a lateral extent is treated with a laser propagating toward the target volume. A tissue layer at a first depth corresponding to the distal extent of the target volume is first photodissected using a femtosecond laser by scanning the laser in multiple directions defining a first treatment plane. . tissue at one or more subsequent depths between the distal extent of the target volume and the proximal extent of the target volume; The laser is refocused in a direction and then photodissected by scanning the laser in multiple directions defining the treatment plane for the second and subsequent times. Photodissection is repeated at various subsequent depths until tissue in the proximal extent of the target volume is photodisrupted. [Selection drawing] Fig. 17

Description

CROSS-REFERENCE TO RELATED APPLICATIONS This application is the subject of "Integrated Surgical System and Method for Treatment in the Irido-Corneal Angle of the Eye," filed July 16, 2018, the entire disclosures of which are incorporated herein by reference. and U.S. Patent Application No. 16, entitled "Non-Invasive and Minimally Invasive Laser Surgery for the Reduction of Intraocular Pressure in the Eye," filed September 7, 2018. 125,588, entitled "Surgical System and Procedure for Treatment of the Trabecular Meshwork and Schlemm's Canal Using a Femtosecond Laser," filed November 5, 2019, each of which is a continuation-in-part of No. 125,588; PCT International Application No. 16/674,850.

FIELD OF THE DISCLOSURE The present disclosure relates generally to the field of medical devices and treatments for ophthalmic conditions, including glaucoma, and more specifically to systems, devices, and methods for treating trabecular meshwork and Schlemm's canal using femtosecond lasers. is.

Before discussing the different types of glaucoma and current diagnostic and treatment options, a brief overview of the anatomy of the eye is provided.

anatomy of the eye

Referring to Figures 1-3, the outer tissue layers of the eye 1 include the sclera 2 which provides the eye-shaped structure. In front of the sclera 2 is the cornea 3, made up of a transparent layer of tissue that allows light to enter the interior of the eye. Within the eye 1 is the lens 4 connected to the eye by zonular fibers 5 which are connected to the ciliary body 6 . Between the lens 4 and the cornea 3 is the anterior chamber 7 containing a flowing clear liquid called the aqueous humor 8 . Surrounding the lens 4 is the iris 9 which forms a pupil around the approximate center of the lens. The posterior chamber 23 is an annular volume surrounded by the ciliary body 6 , zonular fibers 5 , and lens 4 behind the iris 9 . A vitreous humor 10 is located between the lens 4 and the retina 11 . Light entering the eye is focused through the cornea 3 and the lens.

Referring to FIG. 2, the sclerocorneal junction of the eye is the portion of the anterior chamber 7 at the intersection of the iris 9, sclera 2, and cornea 3. FIG. The anatomy of eye 1 at the sclerocorneal junction includes trabecular meshwork 12 . Trabecular meshwork 12 is a fibrous network of tissue surrounding iris 9 in eye 1 . Briefly and broadly, the organization of the corneoscleral junction is such that the iris 9 meets the ciliary body 6, the ciliary body meets the inferior surface of the scleral spine 14, and the superior surface of the scleral spine meets the trabecular meshwork 12. It serves as a point of attachment to the bottom, and so on. The ciliary body is mainly located in the posterior chamber, but also extends into the very angle of the anterior chamber 7 . The network of tissue layers that make up the trabecular meshwork 12 is porous and therefore serves as an escape route for the aqueous humor 8 flowing from the anterior chamber 7 . This pathway is sometimes referred to herein as the aqueous outflow pathway, the water outflow pathway, or simply the outflow pathway.

Referring to FIG. 3 , the pathway formed by the pores of trabecular meshwork 12 connects to a set of thin porous tissue layers called uvea 15 , sclerocorneal trabecular meshwork 16 , and paracanalicular tissue 17 . The paracanalicular tissue 17 in turn abuts a tissue called Schlemm's canal 18 . Schlemm's canal 18 drains a mixture of aqueous humor 8 and blood from the surrounding tissue through a system of collector channels 19 and into the venous system. Next to the sclera 2 is the vascular membrane of the eye, called the choroid 20, as shown in FIG. A space called the suprachoroidal space 21 may exist between the choroid 20 and the sclera 2 . The entire circumferentially continuous area around the perimeter of the wedge between the cornea 3 and the iris 9 is called the iridocorneal angle 13 . The iris corneal angle 13 is sometimes called the corneal angle of the eye, or simply the angle of the eye. All eye tissues shown in FIG. 3 are considered to be within the iridocorneal angle 13 .

Referring to FIG. 4, two possible outflow pathways through which aqueous humor 8 travels include the trabecular meshwork outflow pathway 40 and the uveoscleral outflow pathway 42 . Aqueous humor 8 is produced by the ciliary body 6 and flows from the posterior chamber 23 through the pupil into the anterior chamber 7 and then through one or more of two different outflow pathways 40, 42 to the eye. get out of Approximately 90% of the aqueous humor 8 passes through the trabecular meshwork 12 into Schlemm's canal 18, through one or more plexuses of the collecting channel 19, and then out through drainage 41 into the veins. By entering the system, it exits via the trabecular meshwork outflow pathway 40 . Any residual aqueous humor 8 exits primarily through the uveoscleral outflow pathway 42 . The uveoscleral outflow pathway 42 passes through the plane of the ciliary body 6 and the base of the iris into the suprachoroidal space 21 (shown in FIG. 2). Aqueous humor 8 can flow out of the suprachoroidal space 21 and out of the choroidal space through the sclera 2 .

The intraocular pressure of the eye is determined by the outflow of aqueous humor 8 through the corpus cavernosum outflow pathway 40 and the resistance to outflow of the aqueous humor through the corpus cavernosum outflow pathway. The intraocular pressure of the eye is largely independent of the outflow of aqueous humor 8 through the uveoscleral outflow pathway 42 . Resistance to outflow of aqueous humor 8 through the trabecular meshwork outflow pathway 40 can lead to increased intraocular pressure in the eye, which is a well-known risk factor for glaucoma. Collapsing or malfunctioning of Schlemm's canal 18 and trabecular meshwork 12 may increase resistance through the corpus cavernosum outflow pathway 40 .

Referring to FIG. 5, as an optical system, the eye 1 consists of an idealized central plane of rotational symmetry, entrance and exit pupils, and six origin points (object and image space foci, first and second principal It is represented by an optical model, described by a plane, first and second nodal points). Angular orientations for the human eye are often defined with respect to the optical axis 24 , visual axis 26 , pupillary axis 28 and line of sight 29 of the eye. The optical axis 24 is the axis of symmetry and the line connects the vertices of the idealized surface of the eye. A visual axis 26 connects the fovea 22 to the object by first and second nodal points. A line of sight 29 connects the fovea to the object through the exit and entrance pupils. Pupil axis 28 is perpendicular to the posterior surface of cornea 3 and is oriented at the center of the entrance pupil. These eye axes differ from each other by only a few degrees and lie within what is commonly called the viewing direction.

Glaucoma

Glaucoma is a group of diseases that damage the optic nerve and can lead to decreased vision or blindness. It is the leading cause of irreversible blindness. It is estimated that about 80 million people worldwide have glaucoma, of which about 67 million are blind in both eyes. More than 27 million Americans over the age of 40 have glaucoma. Symptoms begin with loss of peripheral vision and can progress to blindness.

There are two forms of glaucoma, one called closed-angle glaucoma and the other called open-angle glaucoma. 1-4, in angle-closure glaucoma, the iris 9 in the collapsed anterior chamber 7 can impede and block the flow of aqueous humor 8 . In open-angle glaucoma, the more common form of glaucoma, irregularities in para-Schlemm's canal tissue 17 and inner wall 18a of Schlemm's canal, and occlusion of tissue in the iridocorneal angle 13 along the corpus cavernosum outflow pathway 40 lead to loss of ocular tissue. Permeability can be affected.

As noted above, elevated intraocular pressure (IOP) in the eye damages the optic nerve and is a widely recognized risk factor for glaucoma. However, not all people with increased intraocular pressure develop glaucoma, and some develop glaucoma without increased intraocular pressure. Nonetheless, it is desirable to reduce the elevated IOP of the eye in order to reduce the risk of glaucoma.

Methods of diagnosing the condition of the eye in glaucoma patients include visual acuity and visual field tests, mydriatic tests, tonometry, i.e. measuring the intraocular pressure of the eye, and corneal pachymetry, i.e. measuring the thickness of the cornea. . Vision loss begins with narrowing of the visual field and progresses to total blindness. Diagnostic imaging methods include slit lamp examination, observation of the iridocorneal angle through a goniometric lens, and diagnostic imaging by optical coherence tomography (OCT) of the anterior chamber and retina.

Once diagnosed, several clinically proven treatments are available to control or lower intraocular pressure in the eye to slow or halt the progression of glaucoma. The most common treatments include 1) medications such as eye drops or pills, 2) laser surgery, and 3) conventional surgery. Treatment usually begins with drug therapy. However, the efficacy of drug therapy is often hampered by patient noncompliance. When drug therapy is ineffective for a patient, laser surgery is generally the next treatment to be tried. Conventional surgery is invasive, has higher risks than drug therapy and laser surgery, and has a limited time window of efficacy. Therefore, conventional surgery is usually left as a last option for patients whose intraocular pressure cannot be controlled by drug therapy or laser surgery.

laser surgery

Referring to FIG. 2, glaucoma laser surgery targets the trabecular meshwork 12 to reduce the flow resistance of the aqueous humor 8 of the eye. Common laser treatments include argon laser trabeculoplasty (ALT), selective laser trabeculoplasty (SLT), and excimer laser trabeculotomy (ELT).

ALT is the first laser trabeculoplasty procedure. During treatment, a 514 nm wavelength argon laser is applied to the trabecular meshwork 12 180° around the iridocorneal angle 13 . The argon laser induces a thermal interaction with ocular tissue, thereby creating an opening in the trabecular meshwork 12 . However, ALT causes scarring of ocular tissue, followed by an inflammatory response and tissue healing that may eventually close the opening of the trabecular meshwork 12 formed by ALT treatment, resulting in effectiveness is reduced. Furthermore, ALT therapy generally cannot be repeated because of this scarring.

SLT is designed to reduce scarring effects by selectively targeting the pigment in the trabecular meshwork 12 and reducing the amount of heat delivered to the surrounding ocular tissue. During the procedure, a 532 nm wavelength solid-state laser irradiates the trabecular meshwork 12 at 180-360 degrees around the iris angle 13 to ablate the pigmented cells lining the corpus cavernosum of trabecular meshwork. SLT. At 12, the collagen ultrastructure of the trabecular meshwork is preserved. 12. SLT treatment can be repeated, but the effect of lowering intraocular pressure (IOP) decreases after the second treatment.

ELT uses an UltraViolet (UV) excimer laser with a wavelength of 308 nm and non-thermal interaction with ocular tissue to treat the corpus cavernosum 12 and inner wall of Schlemm's canal in a non-healing response. Therefore, the IOP lowering effect is more long lasting. However, since the UV light of a laser cannot penetrate deep into the eye, the laser light is delivered to the trabecular meshwork 12 via an optical fiber inserted into the eye 1 through an opening, where the fiber contacts the trabecular meshwork. Let me. This procedure is highly invasive and is generally performed at the same time as the cataract procedure when the eye is already surgically opened. Like ALT and SLT, ELT cannot control the amount of IOP reduction.

None of these existing laser treatments are ideal treatments for glaucoma. Therefore, lasers in glaucoma that effectively reduce IOP non-invasively without causing significant tissue scarring can be completed in a single procedure and can be repeated later if necessary. Surgical treatment systems, devices, and methods are needed.

The present disclosure relates to a method of treating an ocular tissue target volume at the iridocorneal angle of an eye characterized by a distal extent, a proximal extent, and a lateral extent with a laser propagating toward the ocular tissue target volume. be. The method first involves photodissecting tissue at a first depth corresponding to the distal extent of the ocular tissue target volume. For this, the light from the femtosecond laser is focused to a spot in the tissue that is the first depth. Sufficient light energy is thereby applied to the tissue to photodisrupt the tissue, for example by scanning the laser in multiple directions defining a first treatment plane, thereby removing the first tissue layer of the target volume. is optically cleaved.

The method is followed by one or more subsequent shifts between the distal extent of the ocular tissue target volume and the proximal extent of the target volume by shifting the focal point of the laser in a direction opposite to the direction of propagation of the laser. It also includes photodissection of tissue at a depth of . Because of this, the light from the femtosecond laser is focused to a spot in the tissue that is the second and subsequent depths. Thereby, sufficient light energy is applied to the tissue to photodisrupt the tissue, for example, by scanning the laser in multiple directions defining a second or subsequent treatment plane, thereby resulting in a second or subsequent treatment plane of the target volume. Photodissect tissue layers. Photodissection at one or more subsequent depths is repeated at multiple different subsequent depths until tissue in the proximal extent of the ocular tissue target volume is photodisrupted.

In a further aspect, the method includes, after photocutting the tissue target volume, shifting the focus of the laser in the direction of propagation of the laser and directing the laser to one or more of the second and subsequent treatment planes and the first treatment plane. Rescanning includes photodissecting tissue debris or tissue bubbles between a proximal extent of the ocular tissue target volume and a distal extent of the target volume. The method may further include repeating the first tissue photodissection and the second and subsequent tissue photodissections one or more times.

