JP2024073371A - Ophthalmic surgical instruments and methods of use - Google Patents

Abstract

The present invention relates to an improved ophthalmic surgical instrument and method of using said instrument to perform trabeculotomy in a glaucoma patient. The ophthalmic surgical instrument 10 includes a handpiece 12, a grip 14, and a hollow shaft 18 with an elongated breaking device 20 slidably extending therefrom. The elongated breaking device is adapted to be inserted into a tissue space within the eye. The elongated breaking device may be a barbed catheter, may be an optical fiber, or may be adapted to deliver a payload into the eye, or any combination of the foregoing, and the ophthalmic surgical instrument is used for transluminal or circumferential trabeculotomy to break tissue within the eye to relieve intraocular pressure in a glaucoma patient.Selected Figures:

Description

The present invention relates generally to improved methods and apparatus for relieving elevated pressure in the human eye. In particular, the present invention relates to improved ophthalmic surgical instruments and methods of using said instruments to perform trabeculotomy in patients with glaucoma.

Glaucoma comprises a group of eye diseases characterized by pathological changes in the optic disc and damage to the optic nerve of the eye, which, if left untreated, leads to irreversible vision loss. The primary etiology in all forms of glaucoma is an increase in fluid pressure in the eye, or intraocular pressure, which is usually due to resistance to the outflow of aqueous humor from within the eye.

In most cases, resistance to the outflow of aqueous humor occurs in the trabecular meshwork, located adjacent to Schlemm's canal, and more specifically in the paracanalicular connective tissue. The trabecular meshwork tissue allows aqueous humor to enter a canal called Schlemm's canal, where it then drains into the aqueous collecting duct in the posterior wall of the canal, which eventually connects to the aqueous veins. Intraocular pressure in the eye is determined by the balance between the production of aqueous humor and its outflow via the trabecular meshwork (major pathway) or the uveoscleral outflow pathway (minor pathway).

Trabeculotomy is a procedure commonly performed to reduce resistance in the outflow pathways of the eye, thereby lowering intraocular pressure in patients with glaucoma. Transluminal trabeculotomy, also called circumferential trabeculotomy, involves disrupting or removing some or all of the trabecular meshwork along the circumference of Schlemm's canal by disruption, ablation, cutting, or other techniques.

Gonioscope-assisted transcanal trabeculotomy ("GATT") is a minimally invasive glaucoma treatment procedure that involves visualizing the eye through a gonioscope, also known as a gonioprism, and making one or more incisions in the cornea. These incisions, usually 1 mm in size, are made around the cornea to access the anterior chamber. In some cases, existing corneal incisions from a concurrent cataract surgery are utilized. Once in the eye, the procedure involves making an incision or opening in the trabecular meshwork, inserting a cannula 30-360 degrees into Schlemm's canal, and peeling back the top of the canal. GATT works by restoring the transtrabecular outflow pathway and allowing increased flow of aqueous humor from the anterior chamber directly into and around Schlemm's canal, where it eventually drains through the collecting canal.

There are two commonly performed techniques for transluminal trabeculotomy. In the first approach, a catheter, suture, or other elongated device is inserted through the angle incision. The device is then advanced through Schlemm's canal and intubated from 180 degrees up to 360 degrees before exiting the canal and re-entering the anterior chamber. Tension is then applied to the end of the device, disrupting the trabecular meshwork. This method allows precise control over the extent of the transluminal trabeculotomy, allowing for disruption of specific portions or the entire circumference of the trabecular meshwork. The disadvantages of this technique are the need for two hands and the use of surgical forceps, and the need for the gonioprins to be passed to an assistant or held in place by an assistant.

