阅读说明：本技术 用于微创性青光眼手术的装置、系统和方法 (Devices, systems, and methods for minimally invasive glaucoma surgery ) 是由 G.贝尔维尔德特 J.索伦森 M.米特尔施泰因 S.米尔哈舍米 于 2018-02-16 设计创作，主要内容包括：可用于在哺乳动物的眼的小梁网中形成开口的装置和方法。(Devices and methods useful for forming an opening in the trabecular meshwork of a mammalian eye.)

1. An apparatus, comprising:

A shaft;

A distal member positioned at the distal end of the shaft, the distal member having a leading end and a trailing end;

A front tip formed at a front end of the distal member;

A right edge and a left edge proceeding rearward from the front tip;

A recess, slot, cavity, or open area rearward of the front tip and between the right edge and the left edge;

Wherein at least a portion of the right and left edges are configured to cut tissue as the tissue advances in a rearward direction over the right and left edges.

2. The device of claim 1, wherein at least a portion of the right edge and the left edge are serrated.

3. the device of claim 1, wherein the right edge and the left edge rotate as they advance backward.

4. The device of claim 1, wherein the right edge and the left edge increase in height as they progress rearward.

5. The device of claim 1, wherein the right edge and the left edge increase in height and rotate as they progress rearward.

6. The device of claim 3 or 5, wherein at a first position on the front tip, the right and left edges are positioned at a first height and oriented at a first orientation that is vertical or near vertical.

7. The device of claim 6, wherein at a second location rearward of the first location, the right and left edges are higher than at the first location and each rotate to a second orientation that is between horizontal and vertical and further from vertical than the first orientation.

8. The device of claim 7, wherein at a third position rearward of the second position, the right and left edges are higher than at the second position and each further rotates to a third orientation that is beyond horizontal and slopes downward toward the cavity.

9. the apparatus of claim 8, wherein the right edge and the left edge are higher at a fourth location after the third location than at the third location.

10. The device of claim 8, wherein, in a region including the third location, the right edge and the left edge are configured to cut tissue.

11. The apparatus of claim 10, wherein within the region, the right edge and the left edge have serrations.

12. The device of any one of claims 1 to 11, further comprising an aspiration lumen.

13. The device of any one of claims 1 to 11, further comprising an irrigation lumen.

14. The device of any one of claims 1 to 11, further comprising an aspiration lumen and an irrigation lumen.

15. A system comprising the device of claim 12 or 17 in combination with a suction pump connected to the suction lumen.

16. The system of claim 15, wherein the aspiration pump is part of a phacoemulsification console or a phacoemulsification surgical system.

17. A method for using the device of any one of claims 1 to 16 to form an opening in trabecular meshwork tissue of an eye having a Schlemm's canal, an anterior chamber, and a trabecular meshwork, the method comprising the steps of:

Inserting a distal portion of the device into an anterior chamber, the distal portion comprising a distal member;

Advancing the distal member first with a leading tip through the trabecular meshwork and into a Schlemm tube; and

The distal member is first advanced through a Schlemm tube with a leading tip such that trabecular meshwork tissue contacts and is cut by right and left edges of the distal member.

18. The method of claim 17, wherein the device further comprises an aspiration lumen, and wherein the method further comprises aspirating tissue and/or fluid through the aspiration lumen.

19. The method of claim 18, wherein the device further comprises an irrigation lumen, and wherein the method further comprises delivering fluid into the eye through the irrigation lumen.

20. The method of claim 19, wherein an anterior chamber blood accumulation occurs in the anterior chamber, and wherein irrigation and suction are used to clear blood from the anterior chamber.

21. the method of claim 18, wherein trabecular meshwork tissue cut during the procedure is aspirated into the aspiration lumen.