The present disclosure also relates to a system for laser treating an ocular tissue target volume of the iridocorneal angle of an eye characterized by a distal extent, a proximal extent, and a lateral extent. The system includes a first optical subsystem including a focusing objective lens configured to be aligned with the eye and a second optical subsystem including a laser source configured to output a laser beam. be The second optical subsystem one of focusing the laser beam, scanning the laser beam, and directing the laser beam in a direction of propagation toward the ocular tissue target volume through the focusing objective lens, or It also includes a plurality of components configured to do a plurality of things.

The system is further coupled to a second optical subsystem for focusing and adjusting the laser beam for first photodissection of tissue at a first depth corresponding to the distal extent of the eye tissue target volume. A control system configured to control the scanning is included. To this end, the control system applies sufficient light energy to the tissue to photodisrupt it by focusing the light from the femtosecond laser to a spot in the tissue that is the first depth. is configured as The control system is further configured to scan the laser in a plurality of directions defining a first treatment plane, thereby photodissecting the first tissue layer of the ocular tissue target volume, during application of the optical energy. Controls the focusing and scanning of the laser beam.

The control system also adjusts one or more subsequent depths between the distal extent of the ocular tissue target volume and the proximal extent of the target volume by shifting the focus of the laser in a direction opposite to the direction of propagation of the laser. The laser beam is configured to control the focusing and scanning of the laser beam for subsequent photodissection of the tissue at the depth. To this end, the control system applies light energy to the tissue sufficient to photodisrupt the tissue by focusing light from the femtosecond laser to a spot in the tissue that is at a second or greater depth. is configured to The control system is further configured to photodisrupt subsequent tissue layers of the ocular tissue target volume by scanning the laser in multiple directions defining subsequent treatment planes, thereby applying optical energy to controls the focusing and scanning of the laser beam during

In a further aspect, after photodisrupting the ocular tissue target volume, the control system refocuses the laser in the direction of propagation of the laser and directs the laser onto one or more of the second and subsequent treatment planes and the first treatment plane. Controls the focusing and scanning of the laser beam to photodissect tissue debris or tissue bubbles between the proximal extent of the eye tissue target volume and the distal extent of the eye tissue target volume by rescanning the is configured as The control system is further configured to control the focusing and scanning of the laser beam in conjunction with one or more repetitions of the first tissue photodissection and the second and subsequent tissue photodissections.

The present disclosure also relates to methods of treating the eye, including the anterior chamber, Schlemm's canal, and trabecular meshwork therebetween. The method first involves photodisrupting ocular tissue at or near the interface between the inner wall of Schlemm's canal and the trabecular meshwork. For this, light from a femtosecond laser is focused to a spot in the eye tissue at or near the interface between the inner wall of Schlemm's canal and the trabecular meshwork. Sufficient light energy is thereby applied to the tissue to photodisrupt the tissue. The method also subsequently includes photodissecting the ocular tissue of the trabecular meshwork. For this, light from a femtosecond laser is focused to an intra-tissue spot in the trabecular meshwork. Sufficient light energy is thereby applied to the tissue to photodisrupt the tissue. In a further aspect, the method comprises repeating the first ocular tissue photodissection and the second and subsequent ocular tissue photodissections one or more times until an opening is formed between the anterior chamber and Schlemm's canal. include.

The present disclosure also relates to systems for treating the eye including the anterior chamber, Schlemm's canal, and trabecular meshwork therebetween. The system includes a first optical subsystem including a focusing objective lens configured to be aligned with the eye and a second optical subsystem including a laser source configured to output a laser beam. be The second optical subsystem is further configured to one or more of focus the laser beam, scan the laser beam, and direct the laser beam at the ocular tissue through the focusing objective lens. contains multiple components that are

The system is also coupled to a second optical subsystem and initially adapted to photoablate ocular tissue at or near the interface between the inner wall of Schlemm's canal and the trabecular meshwork. A control system configured to control the focusing and scanning of the is included. To this end, the control system focuses the light from the femtosecond laser to a spot within the ocular tissue that is at or near the interface between the inner wall of Schlemm's canal and the trabecular meshwork so that its energy is It is configured to apply light to the tissue that is sufficient to photodisrupt that tissue. The control system is also configured to subsequently control the focusing and scanning of the laser beam to photodisrupt tissue of the trabecular meshwork. To this end, the control system is configured to apply light energy to the tissue sufficient to photodisrupt the tissue by focusing light from the femtosecond laser to an intra-tissue spot in the trabecular meshwork. ing. In a further aspect, the control system further repeats the first eye tissue photocut and the second and subsequent eye tissue photocuts one or more times until an opening is formed between the anterior chamber and Schlemm's canal. is configured to control the focusing and scanning of the laser beam in accordance with.

It is understood that other aspects of the apparatus and methods will become apparent to those skilled in the art from the following detailed description, in which various aspects of the apparatus and methods are shown and described by way of illustration. As will be realized, these aspects may be embodied in other different forms, and their several details may be modified in various other aspects. Accordingly, the drawings and detailed description are to be regarded as illustrative in nature rather than restrictive.

Various aspects of systems, apparatus, and methods are now presented, by way of example and not by way of limitation, in a detailed description with reference to the accompanying drawings.

1 is a schematic cross-sectional view showing the human eye and internal anatomy; FIG. 2 is a schematic cross-sectional view showing the iris corneal angle of the eye of FIG. 1; FIG. 3 is a schematic cross-sectional view detailing the anatomy of the iridocorneal angle of FIG. 2, including the trabecular meshwork, Schlemm's canal, and one or more water collecting channels branching from Schlemm's canal; FIG. 4A-4D are schematic cross-sectional views showing various outflow pathways of aqueous humor through the trabecular meshwork, Schlemm's canal, and collection channels of FIG. 1 is a schematic cross-sectional view of a human eye showing various axes associated with the eye; FIG. 1 is a schematic cross-sectional view showing an angled optical path along which one or more light rays may access the iris-corneal angle of an eye; FIG. An integrated surgical system for non-invasive glaucoma surgery, including control system, femtosecond laser source, OCT imager, microscope, beam conditioner and scanner, beam combiner, focusing objective lens, and patient contact surface. It is a block diagram. 8 is a detailed block diagram of the integrated surgical system of FIG. 7; FIG. FIG. 8 is a schematic diagram showing a collection objective of the integrated surgical system of FIG. 7 coupled to a patient contacting surface of the integrated surgical system of FIG. 7; FIG. 8 is a schematic diagram showing the collection objective of the integrated surgical system of FIG. 7 separated from the patient contacting surface of the integrated surgical system of FIG. 7; Figure 9b is a schematic diagram showing the components of the collection objective and patient contacting surface included in Figures 9a and 9b; 7 and 8 operatively arranged to form a first optical system and a second optical subsystem that provide access to the iridocorneal angle along the angled optical path of FIG. 6. 1 is a schematic diagram showing the components of the system; FIG. 7 and 8 operatively arranged to form a first optical system and a second optical subsystem that provide access to the iridocorneal angle along the angled optical path of FIG. 6. 1 is a schematic diagram showing the components of the system; FIG. Fig. 10b is a schematic diagram showing the beam passing through the first optical subsystem of Figs. 10a and 10b and into the eye; 8 is a three-dimensional schematic representation of the anatomy of the iris angle, including the trabecular meshwork, Schlemm's canal, a collector channel branching from Schlemm's canal, and an ocular tissue surgical volume treated by the integrated surgical system of FIG. 7; FIG. Laser treatment applied by the integrated surgical system of FIG. 7 to affect the anatomy of the iris angle and the ocular tissue surgical volume between the Schlemm's canal and the anterior chamber, as shown in FIG. 2D schematic diagram with a pattern; FIG. 12 after laser treatment of the ocular tissue surgical volume based on the laser treatment pattern of FIG. 12 forming an opening between Schlemm's canal and the anterior chamber of the eye. FIG. 13 is a series of schematic illustrations of a laser scanning process based on the treatment pattern of FIG. 12, wherein the scanning begins adjacent to the anterior chamber and progresses toward Schlemm's canal; FIG. 13 is a series of schematic illustrations of a laser scanning process based on the treatment pattern of FIG. 12, wherein the scanning begins adjacent to the anterior chamber and progresses toward Schlemm's canal; FIG. 13 is a series of schematic illustrations of a laser scanning process based on the treatment pattern of FIG. 12, where the scan begins adjacent to Schlemm's canal and progresses toward the anterior chamber of the eye; FIG. 13 is a series of schematic illustrations of a laser scanning process based on the treatment pattern of FIG. 12, where the scan begins adjacent to Schlemm's canal and progresses toward the anterior chamber of the eye; FIG. 13 is a series of schematic illustrations of a laser scanning process based on the treatment pattern of FIG. 12, where the scan begins adjacent to Schlemm's canal and progresses toward the anterior chamber of the eye; FIG. 13 is a series of schematic illustrations of a laser scanning process based on the treatment pattern of FIG. 12, where the scan begins adjacent to Schlemm's canal and progresses toward the anterior chamber of the eye; FIG. 13 is a series of schematic illustrations of a laser scanning process based on the treatment pattern of FIG. 12, where the scan begins adjacent to Schlemm's canal and progresses toward the anterior chamber of the eye; FIG. 13 is a series of schematic illustrations of a laser scanning process based on the treatment pattern of FIG. 12, where the scan begins adjacent to Schlemm's canal and progresses toward the anterior chamber of the eye; FIG. 13 is a series of schematic illustrations of a laser scanning process based on the treatment pattern of FIG. 12, where the scan begins adjacent to Schlemm's canal and progresses toward the anterior chamber of the eye; FIG. 15g is a series of schematic illustrations of an optional laser scanning process through the aperture of FIG. 15g, where the scan begins at the edge of the aperture adjacent to the anterior chamber and progresses toward Schlemm's canal; FIG. 15g is a series of schematic illustrations of an optional laser scanning process through the aperture of FIG. 15g, where the scan begins at the edge of the aperture adjacent to the anterior chamber and progresses toward Schlemm's canal; FIG. 4 is a flowchart of a method of treating a volume of ocular tissue; 4 is a flow chart showing a method of treating an eye involving the anterior chamber, Schlemm's canal, and trabecular meshwork.

Disclosed herein are systems, devices, and methods for safely and effectively reducing intraocular pressure (IOP) in the eye to treat or reduce the risk of glaucoma. Systems, devices, and methods provide access to the iridocorneal angle of the eye and integrate the technique of laser surgery with high-resolution imaging to detect eye abnormalities within the iridocorneal angle that can cause elevated IOP. Accurately diagnose, locate, and treat tissue conditions.

The integrated surgical system disclosed herein comprises an aqueous outflow pathway formed by the cornea, the anterior chamber, and one or more collecting channels branching from the trabecular meshwork, Schlemm's canal, and Schlemm's canal. and an iridocorneal angle comprising: The integrated surgical system also includes a first optical subsystem and a second optical subsystem. A first optical subsystem includes a window configured to be coupled to the cornea and an output lens configured to be coupled to the window. A second optical subsystem includes an optical coherence tomography (OCT) imaging device configured to output an OCT beam, a laser source configured to output a laser beam, and an OCT beam and a laser beam. A plurality of components, such as lenses and mirrors, configured to coordinate, combine, and direct toward the first optical subsystem.

The integrated surgical system also includes a control system coupled to the OCT imaging device, laser source, and second optical subsystem. The controller is configured to command the OCT imaging device to output an OCT beam and the laser source to output a laser beam for delivery through the cornea and anterior chamber into the iridocorneal angle. . In one configuration, the control system controls the second optical subsystem so that the OCT and laser beams are offset from the first optical axis and extend along an angled path 30 into the iridocorneal angle. It is directed into the first optical subsystem along an existing second optical axis.

Directing the OCT beam and the laser beam along the same second optical axis and into the iris-corneal angle of the eye allows the assessment of conditions to be accurately applied directly to treatment planning and surgery in one clinical setting. It is beneficial in that Furthermore, combining OCT imaging and laser therapy allows for precise targeting of ocular tissue not available with any existing surgical system and method. The surgical precision provided by the integrated surgical system allows only microscopic target tissue to be affected, leaving the surrounding tissue intact. The microscopic size scale of the diseased ocular tissue to be treated at the iridocorneal angle of the eye ranges from a few micrometers to hundreds of micrometers. For example, referring to FIGS. 2 and 3, the cross-sectional size of normal Schlemm's canal 18 is elliptical, tens of micrometers by hundreds of micrometers. The collecting channels 19 and veins have diameters of tens of micrometers. The thickness of the paracanalicular tissue 17 is several micrometers, and the thickness of the trabecular meshwork 12 is about 100 micrometers.

The control system of the integrated surgical system further applies a laser beam to ocular tissue to define a volume, thereby reducing pathway resistance or creating new pathway resistance through photo-disruptive interaction with ocular tissue. Modifying the volume of ocular tissue within the outflow path to create an outflow path to reduce path resistance present in one or more of the trabecular meshwork, Schlemm's canal, and one or more collecting channels configured to command the laser source to do so.

The laser source may be a femtosecond laser. Femtosecond lasers provide a non-thermal photodestructive interaction with ocular tissue to avoid thermal damage to surrounding tissue. Furthermore, unlike other surgical methods, femtosecond laser treatment can avoid open plane incisions through the eye, allowing for non-invasive treatment. As an alternative to performing treatment in a sterile operating room, non-invasive treatment can be performed in a non-sterile outpatient facility.

