JPH04507202A - Non-aggressive sclerotomy laser device and method - Google Patents

Abstract

(57) [Summary] This bulletin contains application data before electronic filing, so abstract data is not recorded.

Description

[Detailed description of the invention] A method of creating a fistula in the sclera of the eye.

30. Dry the sclera with a dye that enhances the optical absorption of the laser beam by the sclera. 30. The system of clause 29, above, further comprising the step.

31. Dry the sclera with methylene blue and apply the laser light to about 590 nm. 31. The method of claim 30, wherein the method has a wavelength of 100 nm.

32. The method according to item 30 or 31 above, wherein the dye is applied as an ion conductor. .

33. The laser light has a wavelength of 550 to 700 nanometers, The method according to any of paragraph 32.

34. The diameter of the spot is 100 to 200 microns, the above 29th to 33rd The method described in any of the paragraphs.

35. The width of the pulse is less than 25 microseconds, paragraphs 29 to 34 above. The method described in any of the above.

36. The width of the pulse is less than 20 microseconds, paragraphs 29 to 35 above. The method described in any of the above.

37. The width of the pulse is greater than 3 microseconds, as defined in paragraphs 29 to 36 above. Any method described.

38. The width of the pulse is greater than 5 microseconds, as defined in paragraphs 29 to 37 above. Any method described.

39. Any of paragraphs 29 to 38 above, wherein the duration of the pulse is approximately 10 microseconds. The method described in

40. The energy of the pulse is less than 750 millijoules, the above Nos. 29 to 39 The method described in any of the paragraphs.

41, the energy of the pulse is 75-250 millijoules, and the laser 41. The method according to any of the above items 29 to 40, wherein the method is repeatedly pulsed.

42. The energy of the pulse is 150 to 500 millijoules, the above 29th to 41. The method according to any one of Item 40.

43. The cone angle of light in the sclera is less than about 206, the above-mentioned Nos. 29 to 42 The method described in any of the paragraphs.

44. The person according to item 43 above, wherein the cone angle of light in the sclera is about 8° to 156°. Law.

45. The cone angle of light in the sclera is about 10° to 13°, according to item 43 above. Method.

46. The sclera is repeatedly exposed to single pulses of laser light until a hole is formed in the sclera. 46. The method according to any of paragraphs 29 to 45 above, comprising illuminating.

47. The method of item 46 above, wherein the sclera is illuminated with 10 to 15 pulses.

48, the laser is sent through an optical fiber, the optical fiber having a first No. 29 above, tapering from the diameter to the laser straight line at its distal end. 48. The method according to any one of items 47 to 47.

49. Laser is flash lamp, pulsed dye laser or ruby laser - The method according to any one of items 29 to 48 above.

50, the focusing means consists of a goniolens and the laser of the slit lamp. as described in any of paragraphs 29 to 49 above, which is coupled to a laser system. the method of.

Specification The present invention uses a laser to create holes, or fissures, in the sclera. The present invention relates to a method of treating glaucoma that produces a fistula.

Glaucoma is a subclinical condition in the eye in which the intraocular pressure of fluid within the eye rises above normal levels. It is a debilitating disease. Creating a fistula in the sclera in the peripheral area of the cornea directs the fluid pressure associated with glaucoma across the sclera and into the subconjunctival space, Here it is gradually absorbed from inside the eye or moved away from it. It is recognized that Laser light is used to create fistulas like this. It has been used. For example, in 1969, L'E Verance (L'E (sperance) injects Indian ink and uses a continuous wave argon ion laser. By creating a hole in the sclera that allows the use of Increased revenue. L’Esperance, “Laser of the Eye” Laser trabeculosclerotomy in: photocoagulation, photocopying, and surgery ( Laser TrabeculosclerostorrBrin Ophta lmic La5ers: Photocoagulation, Photora dialion, and Surgery) J, St. Louis s) C, V, Mosby Co., 538-54 3.1969゜Furthermore, Latina et al. proposed the development of internal laser sclerotomy using the toIens technique. . ARVO Abstract (Abs t ra) ct), p, 254, No, 12.1986゜Sclera strip from an enucleated eye Apply methylene blue iontophorically to the tips, then 600 ml. 1 microseca at 660 nanometers sent through a Kron optical fiber The sclera was excised using a dyed laser at the length of the needle. Excision is 50 millijoules observed in pulse/pulse. The authors conclude, “The potential of this technology for clinical use The gender is currently being researched."