Other commonly performed techniques involve inserting a long, thin, flexible device, such as a catheter, suture, probe, or similar member, into Schlemm's canal. Once inside the canal, tension is applied to the device or the device itself is used to exert a radial force similar to a garrote in Schlemm's canal. The radial force disrupts the trabecular meshwork lining the portion of Schlemm's canal into which the device is inserted. One advantage of this method is that the surgeon can tailor the size or angle of the goniotomy tear to be performed to tailor the procedure to the patient's clinical requirements. Furthermore, if a handpiece propulsion device is used, the technique can be performed using only one hand. However, a disadvantage of the aforementioned method is that during application of the radial force, the distal tip of the device may move proximally within the canal, causing the device to partially exit the canal, reducing the size of the intended transcanal goniotomy. Furthermore, neither method provides an easy way for the surgeon to visualize the extent of the transluminal trabeculotomy, and the surgeon must require additional assistance or rely on experience.

To overcome the aforementioned shortcomings of the above methods and prior art, there is a need for an ophthalmic surgical device that is easy to use and allows the surgeon to visualize the extent of the transcanalicular trabeculotomy. Furthermore, there is a need for the device to be fixed in place while tension is applied to disrupt the proximal canalicular network.

One aspect of the present invention is to overcome or ameliorate the problems of the prior art by providing an improved ophthalmic surgical instrument for use in transluminal trabeculotomy.

In a first aspect, the present invention includes an ophthalmic surgical instrument comprising a handpiece held by a user having a proximal end and a distal end, the handpiece comprising a hollow shaft extending from the distal end of the handpiece, the hollow shaft comprising a flexible elongated breaking device extending from the hollow shaft, the flexible elongated breaking device adapted to be advanced through a tissue space within the eye.

In one embodiment, the elongate breaking device includes a plurality of rearwardly and outwardly extending barbs adapted to engage surrounding tissue within the tissue space of the eye.

In one embodiment, the barbs are unidirectional.

In one embodiment, the barbs are bidirectional.

In one embodiment, the elongated breaking device comprises a central hollow tube adapted to deliver a payload to the eye.

In one embodiment, the elongated breaking device is an optical fiber, the optical fiber being slidably engaged with the hollow shaft and having an outer diameter between 50 μm and 350 μm.

In another aspect, the invention includes a method for performing an internal trabeculotomy, the method including the steps of: incising the trabecular meshwork of an eye to access the lumen of Schlemm's canal; positioning a distal end of an elongated disruption device through the incision and into Schlemm's canal; advancing the elongated disruption device through Schlemm's canal at an angle between 0 degrees and 360 degrees; applying tension to an optical fiber within the canal, thereby disrupting the surrounding tissue and performing a trabeculotomy; and withdrawing the device through the incision.

In one embodiment, the elongated breaking device includes a barb located along the device, and prior to applying tension to the optical fiber, the elongated breaking device is slightly retracted proximally or tangentially to allow the barb to engage the surrounding tissue.

In one embodiment, the elongated disruption device is advanced around the entire circumference of Schlemm's canal.

In one embodiment, the elongated disruption device is first advanced 180 degrees, and then the procedure is repeated to advance the remaining 180 degrees of the canal, thereby forming a 360 degree trabeculotomy.

Please note that any one of the above aspects may include any of the features of any of the other aspects above, and may also include any of the features of any of the embodiments described below, as appropriate.

Preferred features, embodiments and variations of the present invention can be identified from the following detailed description, which provides sufficient information for one skilled in the art to practice the invention. The detailed description should not be considered in any way as limiting the scope of the foregoing summary of the invention. The detailed description makes reference to several drawings, which are as follows:

FIG. 1 is a side view of an ophthalmic surgical instrument. FIG. 2 is an enlarged side view of the barbed elongated breaking device. FIG. 3 is an enlarged side view of an elongated breaking device adapted to deliver a payload. FIG. 4 is an enlarged side view of an elongated breaking device configured to transmit light. FIG. 5 illustrates several embodiments of an elongated breaking device. FIG. 6 shows a cross-sectional view of the structure of the eye. FIG. 7 illustrates the creation of an incision in the trabecular meshwork of the eye. FIG. 8 illustrates the advancement of an optical fiber within Schlemm's canal in the eye. FIG. 9 shows the completion of the trabeculotomy.

The following detailed description of the invention refers to the accompanying drawings. Wherever possible, the same reference numbers are used throughout the drawings and the following description to refer to the same and like parts. Dimensions of certain parts shown in the drawings may be altered and/or exaggerated for clarity or explanation.