Additional diagnostic imaging components may be included in the integrated surgical system that provide direct visual observation of the iridocorneal angle along the visual observation angle. For example, a microscope or imaging camera may be included to assist the surgeon in the process of docking the eye to a patient contact surface or immobilization device, locating the ocular tissue of the eye, and observing the progress of the surgery. The visual observation angle can also pass through the cornea 3 and the anterior chamber 7 to the iridocorneal angle 13 along the angled optical path 30 .

Images from an OCT imaging device that provides visual observation and additional imaging components, such as a microscope, are combined on a display device such as a computer monitor. The different images can be registered, superimposed on a single window, magnified, processed and differentiated by false colors for easier understanding. Certain features are computationally recognized by a computer processor, and image recognition and segmentation algorithms can be enhanced, enhanced, and marked for display. The geometry of the treatment plan can also be registered in combination with the diagnostic imaging information on the display device and marked with geometric, numerical and textual information. Numerical, textual, and geometric properties for selection, highlighting, and marking of features, entry of location information, by keyboard, mouse, cursor, touch screen, voice, or other user interface device for the same display can also be used for user input of

OCT diagnostic imaging

A primary imaging component of the integrated surgical system disclosed herein is the OCT imaging device. OCT technology may be used to diagnose, position, and guide laser surgery directed at the iridocorneal angle of the eye. For example, referring to FIGS. 1-3, OCT imaging determines the structural and geometrical status of the anterior chamber 7 to assess potential obstruction of the trabecular outflow pathway 40 and to treat therapeutic interventions. may be used to determine the accessibility of ocular tissue. As noted above, a collapsed anterior chamber 7 iris 9 can impede and block the flow of aqueous humor 8, resulting in angle-closure glaucoma. In open-angle glaucoma, in which the macroscopic geometry of the angle is normal, ocular tissue permeability is caused by tissue occlusion along the trabecular meshwork outflow pathway 40 or by collapse of Schlemm's canal 18 or collection channel 19. may be affected.

OCT imaging can provide the spatial resolution, tissue penetration, and contrast necessary to resolve the microscopic details of ocular tissue. When scanned, OCT imaging can provide two-dimensional (2D) cross-sectional images of ocular tissue. As another aspect of the integrated surgical system, 2D cross-sectional images may be processed and analyzed to determine the size, shape, and location of eye structures for surgical targeting. It is also possible to reconstruct a three-dimensional (3D) image from multiple 2D cross-sectional images, although this is often unnecessary. Acquisition, analysis, and display of 2D images is faster and can still provide all the information necessary for accurate surgical targeting.

OCT is a diagnostic imaging modality that can provide high-resolution images of materials and tissues. Diagnostic imaging is based on reconstruction of spatial information of a sample from spectral information of scattered light from within the sample. Spectral information is extracted by using an interferometric method that compares the spectrum of light entering the sample with the spectrum of light scattered from the sample. The spectral information along the direction in which the light propagates within the sample is then transformed into spatial information along the same axis by a Fourier transform. Lateral information of OCT beam propagation is typically collected by laterally scanning the beam and repeatedly probing axially during the scan. 2D and 3D images of the specimen can be acquired in this way. Image acquisition is faster when the interferometer is not mechanically scanned in time-domain OCT, but the interference from a broad spectrum of light is recorded simultaneously, and this implementation is called spectral-domain OCT. Faster image acquisition may also be obtained by rapidly scanning the wavelength of light from a wavelength scanning laser in a configuration called swept-wavelength OCT.

The axial spatial resolution limit of OCT is inversely proportional to the bandwidth of the probe light used. Both spectral-domain and wavelength-swept OCT are capable of axial spatial resolutions of less than 5 micrometers (μm) with sufficiently broad bandwidths of 100 nanometers (nm) or more. In spectral-domain OCT, spectral interference patterns are recorded simultaneously on multi-channel detectors such as charge-coupled device (CCD) or complementary metal-oxide-semiconductor (CMOS) cameras; A digitizer is used to record the interference pattern in successive time steps. Although swept-wavelength OCT has an acquisition speed advantage, both types of systems evolve and improve rapidly, and the resolution and speed are sufficient for the purposes of the integrated surgical system disclosed herein. Standalone OCT systems and OEM components are currently available from Optovue Inc. , Fremont, CA. , Topcon Medical Systems, Oakland, NJ, Carl Zeiss Meditec AG, Germany, Nidek, Aichi, Japan, Thorlabs, Newton, NJ, Santec, Aichi, Japan, Axsun, Billercia, MA, and other specialists. commercially available from vendors.

femtosecond laser source

A preferred surgical component of the integrated surgical system disclosed herein is the femtosecond laser. Femtosecond lasers provide highly localized non-thermal photodestructive laser-tissue interactions with minimal collateral damage to surrounding ocular tissue. Photodestructive interactions of lasers are exploited in optically transparent tissue. The main mechanism of laser energy deposition into ocular tissue is not by absorption, but by highly nonlinear multiphoton processes. This process is effective only at the focus of pulsed lasers with high peak intensities. Areas traversed by the beam but not at the focal point are not affected by the laser. Therefore, the region of interaction with ocular tissue is highly localized both transversely and axially by the laser beam. The process can also be used with weakly absorbing or weakly scattering tissue. Femtosecond lasers with photodestructive interactions have been used successfully in ophthalmic surgical systems and have been commercialized in other ophthalmic laser procedures, but none have been used in integrated surgical systems to access the iridocorneal angle. didn't come

In known refractive procedures, femtosecond lasers are used to create corneal flaps, pockets, tunnels, arcuate incisions, lenticular incisions, partial-thickness or full-thickness keratotomy for keratoplasty. For cataract treatment, the laser makes circular cuts in the eye's capsule for a capsulotomy, breaking the interior of the lens into smaller pieces that are easier to extract from various patterns in the lens. Create an incision. An access incision through the cornea opens the eye for access by manual surgical devices and for insertion of phacoemulsification and intraocular lens insertion devices. Several companies offer such surgical devices, among others, the Intralase system currently available from Johnson & Johnson Vision, Santa Ana, Calif., The LenSx and Wavelight system from Alcon, Fort Worth, TX, Bausch and Lomb, Rochester. , NY, Carl Zeiss Meditec AG, Germany, Ziemer, Port, Switzerland, and other surgical systems from LensAR, Orlando, FL.

These existing systems, developed for their specific application, corneal surgery, and the lens and its capsule, are not capable of performing iridocorneal angle 13 surgery for several reasons. First, the iridocorneal angle 13 is inaccessible to these surgical laser systems because the iridocorneal angle is too far apart in the periphery and is outside the operating range of these systems. Second, the angle of the laser beam from these systems along the optical axis 24 to the eye 1 is not adequate to reach the iridocorneal angle 13, where there is significant scattering and optical distortion at the applied wavelengths. . Third, any imaging capabilities these systems may have are limited in accessibility, penetration depth, and resolution to image tissue with sufficient detail and contrast along the trabecular meshwork outflow pathway 40. don't have

The integrated surgical system disclosed herein provides clear access to the iridocorneal angle 13 along the angled optical path 30 . Tissues, such as the cornea 3 and the aqueous humor 8 in the anterior chamber 7, are transparent along this angled optical path 30 to wavelengths between about 400 nm and 2500 nm, allowing femtosecond lasers operating in this region. can be used. Such mode-locked lasers work with titanium, neodymium, or ytterbium active materials at their fundamental wavelengths. Nonlinear frequency conversion techniques, frequency doubling, tripling, summation, and difference frequency mixing techniques known in the art, optical parameter conversion, effectively convert the fundamental wavelength of these lasers into the corneal transparency described above. Any wavelength within the wavelength range can be converted.

Existing ophthalmic surgical systems applying lasers with pulse durations longer than 1 ns have higher photodestructive threshold energies, require higher pulse energies, have larger dimensions of the photodestructive interaction range, As a result, the accuracy of surgical treatment is compromised. However, when treating the iridocorneal angle 13, higher surgical precision is required. To this end, the integrated surgical system uses pulse durations of 10 femtoseconds (fs) to 1 nanoseconds (ns) to generate photodestructive interactions between the laser beam and ocular tissue at the iridocorneal angle 13. may be configured to apply a laser having a Lasers with pulse durations shorter than 10 fs are available, but such laser sources are more complex and more expensive. Lasers with the described desirable properties, for example pulse durations of 10 femtoseconds (fs) to 1 nanoseconds (ns), are available from Newport, Irvine, Calif., Coherent, Santa Clara, Calif., Amplitude Systems, Pessac, France, NKT It is commercially available from several specialist vendors such as Photonics, Birkerod, Denmark, and others.

Accessing the Iridocorneal Angle

An important feature provided by the integrated surgical system is access to the target ocular tissue at the iridocorneal angle 13 . Referring to FIG. 6, the iridocorneal angle 13 of the eye is accessed along an angled optical path 30 through the cornea 3 and through the aqueous humor 8 in the anterior chamber 7 via an integrated surgical system. good too. For example, one or more of the diagnostic imaging beams, such as the OCT beam and/or the visual observation beam, and the laser beam may access the iris corneal angle 13 of the eye along the angled optical path 30 .

The optical system disclosed herein is configured to direct light rays along an angled optical path 30 to the iris corneal angle 13 of the eye. The optical system includes a first optical subsystem and a second optical subsystem. The first optical subsystem includes a window formed of a material of refractive index _nw and has opposite concave and convex surfaces. The first optical subsystem also includes an exit lens formed of a material having a refractive index _nx . The output lens also has opposing concave and convex surfaces. The concave surface of the output lens is configured to mate with the convex surface of the window to define a first optical axis extending through the window and the output lens. The concave surface of the window is configured to detachably couple to the cornea of the eye having a refractive index n _c such that the first optical axis is substantially aligned with the viewing direction of the eye when coupled to the eye. be.

A second optical subsystem is configured to output a light beam, such as an OCT beam or a laser beam. The optical system is configured such that the light rays are directed to enter the convex surface of the exit lens along the second optical axis at an angle α offset from the first optical axis. The respective geometries of the exit lens and window and their respective refractive indices _nx and _nw allow the refraction of light rays by bending them so that they are directed through the cornea 3 of the eye toward the iris corneal angle 13. and distortion. More specifically, the first optical system directs the light beam at an appropriate angle as it travels through the cornea and aqueous humor 8 towards the iridocorneal angle 13 in a direction along the angled optical path 30 . Bend the light rays out of the first optical subsystem and into the cornea 3 .

Accessing the iridocorneal angle 13 along the angled optical path 30 provides several advantages. An advantage of this angled optical path 30 to the iris-corneal angle 13 is that the OCT and laser beams pass through substantially transparent tissue, such as the cornea 3 and the aqueous humor 8 in the anterior chamber 7 . Therefore, scattering of these beams by tissue is not significant. For OCT imaging, this allows OCT to use shorter wavelengths, less than about 1 micrometer, to achieve higher spatial resolution. A further advantage of the angled optical path 30 through the cornea 3 and the anterior chamber 7 to the iridocorneal angle 13 is that direct laser beam or OCT beam light illuminating the retina 11 is avoided. As a result, higher average power laser and OCT light can be used for diagnostic imaging and surgery, resulting in faster procedures and less tissue movement during procedures.

Another important feature provided by the integrated surgical system is access to target ocular tissue within the iridocorneal angle 13 in a manner that reduces beam discontinuities. To this end, the window and exit lens components of the first optical subsystem reduce the discontinuity in optical refractive index between the cornea 3 and adjacent material, and prevent light from entering through the cornea at an acute angle. configured to facilitate

Having thus described the integrated surgical system and some of its features and advantages, a more detailed description of the system and its components is provided below.

integrated surgical system

Referring to FIG. 7, an integrated surgical system 1000 for non-invasive glaucoma surgery includes a control system 100, a surgical component 200, a first diagnostic imaging component 300, and an optional second diagnostic imaging component. and component 400 . In the embodiment of FIG. 7, the surgical component 200 is a femtosecond laser source, the first diagnostic imaging component 300 is an OCT imaging device, and the optional second diagnostic imaging component 400 is direct or A visual observation device for visual observation using a camera, such as a microscope. Other components of integrated surgical system 1000 include beam conditioner and scanner 500 , beam combiner 600 , focusing objective 700 , and patient contacting surface 800 .

Control system 100 may be a single computer and/or multiple interconnected computers configured to control the hardware and software components of the other components of integrated surgical system 1000. . User contact surface 110 of control system 100 accepts commands from a user and displays information for viewing by the user. Information and commands entered from the user include system commands, motion controls for docking the patient's eye to the system, selection of pre-programmed or live generated surgical plans, navigating through menu selections, and setting surgical parameters. These include, but are not limited to, settings, responses to system messages, determination and acceptance of surgical plans, and commands to execute surgical plans. Outputs from the system to the user include, but are not limited to, display of system parameters and messages, display of images of the eye, graphical, numerical and textual display of the surgical plan, and surgical progress.