In 1987, Latina et al., ARVO, No.

11, at an energy of 30-40 millijoules/pulse, An internal scleral resection using a second length scleral resection was described. strength The conjunctiva covering the membrane is elevated in the local area with a saline solution for subsequent intensification. Inadvertent puncture of the conjunctiva by membrane resection was avoided. Insert the optical fiber between the eyes through the cornea. Insert it contralaterally, pass through the anterior chamber, and make contact with the sclera at the staining site. It was placed side by side. 1 microsecond laser pulse with a wavelength of 660 nanometers The solution was delivered through a 320 micron diameter optical fiber. 7-12 pulses for 30 It was applied using an energy of ~40 millijoules/pulse. attack like this An arbitrary system is not desirable. Because the introduction of infection and inflammation due to aggressive surgery problems and healing problems related to aggressive procedures, and the sclera in an open position. This is because it is difficult to maintain the fistula.

Using a slit lamp and goniolens, Lachina et al. In fact, a non-aggressive procedure was proposed.

Summary of the invention In accordance with the teachings of the present invention, a completely non-aggressive glaucoma treatment procedure is disclosed.

The laser should be at least 75 millijoules/pulse and about 1,0 to 30 mic A pulse of light between 1U1 and 10 seconds is generated. For example, light is transmitted to a goniolens. It is non-aggressively focused through the cornea onto the sclera. Sclera is 100-3 Illumination with a spot of 0.00 micron diameter.

More specifically, a region of the sclera is iontophoretically stained. has relatively high power , which produces maximum energy transmission through the cornea, where it has minimum absorption. Dye laser or other tunable, operable to A laser, for example a ruby laser, is used to direct the stained area of the sclera through a goniolens. It has its transmission path, which can be targeted in minutes. Using the slit lamp transmission system Aim and apply a pulsed laser. Pal Straser excises the sclera in the stained area to release fluid pressure in the eye Open fistula for.

In certain implementations, a visible absorbing dye, e.g., methylene blue, is applied to the periphery of the cornea. transmitted through an iontophoretic probe applied to the Iontophoretic dyes penetrate the conjunctiva through the membrane to an area of the sclera through which a fistula is generated.

Most preferably, the dye is water-soluble, non-toxic, and does not ionize or band in solution. The electricity is on. A laser with a wavelength of approximately 590 nanometers is applied to diluted media in the sclera. Maximize absorption at the tyrene blue dimer peak. 550-700 nano Other wavelengths of the meter can be used. For example, Ruby Laser 694 Nanometer wavelengths lie in the wings of the absorption curve.

The slit lamp's delivery system delivers the gogo to the iontophoretically stained scleral point. The Niolens allows the operator to see a path that is directed laterally through the cornea. include. Slit lamp transmission system has a beam splitter inside the viewing passage - including radiation from a high power laser beam, thus from a dye laser; is tuned to the absorption wavelength of the iontophorically applied dye, and the viewing path so that it can be coupled inside. Low power aiming lever lasers, such as helium-neon lasers, are identical to high-power dye lasers. It has its output beam applied first along the path, and the aiming lever function as a user.

The operator must adjust the transmission system of the slit lamp or the goniolens. Using the knob, aim low at the stained location on the sclera where the fistula is to be created. position the laser beam. Then, by switching the shutter, the high By applying pulsed radiation from a laser of high power to the same point, the fistula opens. Reach the sclera until the ocular fluid can flow from the inner eye to the subconjunctival space. to be accomplished.

having an end diameter of about 100 to 300 microns, preferably less than 200 microns. demagnification using fibers that n) Make a 100-200 micron spot on the sclera without using L/L. It is preferable that Demagnification produces a larger cone angle and the cone angle is kept below about 20°, thus reducing the area at the edge being illuminated. The position should be such that it does not form a shadow at that angle. The cone angle is the best ( Maintain above 8° to avoid high power density in the cornea. Range from 8″ to 15″ range is preferred, and a range of 10" to 13° is most preferred. Also, for best results is greater than 1 microsecond, preferably greater than 3 microseconds, Most preferably, the results are obtained with pulse durations greater than 5 microseconds. It was seen. Periods less than 25 microseconds are preferred; A period of time less than a second is most preferred. A period of about 10 microseconds is best. . The energy/pulse is best between 75 and 750 millijoules. 75-25 Low energy in the range of 0 millijoules, e.g. 10-15 pulses. can be used successfully (with 150-500 millijoules of energy) rugy allows the use of only one or a few pulses.