With reference to FIG. 1, an ophthalmic surgical instrument 10 includes a handpiece 12 with a grip 14 suitable for holding in one hand. The handpiece 12 includes a proximal end and a distal end, the distal end featuring a conical connector 16 from which a hollow shaft 18 extends. An elongated breaking device 20 extends from the hollow shaft and is adapted to be advanced into tissue spaces for use in ophthalmic surgery and is used to cannulate intraocular spaces such as, but not limited to, Schlemm's canal, aqueous collecting duct, aqueous vein, retinal vein, and suprachoroidal space. It is understood that the term "extending" is not limiting and may be interpreted as extending in one of many other embodiments.

The elongated breaking device 20 is made of a flexible material, allowing the device 20 to be advanced through and follow the curvature of a desired tissue space without damaging the surrounding tissue structures. The distal end of the breaking device 20 has a suitable shape, e.g., with a curved distal end, for advancing along the tissue space without breaking the surrounding tissue.

In one embodiment, the elongated breaking device 20 includes barbs 22 that allow the device 20 to hook into surrounding tissue during transluminal goniotomy and prevent slippage of the device 20. The barbs 22 can be structured to protrude when the device is retracted proximally while retracting when the device is pushed distally to advance along the tissue space. The angle of the barbs 22 affects how easily they hook into surrounding tissue; that is, the closer the protruding angle is to 90 degrees, the easier the barbs 22 are to anchor into the surrounding tissue.

Referring to FIG. 2, the barbs 22 can be positioned in any manner to keep the elongated breaking device 20 fixed when pressure is applied to the elongated breaking device 20 or when the device is retracted proximally. The barbs 22 can extend partially or completely along the length and circumference of the device 20 and can be positioned in any suitable manner. What is important is that the barbs 22 are present near the distal end of the device 20 to prevent movement or slippage of the distal end of the device 20 as it breaks the surrounding tissue.

In one embodiment, the barb orientation is unidirectional, however, the present invention also allows for bidirectional barbs 22 having various sizes. This arrangement significantly enhances resistance to catheter movement. This is accomplished by requiring barbs that impede movement in a particular direction to traverse a longer portion of tissue before being withdrawn or displaced from the tissue. The barbs may also be of various shapes, widths, and sizes, e.g., barbs located at the distal end of the device 20 may be longer or shorter than barbs located at the proximal end of the device 20.

Furthermore, while the above description discloses the use of individual barbs 22, it should be understood that the barbs may be a single ring extending around the device 20 and may provide an outwardly and proximally extending wall with an edge adapted to secure to tissue. Additionally, other types of fixation devices may also be used.

In one embodiment, the elongated breaking device is a flexible hollow tube, such as a catheter. The flexible hollow tube features an interior hollow section 25 suitable for delivering a solid or fluid payload to a desired tissue space. Such a payload may be disposed within a payload storage unit 26 that includes a hollow volume 28 adapted to hold the payload. The payload storage unit 26 may be disposed within the handpiece 12, but is not limited to such a configuration, and may be disposed external to the surgical instrument.

Payloads can include fluids and/or solid objects, such as stents and drugs. Examples of fluid payloads include, but are not limited to, viscoelastic fluids, saline, and aqueous solutions. Solid payloads include, but are not limited to, microsurgical instruments such as forceps, tissue penetrating instruments, tissue cutting instruments, stents, optical guides, and wires.

In one embodiment, the elongated breaking device 20 can include a light source (not shown) for illuminating the distal end of the device. The light source can be coupled to the device and can direct light through the device to provide illumination. The light source can also be coupled to a light guide, which refers to an optical element capable of transmitting electromagnetic radiation through a guide, to illuminate the distal end of the catheter. Such light guides can include, but are not limited to, mirrors, flexible optical fibers, and fiber optic bundles arranged to direct light from the source to a destination.

The elongated breaking device 20 can include a connector located at the proximal end of the handpiece. The connector can facilitate coupling, without limitation, an illumination source or an external payload to the device 20. An illumination source coupled to the device can be used to illuminate its distal end.