22. A device that can be used to form an opening in the trabecular meshwork of an eye, the device comprising:

An elongated shaft having a distal end;

a member on the distal end of the elongated shaft, the member having a substantially smooth bottom surface, a slotted upper surface having first and second sloped side edges, a pointed end, a first tissue cutting blade formed on a first side edge of the slotted upper surface, and a second tissue cutting blade formed on a second side edge of the slotted upper surface;

the member can be first inserted through the trabecular meshwork with the tip and into the Schlemm tube, and the member can then be advanced through a section of the Schlemm tube with the trabecular meshwork tissue passing over the tip and upper surface to be cut by the first and second tissue cutting blades.

23. The device of claim 22, wherein the first and second side edges are inclined at an angle from about 20 degrees to about 70 degrees relative to a linear axis extending tangentially to the bottom surface at the tip.

24. the device of claim 23, wherein the angle is from about 30 degrees to about 50 degrees relative to the axis.

25. The device of claim 24, wherein the angle is from about 35 degrees to about 45 degrees relative to the axis.

26. The device of any one of claims 22 to 25, wherein the distance between the side edges is from about 50 μ ι η to about 500 μ ι η.

27. The device of claim 26, wherein the distance is between about 150 μ ι η to about 300 μ ι η.

28. the apparatus of claim 27, wherein the distance is 230 μ ι η.

29. The device according to any one of claims 26 to 28, wherein the distance width (W) of the members varies.

30. The device of claim 8, wherein the width of the member is narrowest near the tip and widest at its junction with the shaft.

31. The device of any one of claims 1 to 9, wherein the bottom surface has a longitudinal curvature.

32. The device of claim 10, wherein the longitudinal bend extends from a junction of the bottom surface and a linear axis to a junction of the member and the shaft, the linear axis extending tangentially to the bottom surface at the tip.

33. the device of claim 10 or 11, wherein the bottom surface further has a lateral curvature.

34. the device of any one of claims 1 to 12, wherein the first and second cutting blades are serrated.

35. the device of any one of claims 1 to 13, further comprising an indicator that indicates a direction of the tip.

36. The device of claim 14, wherein the indicator extends from the shaft at a position that remains above the trabecular meshwork when the member is inserted into the Schlemm's tube below the trabecular meshwork.

37. the device of any one of claims 1 to 15, wherein the shaft extends at an angle of between about 30 degrees and about 120 degrees relative to a linear axis extending tangentially to the bottom surface at the tip.

38. The apparatus of claim 16, wherein the shaft extends at an angle between about 70 degrees and about 100 degrees relative to the linear axis extending tangentially to the bottom surface at the tip.

39. The apparatus of claim 17, wherein the shaft extends at an angle of about 85 degrees relative to the linear axis extending tangentially to the bottom surface at the tip.

40. The device of any one of claims 1 to 18, wherein the shaft is devoid of any lumen.

41. The device of any one of claims 1 to 18, wherein the shaft has at least one lumen.

42. The device of claim 20, wherein the shaft has an irrigation lumen and a suction lumen.

43. A system comprising the device of claim 21 further in combination with an ophthalmic irrigation/aspiration device for delivering irrigation fluid through the irrigation lumen and aspirating fluid and/or debris through the aspiration lumen.

44. The system of claim 22, wherein the ophthalmic irrigation/aspiration device is optionally connectable to and usable with a phacoemulsification handpiece type used in cataract surgery.

45. a method for treating glaucoma or aiding in drainage of fluid from the anterior chamber of the eye, the method comprising the steps of:

Obtaining or providing a device or system according to any one of claims 1-23;

inserting the shaft and the distal portion of the member into the anterior chamber of the eye;

The member is first inserted through the trabecular meshwork with the tip and into the Schlemm's canal, and, thereafter,

Advancing the member through a section of Schlemm's tube with trabecular meshwork tissue passing over the tip and upper surface such that the trabecular meshwork tissue is cut by the first and second tissue cutting blades.