These parameters of short pulse width, small diameter and high energy give exposed to a large amount of abrasion from the beam entering the proximal end of the fiber. . Maximizes wear by minimizing power and energy density at the proximal end. A fiber with a taper is used to reduce the laser beam from the laser. was transmitted to the slit lamp assembly. 600~20 over 1m length It has been found that a taper of 0 microns or 300-100 microns is acceptable. It was seen.

The present invention provides a non-invasive method for ablating small sections of sclera with minimal damage to surrounding tissue. Provide offensive methods. Laser light causes minimal damage to surrounding tissue and has a set of parameters that prevent the potentially harmful auditory effects of laser light.

Since no incisions are required, the number of complications inherent in surgery is minimized. moreover , the proliferation of fibroblasts and therefore the level of subconjunctival scars is reduced, and the resected area The permanence of the area increases.

Brief description of the drawing These and other features of the invention will be described in more detail and in a non-aggressive manner. In the accompanying drawings illustrating a system and related method for relieving pressure of obstacles, More details are provided below.

Figure 1 shows the laser, slit lamp assembly, goniolens and ion 1 is a schematic illustration of a system including an introduction probe.

FIG. 2 is a side view of a modified slit lamp according to the invention.

Figure 3 shows methylene in phosphate buffered saline using scleral pigment as standard. The blue absorption curve is shown.

Preferred embodiment and description The present invention allows the radiated energy of the laser to not attack the sclera in the peripheral corneal region of the eye. It includes systems that transmit information. Absorption frequency for laser applied dyes Specially tuned to the wave number to form a fistula in the sclera and reduce glaucoma pressure Release your power. In particular, FIG. 1 illustrates an eye 12 having a corneal region 14 and a scleral layer 16. glaucoma disease In some cases, areas 20 that, if untreated, can lead to loss of visual acuity. The pressure in the eye fluid increases.

In a procedure according to the invention, an iontophoretic probe 22 is applied to the conjunctiva 18 in a region 2 of the sclera. 4 and in this region 24 one or more selected frequencies. Apply a dye that enhances the absorption of light. Power from the power supply 26 through the probe. A flow is applied to propel the dye particles from the probe 22 into the scleral region 2-4. . This type of probe applies various materials into layers of tissue by iontophoresis. It is technically known that In one embodiment, the applied dye is methylene blue, which emits visible radiation at 668 nanometers. It has an absorption peak that has been announced as follows. In the visible spectrum, other than pigments There is minimal absorption by ocular tissues or fluids, so the laser beam The sclera, which can be focused through and surrounds like non-pigment The tissue is not excised.

A study of the absorption spectrum of methylene blue diluted in water shows that the absorption spectrum is demonstrate a shift to lower wavelengths. Figure 3 shows the pigment in the scleral tissue as a standard. Experimental measurements of the absorption of methylene blue in phosphate-buffered saline are shown. . As this curve illustrates, the laser wavelength of approximately 590 nanometers Maximize the absorption at the peak of the dimer of methylene blue diluted with

The modified slit lamp transmission system allows for the application of racer radiation to region 24. used for. In particular, the transmission system of ordinary slit lamps is 30 and a microscope system 32. The operator passes through area 24 to passage 30. View through the gonio lens 34 along.

The gonio lens 34 has a side flap 36. The slit beam is axis 37 and is reflected by prism 39 and focused onto area 24. be combined.

The goniolens can withstand the high peak power of the laser and the present invention Have a suitable mirror for use in the method. Lasag Corporation (L SAG Corp, )'s CGF goniolens has these quantities: March ( March) et al., 18 Ophthalmic S. 513.1987° lens has no distortion and is completely made of glass. It's a lens. One surface has an angle of 68' and is coated to It forms a radiation surface. The acrylic scleral flange of the lens controls lens tilt. However, when properly placed, it maintains conjunctival elevation.

In a modification of the slit lamp system, the optical path 30 is replaced by a two-color rotating mirror 38. , which allows radiation from optical passageway 40 to be introduced onto passageway 30 . a In other words, a bicolor mirror is provided around the mirror that the physician can see along the optical path 30. can be replaced with a small rotating mirror.