In one embodiment, the elongated breaking device 20 slidably engages the handpiece 12, allowing the breaking device 20 to be extended or retracted to a desired length.

In these embodiments, the elongated disruption device 20 may be manufactured from a variety of suitable materials to allow for insertion into the body and delivery of the fluid payload. Such materials are well known in the art and include, but are not limited to, polymers such as polyimides, polyamides, polyolefins, polyvinyl chloride, fluoropolymers, polysulfones, polyurethanes and compositions thereof.

In one embodiment, the elongated breaking device 20 is a flexible optical fiber adapted to mechanically break tissue. Such an optical fiber may be approximately 200 μm in length. The illuminated breaking device allows the surgeon to visualize the position of the breaking device 20 as it is inserted and advanced along the desired tissue space, enhancing precision of the tear location. Depending on the material, the optical fiber as the elongated breaking device 20 can be distally illuminated 21 or longitudinally illuminated 23 along the length of the device.

In embodiments in which the disruption device 20 is an optical fiber, the optical fiber may be made from a material suitable for simultaneously transmitting light and disrupting tissue. These materials may include, but are not limited to, silica, doped silica, including germanium-doped or phosphorus-doped silica, plastics, including polymethylmethacrylate or polycarbonate, glasses, including fluoride glasses, chalcogenide glasses, or heavy metal oxide glasses, and polymer optical fibers made from perfluorinated polymers or polyethylene.

The use of optical fiber as a breaking tool provides the additional benefit of reducing the manufacturing costs of the surgical device. Unlike existing prior art devices that typically include a catheter or similar device consisting of a hollow tube for delivering the payload, the optical fiber of the present invention does not require such components for payload delivery. This simple design eliminates the need for hollow tubes and payload delivery mechanisms, resulting in a more cost-effective manufacturing process. The device may include a connection portion for coupling light from a light source. Mechanisms for directing light through optical fibers are well known in the art.

Several embodiments of the elongated breaking device 20 are shown in FIG. 5, showing various barb 22 arrangements, embodiments with and without an internal hollow tube 25, and showing distal illumination 21 of the device. However, it should be noted that the elongated breaking device 20 is not limited to such embodiments, and various modifications and alternative configurations may be possible depending on the needs of the user.

A detailed method for performing an internal transluminal trabeculotomy utilizing the present invention is described below. The described method allows for the reduction of intraocular pressure for the treatment of glaucoma. In an embodiment of the present invention, the lumen of Schlemm's canal is accessed from the anterior chamber without the need or prerequisite of a scleral or conjunctival incision. This is possible because the inner wall of Schlemm's canal, the trabecular meshwork, is directly adjacent to the anterior chamber.

Referring to FIG. 6, a cross-sectional view of the eye is shown. Shown are the lens 32, iris 34, cornea 36, location of trabecular meshwork 28, and Schlemm's canal 40.

Microsurgical instruments are used to create a goniotomy or incision in Schlemm's canal. The incision is made from within the anterior chamber with the aid of a gonioplasty or other imaging device to visualize the anterior chamber angle. As shown in FIG. 7, a cutting instrument (not shown) is used from within the anterior chamber to create an incision 42 in the trabecular meshwork 38. The breaking device 20 can then be used to cannulate the goniotomy opening. That is, the device is inserted into the goniotomy opening and advanced along Schlemm's canal 30. The device can be advanced to any desired angle within the canal, typically between 0 degrees and 360 degrees.

In one embodiment, the device 20 can be advanced through the canal by hand, with the user applying force to the handpiece 12 to encourage advancement along the canal. Alternatively, a grasping instrument 44 may be used to assist in positioning and advancing the device 20 through the canal. The grasping instrument 44 may be, but is not limited to, a surgical forceps or an ophthalmic microforceps.