46. A device that can be used to form an opening in the trabecular meshwork of an eye, the device comprising:

An elongated shaft having a distal end;

A member on the distal end of the elongated shaft, the member having a tip, a bottom surface, an upper surface, a first side edge, and a second side edge;

A first wing member extending from the first side edge and a second wing member extending from the second side edge;

The first and second wing members having first and second tissue cutting blades formed thereon;

The member can be first inserted through the trabecular meshwork with the tip and into the Schlemm tube, and the member can then be advanced through a section of the Schlemm tube with trabecular meshwork tissue passing over the tip and upper surface to be cut on the first and second wing members by the first and second tissue cutting blades.

47. The device of claim 25, further comprising an indicator that indicates the direction of the tip.

48. The device of claim 26, wherein the indicator extends from the shaft at a position that remains above the trabecular meshwork when the member is inserted into the Schlemm's tube below the trabecular meshwork.

49. The device of any one of claims 25-27, wherein the shaft extends at an angle between about 30 degrees and about 120 degrees relative to a linear axis extending tangentially to the bottom surface at the tip.

50. The device of claim 28, wherein the shaft extends at an angle between about 70 degrees and about 100 degrees relative to the linear axis extending tangentially to the bottom surface at the tip.

51. The device of claim 29, wherein the shaft extends at an angle of about 85 degrees relative to the linear axis extending tangentially to the bottom surface at the tip.

52. The device of any one of claims 25 to 30, wherein the shaft is devoid of any lumen.

53. The device of any one of claims 25 to 30, wherein the shaft has at least one lumen.

54. The device of claim 32, wherein the shaft has an irrigation lumen and a suction lumen.

55. A system comprising the device of claim 33 further in combination with an ophthalmic irrigation/aspiration device for delivering irrigation fluid through the irrigation lumen and aspirating fluid and/or debris through the aspiration lumen.

56. The system of claim 34, wherein the ophthalmic irrigation/aspiration device is optionally connectable to and usable with a phacoemulsification handpiece type used in cataract surgery.

57. A method for treating glaucoma or aiding in drainage of fluid from the anterior chamber of the eye, the method comprising the steps of:

Obtaining or providing a device or system according to any one of claims 25-35;

Inserting the shaft and the distal portion of the member into the anterior chamber of the eye;

Inserting the member first through the trabecular meshwork with the tip and into a Schlemm's canal; and, thereafter,

Advancing the member through a section of Schlemm's tube with trabecular meshwork tissue over the tip and upper surface such that trabecular meshwork tissue is cut on the first and second wing members by the first and second tissue cutting blades.

58. the device of claim 1, wherein a spacing or width between the right edge and the left edge increases as the right edge and the left edge proceed rearward.

Technical Field

The present invention relates generally to the fields of medicine and engineering, and more particularly to surgical devices and methods for performing surgery.

Background

In accordance with 37 CFR 1.71 (e), this patent document contains material which is subject to copyright protection, and the owner of this patent document reserves any copyright whatsoever.

One surgical procedure for treating certain types of glaucoma is an goniectomy. In surgical goniectomy, a tissue cutting or ablation device is inserted into the anterior chamber of the eye and is used to remove a full thickness strip of tissue from the trabecular meshwork covering the Schlemm's canal. In many cases, strips having a length of about 2mm to about 10mm and a width of about 50 μm to about 500 μm are removed. This creates permanent openings in the trabecular meshwork through which aqueous humor fluid may drain. The goniectomy procedure and certain prior art instruments that may be used to perform such procedures are described in U.S. patent application serial No. 10/052,473, published as 2002/0111608 a1 (Baerveldt), the entire contents of which are expressly incorporated herein by reference.

to open the Trabecular Meshwork (TM) to lower intraocular pressure (IOP) for the treatment of glaucoma, an ocular disease requires removal of the TM strip covering the Schlemm's canal. In addition, the distal or posterior wall of the Schlemm tube (where its mouth is used to drain aqueous humor from the eye via a collection channel) must be protected to maintain its efficacy.

if the device is used for only a single cut (e.g., a classic goniectomy knife used for pediatric glaucoma surgery), all of the TM tissue remains posterior. For adults, the results for such procedures may tend to cause the fluid drainage channels through the collection channels in Schlemm tubes to become clogged over time as this residual tissue blocks such channels for fluid to flow out through the collection channels. Furthermore, if the back wall of the Schlemm tube and its outflow opening are damaged during the procedure, its drainage efficacy will likely be compromised. The means of protecting the back wall of the Schlemm tube when removing the TM strip also greatly improves the safety of such procedures (i.e. provides a means for preventing cuts too deep and thus into the back wall of the Schlemm tube).