Control system 100 is connected to other components 200 , 300 , 400 , 500 of integrated surgical system 1000 . Control signals from control system 100 to femtosecond laser source 200 serve to control internal and external operating parameters of the laser source, including, for example, power, repetition rate, and beam shutter. Control signals from control system 100 to OCT imaging device 300 function to control OCT beam scanning parameters, as well as the acquisition, analysis, and display of OCT images.

A laser beam 201 from a femtosecond laser source 200 and an OCT beam 301 from an OCT imaging device 300 are directed towards a beam conditioner and scanner 500 unit. Different types of scanners can be used for scanning laser beam 201 and OCT beam 301 . For scanning transverse to the beams 201, 301, galvo scanners for angular scanning are available, for example, from Cambridge Technology, Bedford, Mass., Scanlab, Munich, Germany. To optimize scan speed, scanner mirrors are generally sized to a minimum size that still accommodates the required scan angle and beam numerical aperture at the target position. The ideal beam size at the scanner is generally different from the beam size of laser beam 201 or OCT beam 301 and from the size required at the entrance of collection objective lens 700 . Thus, beam conditioners are applied before, after, or between individual scanners. Beam conditioner and scanner 500 includes a scanner that scans the beam transversely and axially. Axial scanning changes the depth of focus in the target area. Axial scanning can be performed by moving the lens axially within the optical path using a servo or stepper motor.

Laser beam 201 and OCT beam 301 are combined using a dichroic, polarized, or other type of beam combiner 600 to reach a common target or surgical volume of the eye. In an integrated surgical system 1000 having a femtosecond laser source 200, an OCT imaging device 300, and a visual observation device 400, the individual beams 201, 301, 401 for each of these components may be individually optimized. , may be collinear or non-collinear with respect to each other. Beam combiner 600 uses dichroic or polarizing beam splitters to split and recombines light of different wavelengths and/or polarizations. Beam combiner 600 may also include optics to vary certain parameters of individual beams 201, 301, 401, such as beam size, beam angle, and divergence. Integrated visual illumination, viewing, or imaging devices assist the surgeon in docking the eye to the system and identifying the surgical site.

To resolve the ocular tissue structures of the eye in sufficient detail, the diagnostic imaging components 300, 400 of the integrated surgical system 1000 may provide OCT and visual observation beams with spatial resolutions of several microns. The resolution of an OCT beam is the spatial dimension of the smallest feature that can be recognized in an OCT image. It is primarily determined by the wavelength and spectral bandwidth of the OCT source, the quality of the optics delivering the OCT beam to the target location of the eye, the numerical aperture of the OCT beam, and the spatial resolution of the OCT imaging device at the target location. In one embodiment, the OCT beam of the integrated surgical system has a resolution of 5 μm or less.

Similarly, the surgical laser beam provided by femtosecond laser source 200 may be delivered to a target location with an accuracy of a few microns. The resolution of a laser beam is the spatial dimension of the smallest feature at the target location that can be modified by the laser beam without significantly affecting the surrounding ocular tissue. It is primarily determined by the wavelength of the laser beam, the quality of the optics delivering the laser beam to the target location of the eye, the numerical aperture of the laser beam, the energy of the laser pulses in the laser beam, and the spatial resolution of the laser scanning system at the target location. be done. In addition, the laser spot size should be about 5 μm or less to minimize the threshold energy of the laser for photodestructive interactions.

Visual observation beam 401 is acquired by visual observation device 400 using fixed, non-scanning optics, while OCT beam 301 of OCT imaging apparatus 300 is laterally scanned in two transverse directions. The laser beam 201 of the femtosecond laser source 200 is scanned in two lateral directions and the depth of focus is scanned axially.

For practical embodiments, beam conditioning, scanning, and combining optical paths are specific functions performed on laser, OCT, and visual observation optical beams. The implementation of those functions may occur in a different order than shown in FIG. The particular optical hardware that manipulates the beam to achieve those functions can have multiple configurations as to how the optical hardware is arranged. They can be arranged to steer individual optical beams separately, or in another embodiment one component may combine functions to steer different beams. For example, a single set of scanners can scan both laser beam 201 and OCT beam 301 . In this case, separate beam conditioners set the beam parameters for laser beam 201 and OCT beam 301, and then a beam combiner combines the two beams for a single set of scanners to scan the beams. Although many combinations of optical hardware configurations are possible for the integrated surgical system, the following sections describe exemplary configurations in detail.

beam delivery

In the following description, the term beam may refer to one of a laser beam, an OCT beam, or a visual observation beam, depending on the context. A combined beam refers to two or more of a laser beam, an OCT beam, or a visual observation beam that are collinearly combined or non-linearly combined. Exemplary combined beams include combined OCT/laser beams, which are collinear or non-collinear combinations of OCT and laser beams, and collinear or non-collinear OCT, laser, and eye beams. A synthetic OCT/laser/eye beam, which is an interesting combination. In the case of collinearly combined beams, different beams may be combined by dichroic or polarizing beam splitters and delivered along the same optical path by multiplex delivery of the different beams. In the case of non-collinearly combined beams, different beams are delivered simultaneously along different optical paths separated either spatially or by an angle in between. In the following discussion, any of the above beams or composite beams may be collectively referred to as rays. The terms distal and proximal are sometimes used to designate the direction of beam travel or the physical position of components relative to each other within an integrated surgical system. The distal direction refers to the direction toward the eye, and thus the OCT beam output by the OCT beam imaging device travels distally toward the eye. The proximal direction refers away from the eye, so the OCT return beam from the eye travels proximally towards the OCT imaging device.

Referring to FIG. 8, an example integrated surgical system delivers a laser beam 201 and an OCT beam 301, respectively, distally toward eye 1 and receives an OCT return beam and a visual observation beam 401, respectively, returning from eye 1. configured as Regarding laser beam delivery, the laser beam 201 output by the femtosecond laser source 200 passes through a beam conditioner 510 where the basic beam parameters, beam size and divergence are set. The beam conditioner 510 may also include additional functions to set the beam power or pulse energy, block the beam and turn that function on and off. After exiting beam conditioner 510 , laser beam 210 enters axial scan lens 520 . Axial scan lens 520 may include a single lens or group of lenses and is movable in axial direction 522 by a servo motor, stepper motor, or other control mechanism. Axial 522 movement of the axial scan lens 520 changes the axial distance of the focal point of the laser beam 210 at the focal point.

According to certain embodiments of the integrated surgical system, intermediate focus 722 is set to lie within conjugate surgical volume 721, which is the image conjugate of surgical volume 720 determined by collection objective 700, in which can be scanned with The surgical volume 720 is the spatial extent of the region of interest within the eye where imaging and surgery are performed. For glaucoma surgery, the surgical volume 720 is the vicinity of the iridocorneal angle 13 of the eye.

A pair of transverse scan mirrors 530, 532 rotated by the galvo scanner scan the laser beam 201 in two essentially orthogonal transverse directions, eg, the x and y directions. Laser beam 201 is then directed toward dichroic or polarizing beam splitter 540 where it is reflected toward beam combining mirror 601 , which is configured to combine laser beam 201 with OCT beam beam 301 . be.

For OCT beam delivery, OCT beam 301 output by OCT imaging device 300 passes through beam conditioner 511 , axially movable collecting lens 521 , and transverse scanner by scan mirrors 531 and 533 . Condenser lens 521 is used to set the focal position of the OCT beam in conjugate surgical volume 721 and actual surgical volume 720 . Condensing lens 521 is not scanned to obtain an OCT axial scan. The axial spatial information of the OCT image is obtained by Fourier transforming the interferometrically recombined OCT return beam 301 and reference beam 302 spectra. However, if the surgical volume 720 is divided into several axial segments, the collecting lens 521 can be used to refocus. In this manner, the optimal imaging spatial resolution of the OCT beam image can be extended beyond the Rayleigh range of the OCT signal beam at the expense of time spent scanning at multiple ranges.

Proceeding distally toward eye 1 , after scanning mirrors 531 and 533 , OCT beam 301 is combined with laser beam 201 by beam combiner mirror 601 . The OCT beam 301 and laser beam 201 components of combined laser/OCT beam 550 are multiplexed, travel in the same direction, and are focused at intermediate focus 722 within conjugate surgical volume 721 . After being focused in conjugate surgical volume 721 , combined laser/OCT beam 550 propagates to second beam combining mirror 602 where it is combined with viewing beam 401 to form combined laser/OCT/viewing beam 701 . .

The distally traveling combined laser/OCT/viewing beam 701 then passes through a focusing objective lens 700 and a window 801 in the patient-contacting surface, at which window the intermediate focus of the laser beam within the conjugate surgical volume 721. 722 is re-imaged to the focal point of surgical volume 720 . The collection objective 700 reimages the intermediate focus 722 onto the ocular tissue within the surgical volume 720 through a window 801 in the patient contacting surface.

The scattered OCT return beam 301 from the ocular tissue travels proximally back to the OCT imaging device 300 along the same path and in reverse order as described above. The reference beam 302 of the OCT imaging system 300 passes through the reference delay path and returns from the movable mirror 330 to the OCT imaging system. The reference beam 302 is interferometrically combined with the OCT return beam 301 as it returns within the OCT imaging apparatus 300 . The amount of delay in the reference delay path can be adjusted by moving movable mirror 330 to equalize the optical paths of OCT return beam 301 and reference beam 302 . For best axial OCT resolution, the OCT return beam 301 and reference beam 302 are also dispersion compensated to equalize the group velocity dispersion in the two arms of the OCT interferometer.

When the combined laser/OCT/viewing beam 701 is delivered through the cornea 3 and anterior chamber 7, the combined beam passes through the posterior and anterior surfaces of the cornea at acute angles off normal incidence. These surfaces in the path of the combined laser/OCT/viewing beam 701 create excessive astigmatism and coma that need to be canceled.

9a and 9b, in one embodiment of the integrated surgical system 1000, the optical components of the focusing objective lens 700 and the patient contacting surface 800 are arranged to minimize spatial and chromatic aberration and distortion. Configured. Figure 9a shows the configuration when the eyes 1, the patient contact surface 800 and the collection objective lens 700 are all coupled together. Figure 9b shows the configuration when the eyes 1, the patient contact surface 800 and the collecting objective 700 are all separated from each other.

Patient contacting surface 800 optically and physically couples eye 1 to focusing objective 700 , which in turn optically couples to other optical components of integrated surgical system 1000 . Patient contacting surface 800 serves multiple functions. It immobilizes the eye relative to the components of the integrated surgical system, creates a sterile barrier between the components and the patient, and provides optical access between the eye and instruments. Patient-contacting surface 800 is a sterile, single-use, disposable device that is detachably coupled to eye 1 and focusing objective 700 of integrated surgical system 1000 .

The patient contacting surface 800 includes a window 801 having a concave surface 812 facing the eye and a convex surface 813 facing the objective lens opposite the concave surface. Therefore, window 801 has a meniscus shape. Referring to FIG. 9c, concave surface 812 is characterized by a radius of curvature r _e and convex surface 813 is characterized by a radius of curvature r _w . Concave surface 812 is configured to couple to the eye by direct contact or by an index-matching material, liquid, or gel disposed between concave surface 812 and eye 1 . Window 801 may be formed of glass and has a refractive index _nw . In one embodiment, window 801 is formed of fused silica and has a refractive index _nw of 1.45. Fused silica has the lowest refractive index of common inexpensive glasses. Fluoropolymers such as Teflon AF are another class of low index materials that have a lower index of refraction than fused silica, but their optical quality is lower than that of glass and they are relatively expensive for mass production. . In another embodiment, window 801 is formed of common glass BK7 and has a refractive index _nw of 1.50. A radiation resistant version of this glass, BK7G18 by Schott AG, Mainz, Germany, allows gamma sterilization of the patient contact surface 800 without altering the optical properties of the window 801 upon gamma irradiation.

Returning to FIGS. 9a and 9b, the window 801 is surrounded by walls 803 of the patient contacting surface 800 and an immobilizing device such as a suction ring 804. FIG. When the suction ring 804 is in contact with the eye 1, an annular cavity 805 is formed between the suction ring and the eye. When vacuum is applied to the suction ring 804 and the cavity via a vacuum tube or vacuum pump (not shown in FIGS. 9a and 9b), the vacuum force between the eye and the suction ring keeps the eye out of patient contact during surgery. Attached to surface 800 . Eye 1 is released or separated by removing the vacuum.

The end of the patient contacting surface 800 opposite the eye 1 is configured to fix the position of the eye relative to other components of the integrated surgical system 100 by attaching to the housing 702 of the focusing objective 700. and attachment contact surface 806 . The attachment contact surface 806 works on mechanical, vacuum, magnetic or other principles and is separable from the integrated surgical system.

The collection objective 700 includes an aspherical exit lens 710 having a concave surface 711 facing the eye and a convex surface 712 opposite the concave surface. Therefore, output lens 710 has a meniscus shape. The exit lens 710 shown in Figures 9a and 9b is an aspheric lens for greater design flexibility, but in other configurations the exit lens may be a spherical lens. Alternatively, constructing the output lens 710 as a compound lens rather than a single lens allows greater design freedom to optimize the optical components while preserving the main properties of the optical system presented here. Referring to FIG. 9c, concave surface 711 is characterized by a radius of curvature r _y and convex surface 712 is characterized by an aspheric shape. The aspheric convex surface 712 combines with the spherical concave surface 711 into an output lens 710 having a variable thickness, the outer edge 715 of the lens being thinner than the central vertex region 717 of the lens. Concave surface 711 is configured to mate with convex surface 813 of window 801 . In one embodiment, exit lens 710 is formed of fused silica and has a refractive index _nx of 1.45.