The device 20 is advanced through Schlemm's canal to the desired angle between 0 and 360 degrees, after which the instrument 10 is retracted (pulled) slightly proximally or tangentially to allow the barbs to engage the surrounding tissue. Traction or tension can then be applied to the device 20 to pull it into the anterior chamber, thereby disrupting the trabecular meshwork and exposing Schlemm's canal to relieve intraocular pressure. The device can then be advanced further along Schlemm's canal and retracted using the grasping instrument 44.

In one embodiment of the present invention, an incision is made through the cornea 36 to insert the elongated disruption device 20.

In one embodiment of the present invention, the elongated breaking device 20 is advanced into Schlemm's canal until the distal end of the optical fiber is near the initial angle incision, i.e., 360 degrees. The distal end of the end of the device 20 can then be retrieved using a grasping instrument 44, as shown in FIG. 8. Traction or tension can then be applied to the device 20 to pull it into the anterior chamber, thereby breaking the trabecular meshwork and exposing Schlemm's canal, allowing a 360 degree internal trabeculotomy 46 to be performed, as shown in FIG. 9.

When Schlemm's canal is scarred or malformed, it is not always possible to advance device 20 around the entire circumference of the canal. In this situation, a surgical device-assisted trabeculotomy is performed on a portion of Schlemm's canal as a partial trabeculotomy. Device 20 is advanced partially through Schlemm's canal 30 degrees or more. The distal end of device 20 may then be retrieved through the trabecular meshwork via a goniotomy. Tension is applied to one or both ends of the optical fiber, creating a partial trabeculotomy between the goniotomy and the distal end of the device.

In certain embodiments of the invention, trabeculotomy can continue to be applied to the untreated portion of Schlemm's canal by cannulating the remaining portion of the canal and repeating the partial trabeculotomy procedure. For example, the entire canal can be treated with two 180 degree procedures, three 120 degree procedures, or any other desired combination. In severely damaged or diseased eyes, only a portion of Schlemm's canal can be cannulated and a partial trabeculotomy can be performed using the techniques described.

The device 20 used to cannulate Schlemm's canal may be flexible and of a suitable size, shape, and thickness to penetrate and cannulate the canal. The meridian diameter of Schlemm's canal typically ranges from 200 to 250 μm, but has been observed to be as large as 350 to 500 μm. The reported length of the canal is approximately 36 mm, but there may be some variation depending on factors such as eye size and pre-existing disease conditions. When cannulating Schlemm's canal, the device 20 is between about 50 μm and 350 μm in diameter and at least 36 mm in length. To facilitate advancement of the optical fiber within the canal, its distal end may be rounded and the device may have a lubricious coating at least at the distal end. Such coatings may be hydrophilic or hydrophobic in nature and are well known in the art. A hydrophilic coating may be applied to aid in the intubation of the device within the eye, while a hydrophobic coating may aid in retention of the device within the ocular structure. The device may be straight or incorporate a curve at the distal end. This curve may be greater than or closer to the curvature of Schlemm's canal. In certain embodiments of the invention, the curved tip has a radius in the range of 2-4 mm. Additionally, the device may have markings along the length or at the tip to aid in visualization of the device within the canal.

Device 20 transmits light from a light source and emits light such that the position of device 20 can be visualized from within the eye through the trabecular meshwork, as well as from outside the eye through the sclera and conjunctiva, to guide its advancement within the canal.

The advantage of the currently described internal technique is that it does not require conjunctival or scleral incisions. Therefore, no scleral incisions are required and there is no risk of causing a pulmonary bleb on the surface of the eye. This technique also preserves the entire conjunctiva and sclera, making it ideal for future traditional glaucoma surgery or other ophthalmic procedures. Postoperative recovery time is at least comparable to patients who have had a 360-degree incision trabeculotomy.

In one embodiment of the present invention, a lid speculum is placed on the eye and a gonioprism (or other anterior chamber angle imaging device) is placed on the eye. The operating microscope is tilted so that the anterior chamber angle at the goniotomy site can be viewed. According to an embodiment of the present invention, the ciliary body structures, trabecular meshwork, and scleral spurs at the anterior chamber angle are identified.