In addition, such devices must be appropriately sized for an internal (ab-interno) passage through a small incision into the anterior chamber of the eye, typically a small corneal incision. In addition, the working end or distal tip of such devices must also be appropriately sized relative to the anatomy of the Schlemm tube and must be appropriately oriented relative to an axis transverse to the Schlemm tube between the incision point and the treatment area in order to function.

there remains a need in the art for the development of new goniectomy devices and methods whereby a strip of TM tissue is removed to expose the orifices of collection channels in the lateral or outer wall of the Schlemm's canal, thereby allowing aqueous humor to freely drain from the anterior chamber of the eye through these collection channels, which in turn results in a reduction of intraocular pressure in the treated eye.

Disclosure of Invention

In accordance with the present invention, devices and methods are provided that can be used to create an opening in the trabecular meshwork of an eye to facilitate drainage of aqueous humor and thus reduced intraocular pressure.

According to one aspect of the present invention, a device is provided that includes a shaft and a distal member or foot on a distal end of the shaft. The distal member or foot may have a front tip, a right edge, a left edge, and a laterally recessed depression, cavity, or space between the right and left edges. The distal member may be inserted into the Schlemm's canal of the eye and may then be advanced through the Schlemm's canal so that the trabecular meshwork tissue will be cut by the right and left edges. In some embodiments, the edges may be sloped. In some embodiments, the edges may be non-parallel and may twist, rotate, curl, or otherwise change orientation as they progress rearwardly. In some embodiments, the device may optionally include a lumen, opening or port and associated connector for injecting irrigation fluid and/or aspiration fluid and/or substance from the eye. In some embodiments, the width of the distal member and/or the width between the edges may become wider as it progresses posteriorly.

In further accordance with the present invention, the distal member may include a front tip, right and left edges, and wing members. The right and left edges extend over the front surface of the wing member.

Further in accordance with the present invention, there is provided a method for using the device of the present invention to form an opening in trabecular meshwork tissue of an eye of a mammal, as described herein.

Still other aspects and details of the present invention will be understood upon reading the detailed description and examples set forth below.

Drawings

The following detailed description and examples are provided for the purpose of non-exhaustive description of some (but not necessarily all) examples or embodiments of the invention and should not be taken in any way to limit the scope of the invention.

Fig. 1 shows one embodiment of a surgical handpiece apparatus of the present invention.

Fig. 2 is an enlarged view of the distal portion of the device of fig. 1.

Fig. 3 is a side view of the distal portion of the device of fig. 1.

Fig. 3A shows a workpiece cut to form the distal member of the device of fig. 1.

Fig. 4 is a front view of the distal portion of the device of fig. 1.

Fig. 4A is an enlarged view of portion 4A of fig. 4.

Fig. 4B is a side view of fig. 4 marked to indicate the Blade Axis (BAX) over which TM tissue is advanced according to one method of the invention.

FIG. 5 shows a modified distal portion of the device of FIG. 1 to include an optional indented region.

fig. 5A is an enlarged schematic view of an edge of the device of fig. 5, with an orientation plane indication shown at three locations along the left edge.

Fig. 6 is a side view of the distal portion shown in fig. 5.

Fig. 6A is a transverse cross-sectional view through line 6A-6A of fig. 6.

Fig. 6B is a transverse cross-sectional view through line 6B-6B of fig. 6.

Fig. 6C is a transverse cross-sectional view through line 6C-6C of fig. 6.

Fig. 6D is a transverse cross-sectional view through line 6D-6D of fig. 6.