FIGS. 10a and 10b are functionally arranged to form an optical system 1010 having a first optical subsystem 1001 and a second optical subsystem 1002 to provide access to an iridocorneal angle surgical volume 720. FIG. 9 is a schematic diagram of the components of the integrated surgical system of FIGS. 7 and 8; FIG. Figures 10a and 10b each include components of the collection objective 700 and patient contacting surface 800 of Figure 9a. However, for the sake of simplicity, the entire collection objective and patient contact surface are not included in Figures 10a and 10b. Also, to further simplify FIG. 10a, the planar beam folding mirror 740 of FIGS. 9a and 9b is not included and the combined laser/OCT/viewing beam 701 shown in FIG. 9a is not folded or stretched. It will be appreciated by those skilled in the art that adding or removing a planar beam folding mirror does not change the principle operation of the optical system formed by the first optical subsystem and the second optical subsystem. . Figure 10c is a schematic diagram of the beam passing through the first optical subsystem of Figures 10a and 10b.

Referring to FIG. 10a, the first optical subsystem 1001 of the integrated surgical system 1000 includes the output lens 710 of the collection objective lens 700 and the window 801 of the patient contacting surface 800. FIG. Output lens 710 and window 801 are positioned relative to each other to define a first optical axis 705 . A first optical subsystem 1001 receives a beam, eg, a combined laser/OCT/viewing beam 701, incident on a convex surface 712 of an output lens 710 along a second optical axis 706 and directs the beam to the iris corneal angle 13 of the eye. is configured to direct toward a surgical volume 720 of .

During a surgical procedure, first optical subsystem 1001 may be assembled by interfacing convex surface 813 of window 801 with concave surface 711 of exit lens 710 . For this purpose, the collection objective lens 700 is docked with the patient contact surface 800 . As a result, concave surface 711 of exit lens 710 is coupled to convex surface 813 of window 801 . Coupling may be by direct contact or by a layer of index-matching fluid. For example, when docking the patient-contacting surface 800 to the focusing objective 700, a droplet of index-matching fluid is applied between the contacting surfaces to eliminate any air gaps between the two surfaces 711, 813. can help the combined laser/OCT/viewing beam 701 pass through the gap with minimal Fresnel reflections and distortion.

First optical subsystem 1001 refracts beam 701 as it passes through exit lens 710 , window 801 , and cornea 3 to direct the beam toward surgical volume 720 at iris-corneal angle 13 of the eye. Designed to be taken into account. For this purpose, referring to FIG. 10c, the refractive index nx of the exit lens 710 and the refractive index _nw of the window 801 are selected with respect to the refractive index _nc of the cornea ₃ so that the beam 701 passes through the subsystem. The beam is appropriately bent through the first optical subsystem 1001 so that the optical path is substantially aligned to be within the iridocorneal angle 13 when exiting and passing through the cornea 3 .

Continuing to refer to FIG. 10c, we begin with the contact surface between window 801 and cornea 3 . At the interface where the combined laser/OCT/viewing beam 701 exits the window 801 and enters the cornea 3, i.e., between the concave surface 812 of the window and the convex surface of the cornea 3, excessive refraction occurs if the angle of incidence is too acute. and distortion. To minimize refraction and distortion at this interface, in one embodiment of first optical subsystem 1001 the refractive index of window 801 is closely matched to the refractive index of cornea 3 . For example, as described above with reference to Figures 9a and 9b, window 801 may have a refractive index of less than 1.42 to closely match the cornea 3, which has a refractive index of 1.36. .

Excessive refraction and distortion at the interface where the combined laser/OCT/viewing beam 701 exits the window 801 and enters the cornea 3 can be further reduced by controlling the bending of the beam 701 as it passes through the exit lens 710 and window 801. may be offset. To this end, in one embodiment of the first optical subsystem 1001, the refractive index nw of the window 801 is higher than the refractive index _nx of the exit lens ₇₁₀ and the refractive index _nc of the cornea 3, respectively. As a result, at the interface where the combined laser/OCT/viewing beam 701 exits the exit lens 710 and enters the window 801, i.e., between the concave surface 711 of the exit lens and the convex surface 813 of the window, the beam A lower refractive index change is passed through, which bends the beam in a first direction. Next, at the interface where the combined laser/OCT/viewing beam 701 exits the window 801 and enters the cornea 3, i.e., the interface between the concave surface 812 of the exit lens and the convex surface of the cornea, the beam travels from low to high. which bends the beam in a second direction opposite the first direction.

The shape of window 801 is chosen to be a meniscus lens. Therefore, the angles of incidence of light have similar values on both surfaces 812 , 813 of the window 801 . The overall effect is that convex surface 813 bends the light away from the surface normal and concave surface 812 bends the light towards the surface normal. This action is similar to when light passes through a plane parallel plate. Refractions at one surface of the plate are canceled by refractions at the other surface, leaving the direction of light passing through the plate unchanged. By setting the curvature at the light input surface such that the angle of incidence β of light 701 at the light input surface is close to the surface normal 707 to the light input surface at intersection 708, the output lens 710 distal to the eye Refraction at the entrance-side convex surface 712 is minimized.

Here, exit lens 710 , window 801 and eye 1 are arranged as an axisymmetric system with first optical axis 705 . In practice, due to manufacturing and alignment errors in optical components, natural deviations from eye symmetry, and errors in alignment of the eye with respect to window 801 and exit lens 710 in clinical settings, axial symmetry is an approximation. However, for design and practical purposes, eye 1 , window 801 and exit lens 710 are considered an axisymmetric first optical subsystem 1001 .

With continued reference to FIG. 10a, the second optical subsystem 1002 is optically coupled to the first optical subsystem 1001 at an angle α with respect to the first optical axis 705 of the first optical subsystem 1001. be. The advantage of this arrangement is that both optical subsystems 1001, 1002 can be designed with a much lower numerical aperture compared to an on-axis designed system where all optical components have a common optical axis. is.

The second optical subsystem 1002 includes a relay lens 750 that creates a conjugate surgical volume 721 of the surgical volume 720 within the eye, as described above with reference to FIG. Second optical subsystem 1002 includes various other components, shown collectively as optical subsystem block 1003 . Referring to FIG. 8, these components may include a femtosecond laser source 200, an OCT imaging device 300, a visual observation device 400, a beam conditioner and scanner 500, and a beam combiner 600.

Second optical subsystem 1002 may include mechanical components (not shown) configured to rotate the entire subsystem about first optical axis 705 of first optical subsystem 1001. . This allows optical access to the entire 360° circumference of the iris corneal angle 13 of the eye 1 .

Referring to FIG. 10b, the flexibility of placement for each of the first and second optical subsystems 1001, 1002 is determined by the optical output of the second optical subsystem 1002 and the optical input of the first optical subsystem 1001. In between, the optical assembly 1004 may be provided by being sandwiched. In one embodiment, optical assembly 1004 receives the optical output of second optical subsystem 1002, such as combined laser/OCT/viewing beam 701, and redirects or adjusts the direction of the combined laser/OCT/viewing beam to one or more planes configured to direct the beam into the optical input of the first optical subsystem 1001 while preserving the angle α between the optical axis 705 of and the second optical axis 706 of A beam folding mirror 740, a prism (not shown), or an optical grating (not shown) may be included.

In another configuration, the optical assembly 1004 of the planar beam folding mirror 740 further rotates the assembly about the first optical axis 705 of the first optical subsystem 1001 while keeping the second optical subsystem 1002 stationary. It includes mechanical parts (not shown) that are configured to rotate. Accordingly, the second optical axis 706 of the second optical subsystem 1002 can be rotated about the first optical axis 705 of the first optical subsystem 1001 . This allows optical access to the entire 360° circumference of the iris corneal angle 13 of the eye 1 .

9a, 9b, and 9c, the design of the first optical subsystem 1001 provides an angular optical access at an angle α with respect to the first optical axis 705 of the first optical subsystem 1001. optimized for Optical access at angle α cancels optical aberrations of first optical subsystem 1001 . Table 1 shows the results optimized with an access angle α=72° using the Zemax optical design software package. This design is a practical embodiment for image-guided femtosecond glaucoma surgery.

This design produces diffraction-limited collection of a 1030 nm wavelength laser beam and an 850 nm wavelength OCT beam with a numerical aperture (NA) of 0.2 or less. In one design, the optical aberrations of the first optical subsystem are canceled to the extent that the Strehl ratio of the first optical subsystem is greater than 0.9 for beams with numerical apertures greater than 0.15 at iridocorneal angles. . In another design, the optical aberrations of the first optical subsystem are partially canceled, and the remaining uncanceled aberrations of the first optical system are reduced by the second optical subsystem to a numerical aperture of 0.0 at the iridocorneal angle. To the extent that the combined Strehl ratio of the first and second optical subsystems for beams greater than 15 is greater than 0.9.

Proofreading

The femtosecond laser source 200, OCT imaging device 300, and visual observation device 400 of the integrated surgical system 1000 are first individually calibrated to ensure their internal integrity and then for system integrity. Cross calibrated. An essential part of system calibration is the focal position achieved when the surgical focus of laser beam 201 is brought to a position in surgical volume 720 as identified by OCT imaging equipment and/or visual observation device 400. is to match the collected focal position within a certain tolerance, typically within 5-10 μm. Also, the graphics and cursor output, images, overlays, and user input of the position of the eye tissue surgical volume 720 received from the user interface 110 displayed on the user interface 110, such as a computer monitor, are within predetermined tolerances of similar accuracy. should correspond to the actual location in the tissue.

One embodiment of this spatial calibration procedure is to calibrate OCT beam imaging apparatus 300 and/or visual observation device 400 and their displays in such a way that the scale values on the display match the actual scale of the calibration target. Begin with imaging of pre-scaled and scaled magnification. A laser calibration pattern is then exposed or printed onto a transparent calibration target, and the calibration pattern is subsequently imaged. The intended pattern and the actual printed pattern are then compared using the diagnostic imaging system of integrated surgical system 1000 or by a separate microscope. If they do not match within specified tolerances, the scaling parameters of the surgical pattern are rescaled by adjusting the scaling of the laser beam scanner. This procedure is repeated as necessary until all spatial calibrations are within tolerance.

minimally invasive surgical treatment

FIG. 11 is a three-dimensional schematic representation of the anatomy of the eye for surgical treatment enabled by the integrated surgical system 1000. FIG. To reduce IOP, laser therapy targets ocular tissues that affect the trabecular outflow pathway 40 . These ocular tissues may include trabecular meshwork 12, scleral spines 14, Schlemm's canal 18, and collector channels 19. The trabecular meshwork 12 has three layers: the uvea 15 , the corneoscleral retinal 16 , and the paraschlemm's canal tissue 17 . These layers are porous and water permeable, with the uvea 15 being the most porous and permeable, followed by the corneoscleral meshwork 16 being the second most porous and permeable. The least porous and least permeable layer of the trabecular meshwork 12 is the para-Schlemm's canal 17 . The inner wall 18 a of Schlemm's canal 18 is also porous and water permeable, with similar properties to the para-Schlemm's canal 17 .

FIG. 12 shows a three-dimensional view of the treatment pattern P1 applied by the integrated surgical system 1000 to affect the ocular tissue surgical volume 900 shown in FIG. A two-dimensional schematic diagram is included. FIG. 13 is a three-dimensional schematic illustration of the anatomy of the eye, including an opening 902 therethrough, resulting from application of the laser treatment pattern of FIG. Aperture 902 provides an outflow pathway 40 that reduces flow resistance in the ocular tissue and increases water flow from anterior chamber 7 to Schlemm's canal 18, thereby lowering IOP of the eye.

Surgical treatment reduces the resistance of the outflow pathway while minimizing ocular tissue modification through the design and selection of the laser treatment pattern. A treatment pattern is thought to define a collection of laser-tissue interaction volumes, referred to herein as cells. The size of the cell depends on the degree of influence of the laser-tissue interaction. If the laser spots or laser cells are closely spaced along the line, the laser creates narrow microscopic channels. A wide channel can be achieved by closely spacing multiple laser spots within the cross-section of the channel. The arrangement of cells can resemble the arrangement of atoms in a crystal structure.

Referring to FIG. 12, the treatment pattern P1 can be in the form of a cubic structure containing individual cells arranged in regularly spaced rows, columns, and slices or layers. The treatment pattern P1 can be characterized by x, y, z dimensions, where the x, y, z coordinates of a cell are column position (x coordinate), row position (y coordinate), layer position (z coordinates) are calculated from neighborhood to neighborhood. Such a treatment pattern P1 defines a three-dimensional model of the ocular tissue to be modified by the laser or of the ocular fluid affected by the laser.