The radiation applied to optical path 40 is pulsed by control system 44. A rotatable dye laser controlled by the operator to generate radiation from the laser. Output beam 4 from rotatable dye laser 42 6, the quartz optical fiber 5 passes through the shutter mechanism 48 and passes through the lens system. Add on top of 0. The fiber is typically located at a distance from the dye laser assembly. The radiation from the beam is transmitted to a laser beam path 40. Emissions from fiber 50 The scattered radiation is collimated and focused by lens system 52. Mirror the light 38 The light is reflected by the gonio lens 34, and then reflected by the reflection device 36. when the dye is iontophoretically applied to the point 24 on the sclera. become.

The transmission system of the slit lamp furthermore includes a aiming laser, e.g. Includes Helium Neon Laser-54. of the output from the aiming laser. The beam is reflected into optical fiber 50 by mirror 56 and shutter mirror 48. , occupy the same path 40 as the beam 46 from the dye laser 42. to this method and aiming laser 54, typically a relatively low power helium tank. The on-laser follows the same path as the radiation from beam 46 and points at the same point. A beam of non-damaging light can be provided that is focused on the . operator by operating the transmission system of the slit lamp, positioning the eye 20, and In particular, fine adjustment by manual positioning of the gonio lens 34 allows the laser to The stained scleral area 24 is intended to provide excision of the laser 54 to the lower Adjust the point at which the laser beam is aimed.

Position the shutter mechanism 48 and aim it toward the optical fiber 50 The dye laser is started and then ejected from this laser. The beam is reflected from the back surface of the printer 48 to the light absorption medium 60. dye laser A beam splitter 62 is disposed in the passage between the shutter 42 and the shutter 48; This beam splitter 62 reflects approximately 5% of the laser, which causes the lens 64 to reflect approximately 5% of the laser beam. through to a pyroelectric detector 66, which is an energy monitor. and work. Within this system, the dye laser is activated as needed to provide the correct energy. After obtaining the energy level, expose the eye to the dye laser.

Once the aiming point is established and the appropriate energy level is established. When the shutter 48 is turned on, the shutter 48 is switched and the operator presses the control 4 4, the dye laser 42 is activated for application of pulses of radiation.

Laser 42 has a dye as the active medium to produce visible laser radiation. , this laser radiation causes iontophoretically applied pigment in area 42 of the sclera. is preferentially absorbed by In the case of methylene blue, the color of the dye laser The element ranges from 550 to 700 nanometers, preferably about 590 nanometers. and radiates.

The aiming established by the low power beam from the aiming laser 54 A high power beam from the dye laser 42, which follows a path that causes the sclera to causing resection and opening of the fistula in area 24 through. that fiss The tellur expels excessive pressure of ocular fluid to the conjunctiva 18, where it is gradually distributed . Has an output beam specifically tuned to the absorption wavelength for the dye The use of a dye laser allows the sclera to be stained with the dye in area 24 with respect to other tissues. Enhances preferential ablation of tissue, thereby limiting the required power application (and also prevents damage to tissues other than the area where the fistula is desired in the sclera) .

Appropriate parameters for use of the above transmission system are those for the surrounding tissue and cornea. to minimize possible damage and maximize the chance of successful invasion of the desired tissue. choose to do so.

In general, the width of the pulses of the transmission system increases the chance of cratering into the sclera. high but low auditory effect, thus preventing the tissue from exploding during irradiation. select. Pulse durations greater than 1 microsecond are sufficient to penetrate the fiber. To transmit energy and minimize potentially undesirable auditory effects preferred. Periods greater than 3 microseconds are preferred, and 5 microseconds Periods greater than the second are most preferred. On the other hand, 30 microseconds less than 25 microseconds, most preferably less than 20 microseconds, preferably less than 25 microseconds, most preferably less than 20 Periods smaller than microseconds do not cause significant thermal damage to surrounding tissue This will tighten the sclera and provide more consistent perforation. Preferred pulse duration is about 10 microseconds.

The transmission system causes perforation, but not just excision of the sclera.