Fig. 7 is a diagram showing the device of fig. 5-6 used to form an opening in TM tissue in a human eye according to the method of the present invention.

Fig. 8 shows a distal portion of another embodiment of a surgical handpiece apparatus of the present invention.

Fig. 8A is a partial enlarged view of the device of fig. 8.

Fig. 8B is a partial left side view of the device of fig. 8.

Fig. 9 shows a workpiece cut from a tubular blank that can be used to form the distal portion of the device of fig. 8.

FIG. 10 shows a modified distal portion of the device of FIG. 8 to include an optional indented region.

Fig. 11 is another illustration showing the device of fig. 5-6 being used to form an opening in TM tissue in a human eye according to the method of the present invention.

Detailed Description

The following detailed description, and the accompanying drawings referred to therein, are intended to describe some, but not necessarily all, examples or embodiments of the invention. The described embodiments are to be considered in all respects only as illustrative and not restrictive. The contents of this detailed description and the accompanying drawings do not limit the scope of the invention in any way.

Non-limiting examples of devices for manually cutting TM strips while avoiding damage to the back wall of Schlemm tubes are described below and shown in the drawings. In these examples, the device may be sized for an internal passage through a small incision into the anterior chamber of the eye (typically a small corneal incision). In addition, the working end or distal tip of each device may be sized relative to the anatomy of the Schlemm tube and appropriately oriented relative to an axis transverse to the Schlemm tube between the incision point and the treatment area so as to act to remove the TM tissue strip via an endoluminal approach.

removal of the TM tissue strip is vital to expose a collection channel in the distal wall of the Schlemm tube to allow water to flow out of the eye and reduce intraocular pressure in glaucoma patients.

Fig. 1-4B show one possible embodiment of a surgical handpiece apparatus 10 in accordance with the present invention. This handpiece 10 generally includes a handle 30, a shaft 12 extending distally from the handle 30, and a distal member 14 (alternatively referred to herein as a "foot") on a distal end of the shaft 12. In this example, the distal member 14 has a bottom surface B, right and left upwardly extending side walls 22, and a cavity or open area 18 between the side walls 22 and the rear of the front tip 16. The front tip 16 may taper to a blunt point, as shown. As explained in more detail below, the edges 20 form the sides of the front tip 16 and transition in orientation as they progress in a rearward direction to form spaced, upwardly inclined top surfaces of the side walls 22. All or a portion of the upwardly sloped regions of the edges 20 may be sharpened, beveled, serrated, or otherwise configured to form cutting regions 21, the cutting regions 21 facilitating the cutting of tissue as it progresses over those edges 20. Further, the sidewalls 22 and/or edges 20 may be non-parallel such that the space 18 between the sidewalls 22 and/or edges 20 becomes wider as it progresses in a rearward direction. This optional widening or nonparallelism of the sidewalls 22 and/or edges 20 can be used to laterally stretch or laterally tighten the tissue as the tissue progresses upward in the progressively widening upward sloped region of the edges 20.

Optionally, the device 10 may include a lumen, an outlet, and a connector for infusing irrigation fluid therein and/or aspirating fluids/substances. In the example shown in fig. 1-4B, the shaft 12 includes an inner tube 24 and an outer tube 26. The inner tube 24 extends out and beyond the distal end of the outer tube 26, as shown. The inner tube 24 has an outer diameter that is less than the inner diameter of the outer tube 26 such that when the inner tube 24 is positioned within (e.g., substantially coaxial with) the outer tube 26, the inner surface of the outer tube 14 is spaced from the outer surface of the inner tube 24, thereby defining an annular lumen in communication with the outlet port 28. The distal end of the outer tube 26 tapers downwardly and is in sealing contact with the outer surface of the protruding inner tube 24, as shown. The opening 28 is positioned slightly above the location where the inner tube 24 exits the distal end of the outer tube 26.