A treatment pattern P1 is typically defined by a set of surgical parameters. The surgical parameters may include one or more of the treatment areas A, which correspond to the ocular tissue surface area or layers through which the laser passes. The treatment area A is determined by the treatment height h and the treatment lateral extent w. The treatment thickness t, which corresponds to the level at which the laser cuts into the ocular tissue, extends from the distal extent or border of the treatment volume at or near Schlemm's canal 18 to at or near the surface of trabecular meshwork 12. It extends to the proximal extent or border. Thus, a laser applied in accordance with the treatment pattern can affect or result in a surgical volume that resembles the three-dimensional model of the treatment pattern, or can be used inside the eye structure that the three-dimensional model resembles. It can also affect the fluid in the

Additional surgical parameters define the placement of the surgical or diseased volume within the eye. For example, referring to FIGS. 11 and 12, the placement parameters include the location l corresponding to where the treatment is to occur relative to the eye circumference angle, and the location l in the eye relative to the reference eye structure. One or more of the treatment depths d may correspond to a portion of a three-dimensional model of ocular tissue or ocular fluid. Below, the treatment depth d is indicated and expressed relative to the area where the anterior chamber 7 meets the trabecular meshwork 12 . Together, the treatment pattern and placement parameters define a treatment plan.

Femtosecond lasers provide highly localized non-thermal light-cutting laser-tissue interactions with minimal collateral damage to surrounding ocular tissue. The photo-cutting interaction of lasers is exploited in light transmissive tissue. The primary mechanism of laser energy deposition into ocular tissue is not through absorption, but through highly nonlinear multiphoton processes. This process is effective only for focusing pulsed lasers with high peak intensities. Areas traversed by the laser beam but not at the focal point are unaffected by the laser. Therefore, the area of interaction with ocular tissue is highly confined both laterally and axially along the laser beam.

11 and 12, according to embodiments disclosed herein, an ocular tissue surgical volume 900 to be treated is identified by the surgical system 1000, and a treatment pattern P1 corresponding to the surgical volume is determined by the integrated surgical system. designed. Alternatively, the treatment pattern P1 may be designed first, and then a suitable surgical volume 900 to apply the treatment pattern may be identified. The ocular tissue surgical volume 900 can consist of a portion of the trabecular meshwork 12 and Schlemm's canal 18 . For example, the ocular tissue surgical volume 900 shown in FIG. 11 includes the uvea 15 , the corneoscleral retinal 16 , the parascleral canal tissue 17 , and a portion of the inner wall 18 a of Schlemm's canal 18 . Treatment pattern P1 defines a laser scanning procedure by which the laser is focused at various depth points in the ocular tissue, thereby forming a three-dimensional tissue consisting of multiple diseased tissue slices or layers. Multiple directions are scanned to affect the volume.

12 and 13, over a laser scanning procedure, a surgical laser 701 follows a treatment pattern P1 from the anterior chamber 7 to the uvea 15 of the trabecular meshwork 12, the corneoscleral retinal 16, and the parascleral canal tissue. 17, as well as the inner wall 18a of Schlemm's canal 18, respectively. Although the example aperture 902 in FIG. 13 is depicted as one unbroken lumen that is considered a fluid pathway, the aperture is a series of adjacent pores that form a sponge-like structure that is considered a fluid pathway. or a combination thereof. The example opening 902 in FIG. 13 is cubical in shape, but the shape of the opening may be other geometric shapes.

The movement of the laser as it scans to affect the surgical volume 900 follows a treatment pattern P1 defined by a set of surgical parameters including treatment area A and thickness t. The treatment area A is defined by width w and height h. Width may be defined as a measurement about an inscribed angle. For example, the width w may be defined as an angle about the circumference angle, eg, 90 degrees.

11 and 12, the first placement of the laser focus in the eye is defined by a set of placement parameters, including depth d and location l. Location l is the point centered on the eye circumference angle where laser treatment begins, while depth d is between the anterior chamber 7 and Schlemm's canal 18 where laser treatment begins or ends. It's about dots. Depth d is measured to the area where the anterior chamber 7 meets the trabecular meshwork 12 . Therefore, it can be said that the first point of the trabecular meshwork 12 closer to the Schlemm's canal 18 side is deeper than the second point of the trabecular meshwork 12 closer to the anterior chamber 7 side. Alternatively, the second point can be said to be shallower than the first point.

Referring to FIG. 13, the aperture 902 resulting from the laser application of treatment pattern P1 resembles surgical volume 900 and is characterized by an area A and thickness t similar to those of the surgical volume and treatment pattern. . The thickness t of the resulting aperture 902 extends from the anterior chamber 7 through the inner wall 18 a of Schlemm's canal 18 , while the area A refers to the cross-sectional size of the aperture 902 .

According to embodiments disclosed herein, over a laser scanning procedure, the laser focus is shifted to different depths d in the ocular tissue, thereby scanning a three-dimensional ocular tissue volume consisting of multiple diseased tissue slices or layers. 900, scan in two lateral dimensions as defined by the treatment pattern P1. The lateral two dimensions are approximately orthogonal to the axis of motion of the laser focus. Referring to FIG. 13, the movement of the laser focus over the laser scan is represented herein in the x-, y-, and z-directions, i. That is, movement of the laser focus to different depths d through the thickness t of the tissue volume 900 corresponds to movement of the focus along the z-axis, and 2) movement of the laser focus in two dimensions or directions orthogonal to the z-axis. Movement corresponds to movement of the laser focus along the treatment pattern P1, ie the width w of the tissue volume 900, in the x-direction, and movement of the laser focus along the treatment pattern P1, ie, the height h of the tissue volume 900, in the y-direction.

As used herein, scanning the laser focal point roughly corresponds to raster movement of the laser focal point in the x-, y-, and z-directions. The laser focal point can be raster scanned in the x and y directions, which are two-dimensional or two-dimensional, if at a point in the z-direction. The focal point of the laser in the z-direction can be the depth d within the treatment pattern P 1 or tissue volume 900 . Bi-directional raster scanning of the laser focus defines the laser scan layer, which in turn results in the tissue layer affected by the laser.

During laser scanning, pulsed shots of the laser are delivered to tissue within the ocular tissue volume corresponding to treatment pattern P1. Since the laser interaction volume is small, on the order of a few micrometers (μm), the interaction of the eye tissue with each laser shot of the repeated laser destroys the eye tissue locally at the laser focus. Laser pulse durations for photodestructive interactions in ocular tissue can range from femtoseconds to nanoseconds and pulse energies from nanojoules to tens of microjoules. A laser pulse at the focal point undergoes a multiphoton process that breaks chemical bonds in molecules, locally photolyzes tissue material, and creates gas bubbles in wet tissue. Mechanical stress due to the breakdown of tissue material and bubble formation causes the tissue to fragment and produce well-defined continuous cuts when laser pulses are brought close together along geometric lines and surfaces.

Table 2 provides examples of treatment pattern parameters and surgical laser parameters for treating tissue. The parameter set range is limited to the practical range depending on the laser repetition rate and scanner scan speed.

11, 12, 13, 14a, and 14b, in certain laser scanning procedures, scanning begins at the edge of the treatment pattern P1 adjacent the anterior chamber 7 and extends in a direction approximately corresponding to the direction of propagation of the laser 701. proceed to More specifically, also referring to FIG. 14a, the laser scan proceeds in the z-direction toward the inner wall 18a of the anatomy, e.g. It advances toward the inner wall 18 a of Schlemm's canal 18 .

However, such laser scanning may be ineffective in creating the desired opening 902 between the anterior chamber 7 and Schlemm's canal 18 due to obstruction by air bubbles that occur during laser application. As mentioned above, femtosecond lasers produce very short pulses of light energy. When such a pulsed beam is focused into a very small spatial volume characterized by a small cross-sectional area, non-linear effects occur within this focal spot. When such a focal spot is aimed at tissue, the tissue is photodissected (broken) leaving behind small gas bubbles. This process is in principle non-thermal and requires negligible energy. The result is that the surrounding tissue is unaffected.

However, when the femtosecond laser beam is scanned across the surface of the tissue, this first superficial laser treatment produces a bubble layer throughout the treated area. As the laser scans tissue layers below the first superficial layer, i.e. deeper than the first superficial layer, such air bubbles create a shadow effect that scatters the incident laser light, effectively preventing further treatment of this tissue. . This negates further laser treatment of tissue below or deeper than the first superficial layer.

An example of this effect with glaucoma surgery is shown in Figures 14a and 14b. In Figure 14a, the focal _point of the laser beam 701 is initially at depth d1. This depth d1 causes the laser focus to hit the tissue layer 904 for the _first time. For example, the first tissue layer 904 can be at the interface between the uvea 15 of the trabecular meshwork 12 and the anterior chamber 7 . In this case, this depth point of the laser focus is the null depth and the first layer 904 to be treated corresponds to the surface of the uvea 15 facing the anterior chamber 7 . Once the laser focus is positioned at the _first depth d1, the focus is scanned in multiple directions while remaining at the first depth. Referring to FIG. 14a, the multiple directions are the x-direction and the y-direction, the x-direction being in the plane of FIG. 14a.

Referring to FIG. 14b, raster scanning in multiple directions results in photodissection of a first tissue layer 904 and formation of an air bubble layer 906 in the first tissue layer. The focus of the laser beam 701 is then shifted in the z _- direction toward the inner wall 18a of Schlemm's canal 18 to another depth d2. This depth d ₂ causes the second and subsequent tissue layers 908 that are deeper than the first layer 904 to be laser focused. For example, the deeper tissue layer may consist of the uvea 15 of the trabecular meshwork 12 . When the laser focus is positioned on layer 908 for the second and subsequent times, the focus is raster scanned in multiple directions while remaining at that depth. However, in this case, the bubble layer 906 scatters the incident laser light, effectively preventing further treatment of the tissue in the layer 908 for the second and subsequent times.

11, 12, 13, 15a-15g, according to embodiments of the present disclosure, the above-described ineffective raster treatment whereby the raster scan begins at the edge of treatment pattern P1 adjacent to Schlemm 18 and laser 701 This is avoided by implementing a raster scanning procedure that runs substantially opposite or in a direction substantially opposite to the direction of propagation. More specifically, also referring to FIG. 15a, the laser scan begins at an anatomical structure, such as the inner wall 18a of Schlemm's canal 18, and proceeds behind that structure in the z-direction toward the anterior chamber 7, while The direction of propagation of laser 701 is toward the structure.

In this scanning procedure, a femtosecond pulsed laser beam is focused into the eye tissue volume at the first depth of the tissue volume, ie away from the surface of the tissue volume. A first tissue layer at a first depth is treated which creates an air bubble layer in the area of the first layer. After treating the first tissue layer, the laser is refocused on subsequent tissue layers that are shallower than the first tissue layer, ie, at a depth closer to the surface of the ocular tissue volume than the first depth. Since the bubble layer in the area of the first layer is below the second layer, the bubbles do not block the second layer. This process is repeated until the laser scans layer-by-layer through the ocular tissue volume and onto the surface of the tissue volume.

An example of this scanning procedure following glaucoma surgery is shown in Figures 15a-15g. In Figure 15a, the focal _point of the laser beam 701 is initially at depth d1. This depth d1 causes the laser focus to hit the tissue layer 910 for the _first time. For example, the first tissue layer 910 can consist of the inner wall 18 a of Schlemm's canal 18 . Once the laser focus is positioned at the _first depth d1, the focus is scanned in multiple directions while remaining at the _first depth d1. Referring to FIG. 15a, the multiple directions are the x-direction and the y-direction, with the x-direction being in the plane of FIG. 15a.

Referring to FIG. 15b, laser scanning in multiple directions results in photodissection of the formation of a first tissue layer 910 and an air bubble layer 912 at the point of the first tissue layer. The focus of the laser beam 701 is then shifted in the z-direction toward the anterior chamber 7 to a _second and subsequent depth d2. The second and subsequent depths d ₂ bring the laser focus to second and subsequent tissue layers 914 that are shallower than the first tissue layer 910 . For example, the second and subsequent tissue layers 914 can consist of the inner wall 18 a of Schlemm's canal 18 , the para-Schlemm's canal tissue 17 , and a portion of the corneoscleral retina 16 . When the laser focus is positioned at the _second and subsequent depths d2, the focus is scanned in multiple directions while remaining at the _second and subsequent depths d2. Because the bubble layer 912 is below the second and subsequent layers 914, the bubble does not impede or block laser access to photoablation of the second or subsequent layers.

Referring to FIG. 15c, laser scanning in multiple directions results in photodisruption of the second and subsequent tissue layers 914 and the formation of the bubble layer 916 at the point of the second and subsequent tissue layers. The focus of the laser beam 701 is then shifted in the z-direction toward the anterior chamber 7 to a _second and subsequent depth d3. The second and subsequent depths d ₃ bring the laser focus to the second and subsequent tissue layers 918 that are shallower than the second and subsequent tissue layers 914 . For example, the second and subsequent tissue layers 914 can consist of part of the parasclemman canal tissue 17 and of the horn scleral retina 16 . When the laser focus is positioned at the _second and subsequent depths d3 _, the focus is scanned in multiple directions while remaining at the second and subsequent depths d3. Because the bubble layers 912, 916 are below the second and subsequent layers 918, the bubbles do not impede or block laser access to photodissection of the second or subsequent layers.