Thus, the energy of the pulses of the transmission system is reduced to 100%, which takes a large amount of time to perforate the sclera. Select the fraction as possible. Again, this energy is absorbed by the laser beam. Select to reduce sensory effects. Generally, the pulse energy is 75-750 It is between millijoules. Energy between 75 and 750 millijoules is a large number laser pulses, e.g. 10-15 pulses, at a relatively low energy level. Enables use of bell. 150-5 to use a few pulses of heat Higher energies of 0.00 mJ may be required.

The diameter of the spot is such that sufficient energy is provided to allow penetration of the sclera. , choose not to allow excision just yet. Smaller spots are Demagni smaller fibers to avoid fication and resulting larger cone angles. small fibers limit the amount of energy that can be transmitted. Ru. As an alternative to textiles, an articulated arm transmission system can be used. Wear. Fiber limitations are no longer an issue, and articulated arms are less convenient and and create other industrial problems. In either case the spot is too large and requires significantly more energy to penetrate into the sclera. high energy Ghee can also have dangerous effects within the eye. In general, the diameter of the spot is 100-300 microns.

The conical angle or multiple apertures of the transmission system focus the laser light onto the sclera. , and the tissue that the laser light traverses before reaching the sclera or deeper tissues within the eye. The fabric is selected to ensure that the laser energy will not damage it. smaller than The cone angle increases the power density at the cornea for a given power at the sclera. Add. The angle should not be so small as to cause damage to the cornea and should not be so small as to cause damage to the cornea. so thick that it casts a shadow at that angle (must not, avoid the formation of shadows) In order to do so, the angle should be about 206 or less. In general, the cone angle is best is 8e to 15°, preferably 10° to 13°.

With a spot size of 100-200 microns in diameter, the end of the fiber is 1 00 to 200 microns in diameter and of demagnification to region 24. The need should be avoided. Demagnification produces a larger cone angle. Similarly, this makes it difficult to illuminate area 24 at the limbus without interference from other parts of the eye. will.

High energy/pulse, small spot size and short pulse duration give When exposed, the proximal ends of the fibers 50 experience a large amount of wear.

from 600 to 200 microns or 300 microns to minimize wear. Using tapered fibers with a taper from Kron to 100 microns . In fact, this fiber can be removed from its proximal end without increasing the cone angle in the eye. magnification and uses less power and less power at the proximal end of the fiber. and energy density.

2 is a side view of the modified slit lamp schematically shown in FIG. 1; FIG. Second The figure is a view from the opposite side of the system with respect to the diagram in figure 1: thus the eye It will be located on the left side of Figure 2. As mentioned above, ordinary slit lamps are It includes a binocular viewing device 32 in which the teacher views the image in the eyes. Safety shutter 67 , closes when a high power laser is activated. The slit beam is also , is focused from a light source 68 to an image plane within the eye. Slit beam is a prism 39.

Modify the slit lamp to focus the light from the tapered fibers 50 to the same point on the eye. Try to match the dots. A lens system 52 that focuses the laser beam flattens the light. A lens system 70 for focusing the beam and an achromatic lens 72 for focusing the beam. include. A lens with a focal length of 12 cm and a diameter of 4 Q mm was initially used. Ta. They were replaced by lenses with a focal length of 140 mm and a diameter of 30 mm. . A focused beam is reflected from the dichroic mirror 38 into the eye.

There is an energy monitor between lenses 70 and 72. energy monitor The target includes a beam splitter 74 that reflects 5% of the laser light to the right in Figure 2. Contains. The reflected light is focused onto a pyroelectric detector 78 by a lens 76. vinegar. This monitor provides an indication of the amount of light actually reaching the focusing lens 72. the level of energy provided and determined by monitor 78 and detector 66. The difference between the two signals indicates the condition of the optical path from the laser.

An example of the use of the above laser for puncturing the sclera is described below.

This example does not limit the invention.

Prior to laser treatment, the eye to be treated was anesthetized with topical provaricaine. eye After placing the eyelid speculum, the site of the filtration channel was selected by standard techniques. This section At this point, methylene blue dye ( (1% solution in distilled water) for a period of 5 minutes or until the dye is visualized within the anterior chamber of the eye. Local staining was performed with a current of 200-400 microamps until the staining was completed. less The stained spots, both 1 mm in diameter, are well-proportioned when irradiated with laser light. required to ensure proper penetration. The patient then undergoes a laser slit run. sit down at the pool and position yourself appropriately. The dye penetrates the entire thickness of the sclera. Place a single mirror gonioscope lens over the eye to ensure to visualize the presence of the dye on the inner surface of the sclera and to determine the location of the stained area. Guaranteed to be correct. The stained conjunctival area is then removed from the sclera by viscoelastic e.g. , Healonl+ [Pharmacia] or ]ViscohViscat”) [Cooper Vis on)] using a 27-gauge needle inserted adjacent to the planned filtration bleb. was used to inflate it.