The inner tube 24 has an open distal end that is positioned directly above the space 18 defined between the rim 20 and the sidewall 22. As seen in fig. 2, embodiments that include optional infusion and/or aspiration may also have tubular infusion and aspiration connectors 32, 34 for connecting irrigation fluid and an aspiration source to the desired irrigation/aspiration lumen of the shaft 12.

More specifically, in the particular non-limiting example shown, the tubular connector 32 is configured for connection to a source of irrigation fluid and is in communication with an annular lumen extending through the outer tube around the outer surface of the inner tube 24, thereby facilitating injection of irrigation fluid through the outer tube 26 and out the openings 28. The tubular connector 34 is configured for connection to a suction pump or suction source to facilitate drawing fluid and/or other substances from the space 18 into the open distal end of the inner tube 24, through the lumen of the inner tube 24 and out of the tubular connector 34.

In many procedures, it would be advantageous to perform active irrigation (to pressurize and maintain the volume of the anterior chamber and to open a channel between the top of the iris and the inner surface of the cornea to facilitate access to the TM) and active suction (to clear the treated area of visibility from debris and blood reflux) during angled surgical procedures. Active irrigation also generally eliminates the need to inject viscoelastics into the cornea during surgery, saves surgical costs, and improves the surgical field of the TM (the use of viscoelastics typically distorts the TM field of view due to variations in the refractive index between the viscoelastics and the irrigation fluid). However, if the device 10 includes optional insufflation/aspiration capabilities as described herein and the user does not wish to use irrigation or aspiration in a particular procedure, the user may optionally purge air from the I/a channel and connect the irrigation and aspiration connectors 32, 34 together. Optionally, in some embodiments, the I/a channel may be inserted or not present. During procedures where irrigation and aspiration are not used or available, viscoelastic can be injected into the anterior chamber of the eye to maintain visibility of the channel and angle of angulation during the procedure.

In embodiments equipped with optional irrigation/aspiration capabilities, an aspiration flow rate of about 10-12 ml/min may be desirable to keep the field of view free from backflow blood, stabilize the TM during resection, and enable removal by aspirating the TM tissue cutting strip without requiring the use of additional instruments (e.g., forceps) for removal. Aspiration flow rates in the larger range of about 4-15 ml/min may also have some utility, and all aspiration flow rates >0 ml/min may be at least effective in clearing backflow blood buildup.

When the distal member 14 is inserted in and advanced through a Schlemm tube in the manner described herein, the base B of the distal member 14 is preferably smooth and non-damaging to the outer wall of the Schlemm tube or to a collection channel extending from the Schlemm tube. As can be appreciated from fig. 6 (including the transverse cross-sectional views of fig. 6A-6D), the distal member 14 is transversely concave or U-shaped in this non-limiting example. However, it should be understood that distal member 14 may have other alternative shapes, including a trough-like shape, a V-shape, or other shapes in which there is a transverse cavity or depression between edges 20. The bottom surface B of the distal member 14 is preferably smooth, and/or otherwise configured such that as the distal member 14 is advanced through the Schlemm tube, it will not cause damage or clinically significant damage to the outer wall of the Schlemm tube, as described herein. The forward tip 16 of the distal member 14 may be pointed or otherwise configured to easily pierce through the TM for entry of the tip and distal member into the Schlemm tube. However, this tip 16 (including its edges) is preferably sufficiently blunt and/or atraumatic so as not to damage the distal wall of the Schlemm tube or the collection channel extending from the Schlemm tube as the distal member 14 is advanced (tip 16 first) through the TM and into and along the Schlemm tube. The tip 16 may also help guide the distal member along the path of the lumen of the Schlemm tube as the distal member is advanced through the Schlemm tube.

In the non-limiting example shown, the upper surface of the distal member is generally channel-shaped (e.g., U-shaped), with tissue-cutting edges or blades 20 formed onto first and second sloped sidewalls 22. These edges 20 are spaced apart as shown.