Referring to FIG. 15d, laser scanning in multiple directions results in photodisruption of a second and subsequent tissue layer 918 and formation of a bubble layer 920 at the point of the second and subsequent tissue layers. The focus of the laser beam 701 is then shifted in the z-direction toward the anterior chamber 7 to a _second and subsequent depth d4. The second and subsequent depths d4 bring the laser focus to the second and subsequent tissue layers 922 that are shallower than the second and subsequent tissue layers 918 . For example, the second and subsequent tissue layers 922 can consist of portions of the corneoscleral retina 16 and of the uvea 15 . When the laser focus is positioned at the _second and subsequent depths d4, the focus is scanned in multiple directions while remaining at the _second and subsequent depths d4. Because the bubble layers 912, 916, 920 are below the second and subsequent layers 922, the bubbles do not impede or prevent laser access to photodissection of the second or subsequent layers.

Referring to FIG. 15e, laser scanning in multiple directions results in photodisruption of a second and subsequent tissue layer 922 and formation of a bubble layer 924 at the point of the second and subsequent tissue layers. The focus of the laser beam 701 is then shifted in the z-direction toward the anterior chamber ₇ to a second and subsequent depth d5. The second and subsequent depths d ₅ bring the laser focus to the second and subsequent tissue layers 926 that are shallower than the second and subsequent tissue layers 922 . For example, the second and subsequent tissue layers 926 can consist of the uvea 15 . _When the laser focus is positioned at the second and subsequent depths d5, the focus is scanned in multiple directions while remaining at the second and subsequent depths _d5 . Because the bubble layers 912, 916, 920, 924 are below the second and subsequent layers 926, the bubbles do not impede or block laser access to photodissection of the second or subsequent layers.

Referring to FIG. 15f, laser scanning in multiple directions results in photodisruption of a second and subsequent tissue layer 926 and formation of an air bubble layer 928 at the point of the second and subsequent tissue layers. The focus of the laser beam 701 is then shifted in the z-direction toward the anterior chamber ₇ to a second and subsequent depth d6. The second and subsequent depths d ₆ bring the laser focus to the second and subsequent tissue layers 930 that are shallower than the second and subsequent tissue layers 926 . For example, the second and subsequent tissue layers 930 can consist of the uvea 15 and the inner surface of the uvea facing the anterior chamber 7 . Once the laser focus is positioned at the second and subsequent depths _d6 , the focus is scanned in multiple directions while remaining at the second and subsequent depths _d6 . Because the bubble layers 912, 916, 920, 924, 928 are below the second and subsequent layers 930, the bubbles may or may not prevent laser access to photodissection of the second or subsequent layers. Absent.

Referring to FIG. 15g, laser scanning in multiple directions results in photodisruption of a second and subsequent tissue layer 930 and formation of a bubble layer 932 at the point of the second and subsequent tissue layers. This second and subsequent photocutting of the tissue layer 930 results in the formation of an opening 920 between the anterior chamber 7 and Schlemm's canal 18, thereby completing the laser treatment procedure.

Referring to Figure 16a, at the completion of the laser scan, the aperture 902 may be partially obscured or occluded by air bubbles 912, 916, 920, 924, 928 introduced during treatment. Thus, according to the embodiments described herein, the air bubble is forced into Schlemm's canal 18 to force any remaining air bubbles, thereby clearing the obstruction from opening 902, as shown in FIG. 16b. The direction of laser scanning mentioned with reference to 15a-15g can be reversed.

FIG. 17 is a flowchart of a method of treating an eye tissue target volume with a laser propagating toward the eye tissue target volume. Referring to FIG. 12, ocular tissue target target volume 60 is characterized by distal extent 62 , proximal extent 64 , and lateral extent 66 . Distal extent 62 corresponds to the portion or point of target volume 60 that is furthest along the direction of propagation of laser 701 . Proximal extent 64 corresponds to the portion or point of target volume 60 that is most proximal along the direction of propagation of laser 701 . Lateral extent 66 corresponds to the spacing or width w of target volume 60 along the circumferential angle.

The method that may be performed by the integrated surgical system 1000 of FIGS. 7-10b begins at the time of the surgical procedure, where access to the iridocorneal angle has already been obtained and an ocular tissue target volume 60 to be treated has been identified. Iridocorneal angle access systems and methods are disclosed in U.S. Patent Application No. 16, entitled "Integrated Surgical System and Method for Treatment in the Irido-Corneal Angle of the Eye," the disclosure of which is incorporated herein by reference. /036,883. Systems and methods for identifying ocular tissue target volumes to be treated and devising treatment pattern criteria are described in Non-Invasive and Minimally Invasive Laser Surgery for the Reduction of Intraocular US patent application Ser. No. 16/125,588 entitled "Pressure in the Eye".

At block 1702 , the integrated surgical system 1000 first photodisrupts tissue at a first depth d ₁ corresponding to the distal extent 62 of the ocular tissue target volume 60 . To this end, and referring to FIG. 15a, the integrated surgical system 1000 focuses light from the femtosecond laser 701 to a spot in tissue that is a _first depth d1, sufficient to photodisrupt the tissue. Apply light energy at an appropriate level to the tissue. Optical energy is applied by scanning the laser 701 in multiple directions defining a first treatment plane 910 of a _first depth d1, thereby photodissecting the first tissue layer of the ocular tissue target volume. . Referring to FIG. 13, the scan is such that the laser is scanned in a first direction along side area 66, the x-direction, then slightly shifted in a second direction, the y-direction, and then again. It may also be in the form of a raster scan in which the side areas are scanned.

As a further aspect of the first photocutting process of block 1702, the integrated surgical system 1000 can locate the distal extent 62 of the ocular tissue target volume. To this end, in one configuration, control system 100 processes images captured by OCT imaging device 300 to locate distal extent 62 of target volume 60 using known techniques. In another configuration, the integrated surgical system 1000 includes a multiphoton imaging device (see FIG. 10) that provides a visual display on the display of the user interface 110 indicating the location of the focal point of the laser 701 relative to the distal extent 62 of the ocular tissue target volume 60 . not shown) may be included. Integrated surgical system 1000 may also identify lateral extent 66 of ocular tissue target volume 60 based on OCT imaging.

At block 1704, and with reference to FIGS. 15b-15f, the integrated surgical system 1000 continues by performing one or more ocular tissue target volumes between the distal extent 62 of the ocular tissue target volume 60 and the proximal extent 64 of the ocular tissue target volume. The tissue is photodissected at subsequent depths d ₂ -d ₆ by refocusing the laser 701 in a direction opposite to the direction of laser propagation. To this end, the integrated surgical system 1000 focuses light from the femtosecond laser 701 onto one or more spots within the tissue that are at depths d ₂ -d ₆ for a second or subsequent time to photodisrupt the tissue. light energy is applied to the tissue at a level sufficient to Optical energy is applied by scanning the laser 701 in multiple directions defining subsequent treatment planes 914, 918, 922, 926, 930 of respective different depths d ₂ -d ₆ , thereby causing ocular tissue One or more subsequent tissue layers of the target volume 60 are photodissected. Referring to FIG. 13, the scan is such that the laser is scanned in a first direction along side area 66, the x-direction, then slightly shifted in a second direction, the y-direction, and then again. It may also be in the form of a raster scan in which the side areas are scanned.

As a further aspect of the second and subsequent photocutting processes of block 1704 , the integrated surgical system 1000 can locate the distal extent 64 of the ocular tissue target volume 60 . To this end, in one configuration, control system 100 processes images captured by OCT imaging device 300 to locate proximal extent 64 of target volume 60 using a known technique. In another configuration, the integrated surgical system 100 includes a multiphoton imaging device (see FIG. 1 ) that provides a visual display on the display of the user interface 110 indicating the position of the focal point of the laser 701 relative to the proximal extent 64 of the ocular tissue target volume 60 . not shown) may be included. In yet another configuration, the integrated surgical system 1000 includes an opto-mechanical imaging device that provides a visual display on the display of the user interface 110 indicating the position of the focal point of the laser 701 relative to the proximal extent 64 of the ocular tissue target volume 60. (not shown) may be included.

At block 1706, the integrated surgical system 1000 determines whether the proximal extent 64 of the ocular tissue target volume 60 is photodisrupted. If the proximal region 64 has not been photodisrupted, the process returns to block 1704 and the integrated surgical system 1000 continues to photodisrupt the tissue in the proximal region 64 of the ocular tissue target volume 60 until the tissue in the proximal region 64 is photodisrupted. Repeat the photosection at subsequent depths.

Returning to block 1706 and referring to FIG. 16a, if the proximal extent 64 has been photodisrupted, the process returns to block 1798 and the integrated surgical system 1000 aligns the proximal extent 64 of the ocular tissue target volume 60 with the target. The tissue debris or bubble 906 between the distal extent 62 of the volume is photodissected by shifting the focus of the laser 701 in the direction of propagation of the laser. To this end, the integrated surgical system 1000 focuses light from the femtosecond laser 701 onto spots within the tissue debris or tissue bubble 906 volume at one or more second and subsequent depths, and illuminates the tissue debris or tissue bubble 906 . Apply energy. The light energy is applied to the previously scanned treatment planes 910, 914, 918 so as to photodisrupt tissue debris or tissue bubbles 906 between the proximal extent 64 and the distal extent 62 of the target volume 60 to be photodisrupted. , 922, 926, 930 by scanning laser 701 in multiple directions.

At block 1710, the integrated surgical system 1000 determines whether to repeat the treatment of the photodisrupted ocular tissue target volume 60 or terminate the treatment. If the treatment is to be repeated, the process returns to block 1702, where the integrated surgical system 1000 repeats the first cut of tissue, and then proceeds to blocks 1704 and 1706, where the system cuts the tissue for a second and subsequent cut. Repeat photocleavage one or more times. If the therapy is not to be repeated, the process proceeds to 1712 where the therapy ends.

With respect to using a multiphoton imaging device to locate the distal extent 62 of the ocular tissue target volume or the proximal extent 64 of the target volume, such a device uses a second is configured to present a dimmed image of When the focal point of laser 701 does not encounter tissue, the intensity of the second dimming is zero or very low. When the focus encounters tissue, the intensity of the second dimming is increased. Based on this, the distal region 62, such as that shown in FIG. 12, first advances the focal point of the laser 701 through the trabecular meshwork 12 and the inner wall 18a of Schlemm's canal into Schlemm's canal 18, where the focal point is , no light is encountered and the intensity of the second dimming is zero or very low, so the focus is drawn back to the inner wall 18a of Schlemm's canal and one observes on the display that the intensity of the second dimming has increased. and that the focal point is on the inner wall.

With respect to using an opto-mechanical imaging device to locate the proximal extent 64 of the ocular tissue target volume 60, such a device would align the first beam and the second beam such that they intersect at a point corresponding to the focal point of the laser. of rays to be incident on the target volume, and to align the positions of the first and second rays with each other and with respect to the laser beam. The apparatus is configured to capture a first spot image corresponding to the first ray and a second spot image corresponding to the second ray for the proximal extent 64 of the ocular tissue target volume 60. is also configured. The first and second spots appear in the image as two separate visible spots on the surface of the proximal region 64 when the focus is out of that plane and as one when the focus is on the surface. appear as overlapping spots only. Therefore, the proximal extent 64 is known when the spots overlap.

7-10b, surgical system 1000 for performing the method of FIG. and a second optical subsystem 1002 including a laser source 200 configured to output /701. The second optical subsystem 1002 one of focussing the laser beam, scanning the laser beam, and directing the laser beam through a focusing objective lens in a direction of propagation towards the ocular tissue target volume, or It also includes a plurality of components 1003 configured to do a plurality of things.

The surgical system 1000 further includes a control system 100 coupled to a second optical subsystem 1002 that illuminates tissue at a first depth corresponding to the distal extent of the ocular tissue target volume. It is configured to control the focusing and scanning of the laser beam 701 as it cuts. To this end, the control system 100 focuses the light from the femtosecond laser source 200 to a spot in the tissue that is the first depth, thereby providing sufficient light energy to photodisrupt the tissue. configured to apply to tissue; The control system 100 is further configured to photodisrupt the first tissue layer of the ocular tissue target volume by scanning the laser in a plurality of directions defining a first treatment plane, thereby applying optical energy. control the focusing and scanning of the laser beam 701 in the .

The control system 100 coordinates the laser to photodisconnect tissue at one or more subsequent depths between the distal extent of the eye tissue target volume and the proximal extent of the eye tissue target volume. It is also configured to control the focusing and scanning of laser beam 701 by shifting the focus of the laser in a direction opposite to the direction of propagation. To that end, the control system 100 focuses the light from the femtosecond laser source 200 to a spot within the tissue that is at a second or greater depth, thereby providing sufficient light energy to photodisrupt the tissue. is configured to apply to The control system 100 is further configured to photoablate subsequent tissue layers of the ocular tissue target volume by scanning the laser in multiple directions that define subsequent treatment planes, whereby the optical energy is controls the focusing and scanning of the racer beam 701 during the application of .

After photocutting the eye tissue target volume, the control system 100 focuses the laser in the direction of propagation of the laser to remove tissue debris or tissue bubbles between the proximal extent of the eye tissue target volume and the distal extent of the target volume. It is also configured to control the focusing and scanning of the laser beam 701 as it photodisconnects by translating. Control system 100 is further configured to control the focusing and scanning of laser beam 701 in conjunction with one or more tissue photodissections and subsequent tissue photodissections.