In one embodiment of the present invention, a tangential paracentesis incision is made in the cornea, through which an intraocular composition is injected to constrict the pupil and facilitate access from the anterior chamber to the trabecular meshwork. In a particular embodiment of the present invention, the composition used comprises acetylcholine. Examples of such compositions include Miochol-E® and Miostat®.

According to one embodiment of the present invention, a surgical viscoelastic, such as a sodium hyaluronate solution, is injected into the anterior chamber to maintain or expand the chamber dimensions. Compositions include, but are not limited to, Healon®, a non-pyrogenic solution of a highly purified, high molecular weight fraction of sodium hyaluronate extracted from animal tissue dissolved in a physiological buffer. After injection of the viscoelastic, and approximately 3 hours after paracentesis, a clear corneal incision approximately 1-3 mm wide is made using a microsurgical blade. Another microsurgical blade is inserted into the corneal incision and cuts the trabecular meshwork in the area directly opposite the eye from the corneal incision to create a corneal incision that allows direct access to the lumen of Schlemm's canal.

The device 20 is inserted into the puncture site and a gonioplast is placed on the eye to visualize the distal end of the device approaching the angular structures at the canal incision area. Surgical forceps are then inserted into the eye through the clear corneal incision. These are used to grasp the device and guide the distal portion of the device into the Schlemm's canal incision. A gonioprism (or other device used for anterior chamber angle imaging) is placed in or on the eye to allow visualization of the procedure. The device is inserted into Schlemm's canal through the incision made by the microsurgical blade.

The positioning of the device 20 is confirmed through visual inspection of the eye. Optical transillumination of the device 20 in Schlemm's canal can be visualized internally or externally.

After cannulation of Schlemm's canal, the surgical forceps may be returned to the eye with a gonioprism on the eye for visualization, and the optical fiber may be advanced around the canal. The distal end of the device is retrieved with the surgical forceps and removed from the eye through the clear corneal incision, creating an inferior 180 degree trabeculotomy. The 360 degree trabeculotomy is then completed by grasping the proximal end of the optical fiber and applying tension, allowing the trabeculotomy to finish at the superior 180 degree. The device is then removed from the eye by paracentesis.

According to one embodiment of the present invention, an endoscopic camera can be used to visualize the surgical procedure in the anterior chamber to facilitate proper placement and use of instruments in the anterior chamber. Once the trabeculotomy is completed, blood reflux from the tract is typically observed. A surgical viscoelastic may be injected into the eye to reshape the anterior chamber and maintain appropriate pressure, with the additional goal of blocking blood flow. If necessary, a single suture, such as a cut 10-0 nylon suture, is placed through the clear corneal incision. Prior to tying the suture, the anterior chamber is flushed with the previously injected surgical viscoelastic, as well as any blood that has refluxed into the anterior chamber. The suture is then tied and the eye is pressurized to at least 10-15 mmHg pressure by injecting balanced salt solution by palpation.

The reader will now understand that the present invention provides an ophthalmic surgical instrument and a method for using said instrument in the treatment of glaucoma.

Although the present invention has been described with reference to specific embodiments, the description is illustrative of the present invention and should not be construed as limiting the present invention. Those skilled in the art will appreciate that various modifications and applications may occur to those skilled in the art without departing from the true spirit and scope of the present invention as set forth in the appended claims.

The drawings include the following numbers:
10 Ophthalmic surgical instrument 12 Handpiece 14 Grip 16 Connector 18 Hollow shaft 20 Elongated breaking device 21 Distal illumination 22 Barb 23 Longitudinal illumination 25 Hollow tube 26 Payload storage 28 Payload storage chamber 32 Lens 34 Iris 36 Cornea 38 Trabecular meshwork 40 Schlemm's canal 42 Incision 44 Grasping device 46 Trabecular meshwork incision

Further advantages and improvements can be made to the present invention without departing from the scope of the present invention. While the present invention has been shown and described in what is considered to be the most practical and preferred embodiments, it is recognized that departures can be made therefrom within the scope of the invention, and it is not intended to be limited to the details disclosed herein, but the full scope of the claims should be accorded to encompass all equivalent apparatus and devices. Any discussion of the prior art throughout this specification should in no way be taken as an admission that such prior art is widely known or forms part of the common general knowledge in this field.