Methyl cellulose over the eye with an all glass goniometric lens with a 68" mirror. the stained area of the sclera in the anterior chamber of the eye through a slit lamp. I visualized it. Sulphoroda emits laser light at 660 nanometers Min 640 dye was used in a flash lambuv pulsed dye laser. . Use the laser to aim the laser over the stained area. focused on. The light is then slightly defocused into the sclera. us) t7, this is called burying beam, and The laser was started manually in single pulse mode. Then, the excised Visualize the membrane and refocus the laser light into the ablation crater. The laser was then started manually. This process visualizes the pores passing through the sclera. or if there is turbulence in the area of the new sclerotomy, the water Continue until fluids are shown to flow freely from the anterior chamber into the subconjunctival space. Ta. The goniolens is then removed from the eye and the conjunctiva is examined for bleb formation. Inspected. Intraocular pressure was then measured by applanation tonometry. subconjunctival steroids injected from the bleb site at 1806, and topical antropin 1% and Polysporin ointment was applied to the treated eye. Treat the patient with topical prednisolone acetate 1 % eye drops 1 to 6 times/day and Atrobin 1% eye drops 2 times/day. Ta.

While the invention has been particularly shown and described with reference to preferred embodiments thereof, those skilled in the art will appreciate that The form and scope may be modified without departing from the spirit and scope defined by the appended claims. It will be understood that various changes in detail may be made.

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Claims (1)