FIG. 18 is a flowchart of a method of treating an eye including the anterior chamber, Schlemm's canal, and trabecular meshwork therebetween. A method that may be performed by the integrated surgical system 1000 of FIGS. It begins at the point of the surgical procedure that

At block 1802, and referring to FIGS. 15a and 15b, the integrated surgical system 1000 first photocuts ocular tissue at or near the interface between the inner wall 18a of Schlemm's canal 18 and the trabecular meshwork 12. do. To that end, the integrated surgical system 1000 focuses light from the femtosecond laser 701 to a spot in the ocular tissue that is at or near the interface between the inner wall 18a of Schlemm's canal 18 and the trabecular meshwork 12, and Light energy is applied to the tissue at a level sufficient to photodisrupt the tissue.

As a further aspect of the first photoablation process of block 1802, the integrated surgical system 1000 may locate ocular tissue at or near the interface between the inner wall 18a of Schlemm's canal 18 and the trabecular meshwork 12. obtain. To this end, in one configuration, using known techniques, images captured by the OCT imaging device 300 are sent to the control system 100 to find the interface between the inner wall 18a of Schlemm's canal 18 and the trabecular meshwork 12. processed by In another configuration, the integrated surgical system 1000 provides a visual display on the display of the user interface 110 indicating the location of the focal point of the laser 701 relative to the interface between the inner wall 18a of Schlemm's canal 18 and the trabecular meshwork 12. A photon imaging device (not shown) may be included. The integrated surgical system 1000 can also identify the lateral extent 66 of photodissected ocular tissue based on OCT imaging.

At block 1804 and referring also to FIGS. To this end, the integrated surgical system 1000 focuses light from a femtosecond laser 701 to an intra-tissue spot in the trabecular meshwork 12 and applies light energy to the tissue at a level sufficient to photocut the tissue. .

As a further aspect of the second and subsequent photocutting processes of block 1804, the integrated surgical system 1000 can locate the proximal tissue extent of the trabecular meshwork. To this end, in one configuration, using known techniques, images captured by the OCT imaging device 300 are processed by the control system 100 to locate the proximal tissue extent 64 of the trabecular meshwork. In another configuration, the integrated surgical system 1000 includes a multiphoton imaging device (not shown) that provides a visual display on the display of the user interface 110 indicating the location of the focal point of the laser 701 relative to the proximal tissue area 64 of the trabecular meshwork. ) can be included. In yet another configuration, the integrated surgical system 1000 provides a visual display on the display of the user interface 110 indicating the location of the focal point of the laser 701 relative to the proximal tissue area 64 of the trabecular meshwork. not shown) may be included.

At block 1806, the integrated surgical system 1000 determines whether an opening has been formed between the anterior chamber and Schlemm's canal. If an opening has not been formed, the process returns to block 1802 and the surgical system 1000 repeats the first ocular tissue photocut and then proceeds to block 1800 to form an opening between the anterior chamber and Schlemm's canal. Repeat the second and subsequent ocular tissue photodissections one or more times until the If an opening has been formed, the process proceeds to block 1808 where treatment ends.

7-10b, a system 1000 for implementing the method of FIG. and a second optical subsystem 1002 including a laser source 200 configured to output a. The second optical subsystem 1002 is configured to one or more of focus the laser beam, scan the laser beam, and direct the laser beam through the focusing objective lens at the ocular tissue. It also includes a plurality of components 1003 that are configured.

Surgical system 1000 is further coupled to a second optical subsystem 1002 and is used to focus and scan laser beam 701 initially at or near the interface between the inner wall of Schlemm's canal and the trabecular meshwork. A control system 100 is included that is configured to control the photodisruption of ocular tissue. To this end, the controller 100 focuses light from the femtosecond laser source 200 to a spot in the ocular tissue at or near the interface between the inner wall of Schlemm's canal and the trabecular meshwork, thereby The light is configured to apply light to the tissue, the energy of which is sufficient to photodisrupt the tissue.

The control system 100 is also configured to subsequently control the focusing and scanning of the laser beam 701 to photodisrupt tissue of the trabecular meshwork. To this end, control system 100 is configured to focus light from a femtosecond laser onto an intra-tissue spot in the trabecular meshwork, thereby applying light energy to the tissue that is sufficient to photodisrupt the tissue. It is The control system 100 is further adapted to repeat the first ocular tissue photodissection and the second and subsequent ocular tissue photodissections one or more times until an opening is formed between the anterior chamber and Schlemm's canal. , is configured to control the focusing and scanning of the laser beam 701 .

Various aspects of the disclosure are provided to enable any person skilled in the art to practice the invention. Various modifications to the example embodiments presented throughout this disclosure will become apparent to those skilled in the art. Accordingly, the claims are not to be limited to the various aspects of this disclosure, but are to be accorded the full scope consistent with the language of the claims. All structural and functional equivalents to the various components of the exemplary embodiments described throughout this disclosure that are known, or later become known, to those of ordinary skill in the art are expressly incorporated herein by reference. is incorporated into and encompassed by the claims. Moreover, none of the material disclosed herein is intended to be dedicated to the public, whether or not such disclosure is explicitly recited in the claims. Any claim element is explicitly recited using the phrase "means for" or, in the case of a method claim, the element is recited using the phrase "step for". 112, sixth paragraph of the U.S.C.

It should be understood that the embodiments of the invention described herein are merely illustrative of the application of the principles of the invention. Reference herein to details of the illustrated embodiments is not intended to limit the scope of the claims, which recite those features regarded as essential to the invention.

Claims (30)

1. A method of treating an ocular tissue target volume at the iridocorneal angle of an eye with a laser in a direction of propagation toward the ocular tissue target volume characterized by a distal extent, a proximal extent, and a lateral extent, comprising:
first photocutting tissue at a first depth corresponding to the distal extent of the ocular tissue target volume;
followed by cutting tissue at one or more subsequent depths between the distal extent of the eye tissue target volume and the proximal extent of the eye tissue target volume opposite to the propagation direction of the laser. and photodisrupting by shifting the focus of the laser in a direction. The photodisrupting at one or more subsequent depths is repeated at a plurality of different subsequent depths until tissue in the proximal extent of the ocular tissue target volume is photodisrupted. The method of claim 1, wherein after photocutting the eye tissue target volume, removing tissue debris or tissue bubbles between the proximal extent of the eye tissue target volume and the distal extent of the eye tissue target volume in the propagation direction of the laser; 2. The method of claim 1, further comprising photodisrupting by shifting the focus of the laser. first or subsequently photodissecting the tissue,
focusing light from a femtosecond laser into a spot at the first depth or the one or more subsequent depths in the tissue;
2. The method of claim 1, comprising applying light energy to the tissue. applying light energy
Photodissecting a first tissue layer of the ocular tissue target volume or one or more subsequent tissue layers of the ocular tissue target volume by scanning the laser in multiple directions that define a treatment plane. 5. The method of claim 4, comprising: 2. The method of claim 1, further comprising repeating said first tissue photodissection and said second and subsequent tissue photodissections one or more times. finding the distal extent of the ocular tissue target volume;
finding the proximal extent of the ocular tissue target volume;
3. The method of claim 1, further comprising confirming the lateral extent of the ocular tissue target volume. 8. The method of claim 7, wherein the distal extent of the eye tissue target volume and the proximal extent of the eye tissue target volume are found based on one or more eye tissue images. 9. The method of claim 8, wherein the one or more ocular tissue images are obtained using one or more of optical imaging techniques, multiphoton imaging techniques, and opto-mechanical imaging techniques. 1. A system for laser treating an ocular tissue target volume at the iridocorneal angle of an eye characterized by a distal extent, a proximal extent, and a lateral extent, comprising:
a first optical subsystem including a focusing objective lens configured to be aligned with the eye;
focusing the laser, scanning the laser, and directing the laser in a direction of propagation toward the ocular tissue target volume through a laser source configured to output a laser beam and the focusing objective lens; a second optical subsystem comprising a plurality of components configured to do one or more of:
a control system coupled to the second optical subsystem and configured to control the focusing and scanning of the laser, wherein the focusing and scanning of the laser comprises:
first photocutting tissue at a first depth corresponding to the distal extent of the ocular tissue target volume;
followed by scanning tissue at one or more subsequent depths between the distal extent of the eye tissue target volume and the proximal extent of the eye tissue target volume with the propagation direction of the laser; and a control system controlled to photodisconnect by shifting the focus of the laser in opposite directions. The focusing of the laser as the control system repeats the photodissection at a plurality of different second and subsequent depths until tissue in the proximal extent of the ocular tissue target volume is photodisrupted. and scanning. The control system photodisrupts the eye tissue target volume and then photodisrupts tissue debris or tissue bubbles between the proximal extent of the eye tissue target volume and the distal extent of the eye tissue target volume. 11. The system of claim 10, further configured to control the focusing and scanning of the laser by shifting the focus of the laser beam in the direction of propagation of the laser beam in accordance with. The control system is
focusing light from a femtosecond laser to a spot at the first depth or at the one or more subsequent depths in the tissue;
11. The method of claim 10, further configured to apply optical energy to the tissue to control the focusing and scanning of the laser during a first tissue photocutting or a second or subsequent tissue photocutting. system. The control system is
scanning the focal point of the laser in multiple directions defining a treatment plane to light a first tissue layer of the ocular tissue target volume or one or more subsequent tissue layers of the ocular tissue target volume; 14. The system of claim 13, further configured to cut, to control the focusing and scanning of the laser during application of optical energy. The control system is further configured to control the focusing and scanning of the laser in conjunction with one or more repetitions of the first tissue photodissection and the second and subsequent tissue photodissections. 11. The system of claim 10. further comprising an imaging device configured to capture an ocular tissue image, wherein the control system is coupled to the imaging device;
finding the distal extent of the ocular tissue target volume;
11. The method of claim 10, configured to perform one or more of: finding the proximal extent of the eye tissue target volume; and identifying the lateral extent of the eye tissue target volume. System as described. 17. The system of claim 16, wherein the imaging device comprises at least one of an optical imaging device, a multiphoton imaging device, and an opto-mechanical imaging device. A method of treating an eye comprising the anterior chamber, Schlemm's canal, and trabecular meshwork therebetween, comprising:
first photoablating ocular tissue at or near the interface between the inner wall of the Schlemm's canal and the trabecular meshwork;
subsequently photodissecting the trabecular meshwork ocular tissue. First, photodissection of ocular tissue
focusing light from a femtosecond laser onto the intra-tissue spot at or near the interface between the inner wall of the Schlemm's canal and the trabecular meshwork;
19. The method of claim 18, comprising applying optical energy to the tissue. Subsequent photodissection of the tissue
focusing light from a femtosecond laser onto an intra-tissue spot of the trabecular meshwork;
19. The method of claim 18, comprising applying optical energy to the tissue. 12. The method of claim 1, further comprising repeating the first ocular tissue photocutting and the second and subsequent tissue photocuttings one or more times until an opening is formed between the anterior chamber and the Schlemm's canal. 18. The method according to 18. locating ocular tissue at or near the interface between the inner wall of the Schlemm's canal and the trabecular meshwork;
locating the proximal tissue extent of the trabecular meshwork;
19. The method of claim 18, further comprising identifying a lateral eye tissue area to be photodisrupted. ocular tissue at or near the interface between the inner wall of the Schlemm's canal and the trabecular meshwork and tissue of the trabecular meshwork are located based on one or more ocular tissue images; 23. The method of claim 22. 24. The method of claim 23, wherein the one or more ocular tissue images are obtained using one or more of optical imaging techniques, multiphoton imaging techniques, and opto-mechanical imaging techniques. A system for treating an eye comprising the anterior chamber, Schlemm's canal, and trabecular meshwork therebetween, comprising:
a first optical subsystem including a focusing objective lens configured to be aligned with the eye;
a laser source configured to output a laser beam; and focusing the laser beam, scanning the laser beam, and directing the laser beam through the focusing objective lens onto ocular tissue. a second optical subsystem comprising a plurality of components configured to perform one or more of
a control system coupled to the second optical subsystem and configured to control the focusing and scanning of the laser beam, wherein the focusing and scanning of the laser beam comprises:
first photocutting ocular tissue at or near the interface between the inner wall of the Schlemm's canal and the trabecular meshwork;
subsequently, a control system controlled in concert with photodisrupting the trabecular meshwork ocular tissue. The control system is
focusing light from a femtosecond laser to a spot in tissue that is at or near the interface between the inner wall of the Schlemm's canal and the trabecular meshwork;
26. The system of claim 25, further configured to apply optical energy to the tissue to control the focusing and scanning of the laser beam during a first photocutting of ocular tissue. The control system is
focusing light from a femtosecond laser onto an intra-tissue spot of said trabecular meshwork;
26. The system of claim 25, further configured to apply optical energy to the tissue to control the focusing and scanning of the laser beam during second and subsequent ocular tissue photodissections. The control system repeats the first eye tissue photocutting and the second and subsequent eye tissue photocutting once or more times until an opening is formed between the anterior chamber and the Schlemm's canal. 26. The system of claim 25, further configured to control the focusing and scanning of the laser beam in accordance with. further comprising an imaging device configured to capture an ocular tissue image, wherein the control system is coupled to the imaging device;
locating ocular tissue at or near the interface between the inner wall of the Schlemm's canal and the trabecular meshwork;
26. The method of claim 25, configured to perform one or more of: locating tissue areas proximal to the trabecular meshwork; System as described. 30. The system of claim 29, wherein the imaging device comprises at least one of an optical imaging device, a multiphoton imaging device, and an opto-mechanical imaging device.

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