In this specification and claims (where present), the word "comprising" and its derivatives, including "comprise" and "comprises," include each of the recited numbers but do not exclude the inclusion of one or more additional numbers.

Claims (19)

a handpiece held by a user and having a proximal end and a distal end, the handpiece including a hollow shaft extending from the distal end of the handpiece;
a flexible, elongated breaking device extending from the hollow shaft, the flexible, elongated breaking device adapted to be advanced through a tissue space within the eye. The ophthalmic surgical instrument of claim 1, wherein the flexible elongated breaking device comprises a plurality of rearwardly and outwardly extending barbs adapted to engage surrounding tissue within the tissue space of the eye. The ophthalmic surgical instrument of claim 2, wherein the barbs are unidirectional. The ophthalmic surgical instrument of claim 2, wherein the barbs are bidirectional. The ophthalmic surgical instrument of any one of claims 1 to 4, wherein the flexible elongated breaking device comprises a central hollow tube adapted to deliver a payload to the eye. The ophthalmic surgical instrument of claim 5, wherein the proximal end of the flexible elongated breaking device further comprises a connector, the connector being connectable to an illumination source to provide visualization of the position of the flexible elongated breaking device within the eye. The ophthalmic surgical instrument of any one of claims 1 to 6, wherein the flexible elongated breaking device comprises, in whole or in part, an optical fiber. a handpiece held by a user and having a proximal end and a distal end, the handpiece including a hollow shaft extending from the distal end of the handpiece;
and a flexible, elongated breaking device comprising an optical fiber having an outer diameter of 50 μm to 350 μm slidably extending from the hollow shaft,
An ophthalmic surgical instrument, wherein the flexible elongated breaking device is adapted to be advanced through a tissue space within an eye. The ophthalmic surgical instrument of claim 8, wherein the proximal end of the flexible elongated breaking device further comprises a connector, the connector being connectable to an illumination source to provide visualization of the position of the flexible elongated breaking device within the eye. The ophthalmic surgical instrument of claim 8 or 9, wherein the flexible elongated breaking device comprises a plurality of rearwardly and outwardly extending barbs adapted to engage surrounding tissue within the tissue space of the eye. The ophthalmic surgical instrument of claim 8, wherein the barbs are unidirectional. The ophthalmic surgical instrument of claim 8, wherein the barbs are bidirectional. The ophthalmic surgical instrument of any one of claims 1 to 12, wherein the flexible elongated breaking device further comprises a hydrophilic coating that aids in intubation of the ocular structure. The ophthalmic surgical instrument of any one of claims 1 to 13, wherein the flexible elongated breaking device further comprises a hydrophobic coating that assists in retaining the flexible elongated breaking device within the ocular structure when tensioned. 1. A method for performing an internal trabeculotomy, comprising:
dissecting the trabecular meshwork of the eye to access the lumen of Schlemm's canal;
placing a distal end of a flexible elongated disruption device through the incision and into the Schlemm's canal;
advancing the flexible elongated rupture device through the Schlemm's canal at an angle between 0 and 360 degrees;
disrupting surrounding tissue by applying tension to the flexible elongated disruption device within the Schlemm's canal, thereby forming a trabeculotomy;
and retrieving the flexible elongated breaking device from the incision. 16. The method of claim 15, wherein the flexible elongate breaking device includes barbs disposed along the flexible elongate breaking device, and prior to tensioning the flexible elongate breaking device, the flexible elongate breaking device is slightly retracted proximally or tangentially to cause the barbs to engage the surrounding tissue. The method of claim 16, wherein the flexible elongated disruption device is advanced around the entire circumference of the Schlemm's canal. 18. The method of claim 17, wherein the flexible elongated disruption device is first advanced 180 degrees, and then the procedure is repeated to advance the remaining 180 degrees of the Schlemm's canal, thereby forming a 360 degree line of trabecular incisions. The method of any one of claims 15 to 17, wherein the flexible elongated breaking device comprises, in whole or in part, an optical fiber.