[Claims] 1. A laser that generates pulses of laser light, each pulse containing 75 millijoules. energy or greater and a duration of approximately 1 to 30 microseconds. and non-aggressively focuses the light from the laser through the cornea and onto the sclera. Together, the sclera is illuminated in a spot of 100-300 microns in diameter. A device that creates a fistula in the sclera of the eye, consisting of steps. 2. Drying the sclera with a dye that enhances the optical absorption by the sclera caused by laser light 2. The apparatus of claim 1, further comprising a stage. 3. The dye is methylene blue, and the laser light is about 590 nanometers. 3. The device according to item 2 above, having a wavelength. 4. The means for applying the dye is to apply the dye iontophoretically, as described in item 2 or 3 above. The device described. 5. The wavelength of the laser light is 550 to 700 nanometers, the above items 1 to 4. The device described in any of the above. 6. Any of the above items 1 to 5, wherein the spot diameter is 100 to 200 microns. The device described in Crab. 7. The width of the pulse is less than 25 microseconds, any of the above items 1 to 6. The device described in. 8. The pulse width is less than 20 microseconds, any of the above items 1 to 7. The device described in. 9. The width of the pulse is greater than 3 microseconds, according to any of paragraphs 1 to 8 above. The device described. 10. The width of the pulse is greater than 5 microseconds, any of the above items 1 to 9. The device described in. 11. Any of the above items 1 to 10, wherein the pulse period is about 10 microseconds. The device described in Crab. 12. The energy of the pulse is less than 750 millijoules, items 1 to 11 above. The device described in any of the above. 13. The energy of the pulse was 75-250 millijoules and repeated 13. The apparatus of claim 12, wherein the device applies a pulse. 14. The energy of the pulse is 150 to 500 millijoules, item 12 above. The device described. 15. The cone angle of light at the sclera is less than about 20°, items 1 to 14 above. The device described in any of the above. 16. The cone angle of light in the sclera is approximately 8° to 15°, as described in items 1 to 15 above. The device described in any of the above. 17. The cone angle of light in the sclera is about 10° to 13°, as described in items 1 to 16 above. The device described in any of the above. 18. The laser light is sent through the optical fiber to the focusing means, and the optical fiber from a first diameter at its proximal end that receives light from the laser to a laser at its distal end; 18. A device according to any of the preceding clauses, having a taper to the diameter of the laser. 19. The laser is a flash lamp-pulsed dye laser. 19. The device according to any of paragraph 18. 20. Any of the above items 1 to 19, wherein the laser is a ruby pulsed laser. The device described in Crab. 21. Any of the above items 1 to 20, wherein the focusing means consists of a goniolens. The device described in. 22. The laser and focusing means are coupled to a slit lamp. 22. The device according to any one of items 1 to 21 above. 23. a second low power aiming laser and a hand for directing said low power laser; 23. Apparatus according to any of paragraphs 1 to 22 above, further comprising a stage. 24. Laser: goniolens that receives light from the laser and directs it to the sclera; light from the laser an optical fiber that conducts the image; and the end of the optical fiber passes through a goniolens to image the sclera. Lens system to form; Consisting of The optical fiber has a first diameter at its proximal end to a smaller diameter at its distal end. has a taper toward A system that creates a fistula in the sclera of the eye. 25. The laser has an energy level between 75 and 750 millijoules/pulse. the optical fiber provides a pulse between 1 and 30 microseconds at a about 200 microns or less from the laser to the distal end. system. 26. The laser has an energy level between 150 and 500 millijoules/pulse. 26. The method according to claim 25, wherein the pulse is between 3 and 20 microseconds. system. 27. The laser has a pulse duration of about 10 microseconds, 27. The system according to any one of items 26 to 26. 28, the optical fiber has a taper of a 3:1 change in diameter along its length, The system according to any one of items 24 to 27. 29. Laser and hand focusing light from the laser through the cornea onto the sclera Prepare the steps; each with an energy greater than 75 millijoules and 1 to 30 microseconds generating at least one pulse of laser light having a duration of: and The sclera is illuminated with a pulse of laser light with a spot 100-300 microns in diameter. Ru; A method of creating a fistula in the sclera of the eye. 30. Dry the sclera with a dye that enhances the optical absorption of the laser beam by the sclera. 30. The system of clause 29, above, further comprising the step. 31. Dry the sclera with methylene blue and apply the laser light to about 590 nm. 31. The method of claim 30, wherein the method has a wavelength of 100 nm. 32. The method according to item 30 or 31 above, wherein the dye is applied iontophoretically. . 33. The laser light has a wavelength of 550 to 700 nanometers, The method according to any of paragraph 32. 34. The diameter of the spot is 100 to 200 microns, the above 29th to 33rd The method described in any of the paragraphs. 35. The width of the pulse is less than 25 microseconds, paragraphs 29 to 34 above. The method described in any of the above. 36. The width of the pulse is less than 20 microseconds, paragraphs 29 to 35 above. The method described in any of the above. 37. The width of the pulse is greater than 3 microseconds, as defined in paragraphs 29 to 36 above. Any method described. 38. The width of the pulse is greater than 5 microseconds, as defined in paragraphs 29 to 37 above. Any method described. 39. Any of paragraphs 29 to 38 above, wherein the duration of the pulse is approximately 10 microseconds. The method described in 40. The energy of the pulse is less than 750 millijoules, Nos. 29 to 39 above. The method described in any of the paragraphs. 41, the energy of the pulse is 75-250 millijoules, and the laser 41. The method according to any of the above items 29 to 40, wherein the method is repeatedly pulsed. 42. The energy of the pulse is 150 to 500 millijoules, the above 29th to 41. The method according to any one of Item 40. 43. The cone angle of light in the sclera is less than about 20°, Nos. 29 to 42 above. The method described in any of the paragraphs. 44. The person according to item 43 above, wherein the cone angle of light in the sclera is about 8° to 15°. Law. 45. The cone angle of light in the sclera is about 10° to 13°, according to item 43 above. Method. 46. The sclera is repeatedly exposed to single pulses of laser light until a hole is formed in the sclera. 46. The method according to any of paragraphs 29 to 45 above, comprising illuminating. 47. The method of item 46 above, wherein the sclera is illuminated with 10 to 15 pulses. 48, the laser is transmitted through the optical fiber, and the optical fiber is connected to the first tapering from the diameter to the diameter of the laser at its distal end; 47. The method according to any of paragraphs 47. 49. Laser is flash lamp, pulsed dye laser or ruby laser - The method according to any one of items 29 to 48 above. 50, the focusing means consists of a goniolens and the laser of the slit lamp. as described in any of paragraphs 29 to 49 above, which is coupled to a laser system. the method of.