The open distal end of the inner tube 24 is positioned at the top of the lumen 18, which lumen 18 resides between the side walls 22 of the distal member 14, such that the aspirated material or tissue strip cut by the rim 20 travels through the elongate lumen 18 and into the open distal end of the inner tube 24. Furthermore, such capabilities of device 10 may enable an operator to maintain a stable desired fluid pressure within the anterior chamber of the eye when both suctioning and irrigation are performed. Furthermore, during such angled procedures, flow from the irrigation to the suction port of the device maintains visualization of the treatment area by actively removing any tissue debris and/or blood backflow typically associated with exposure of the collection channel to the anterior chamber.

When provided as a sterile disposable, the overall surgical steps for the embodiment shown above in fig. 1, with or without active I/a during the surgical procedure, are described in detail as follows:

First selection: for use with ophthalmic I/A systems.

1. All packages were inspected prior to use. If the package is opened or damaged, it is not used.

2. The hand piece is removed from its packaging in the sterile field.

3. The flush connector 32 of the handpiece is connected to the flush line connector of the fluid set of the I/a system. The suction connector 34 of the handpiece is connected to the suction line connector of the fluid set of the I/a system. The tip places the handpiece (with the clearance chamber in place) with a downward slope.

4. The irrigation and aspiration of the I/a system are activated and the fluid line is purged until all air bubbles in both the handpiece and irrigation and aspiration lines of the I/a system are removed. Irrigation and aspiration of the I/a system are turned off.

5. A clear corneal incision was performed using a scalpel. Allowing anterior chamber decompression helps to engorge blood into the Schlemm's canal and helps identify the location of the TM.

6. The clean out chamber/transparent cover 36 is carefully removed from the device 10 so that the shaft 14 components do not contact the clean out chamber.

7. The raised indicator 30 on the handpiece device 10 corresponds to and is directed to the direction of rotation of the distal member 14 and should remain perpendicular to the corneal incision.

8. Flushing of the I/a system is activated. The shaft 12 of the handpiece device 10 is inserted through a corneal incision and into the anterior chamber of the patient's eye. When the irrigation opening 28 of the handpiece device 10 passes through the corneal incision and irrigation fluid begins to flow into the anterior chamber, the anterior chamber should be deepened.

9. The distal member 14 is advanced toward the TM opposite the incision. An oblique view of the TM is established and the member is continued to be advanced until its smooth bottom surface B contacts the TM.

10. The TM is pierced with a pointed forward tip 16 so that the distal member 14 enters the Schlemm tube while avoiding damage to the posterior wall.

11. Suction of the I/a system is activated (irrigation is also kept active). The distal member 14 is then advanced along the Schlemm tube in a direction intended to cut the TM. Examples of which are shown in fig. 7 and 11 and discussed more fully below. As the distal member 14 is advanced in a forward direction through the Schlemm tube, the smooth bottom surface B of the distal member 14 should only exert minimal pressure against the back wall of the Schlemm tube.

12. As the TM is resected, backflow of blood or an atrioventricular blood from the collection channel may occur. The irrigation/aspiration components of the device 10 may be used to irrigate any such blood or other debris from the anterior chamber, thereby improving or maintaining a clear visualization of the treatment area.

13. Once the TM tissue strip has been cut and separated, if it is not completely removed by suction through the inner tube 24, as described above, such tissue can be manually grasped and removed using micro-forceps according to operating techniques known in the ophthalmic art.

14. Shaft 12 and distal member 14 are gently removed from the corneal incision following the same directional procedure as with raised indicator 30 during insertion.

15. at the end of the procedure, it is recommended to remove any viscoelastics that may be used completely using standard I/a procedures to avoid post-operative pressure spikes.

Second selection: not used with ophthalmic I/a systems.

1. All packages were inspected prior to use. If the package is opened or damaged, it is not used.

2. the hand piece apparatus 10 is removed from its packaging in the sterile field.

3. It is important to remove air from the handpiece and its I/a channel to avoid air bubbles entering the anterior chamber. The flush line connector 32 is connected to a syringe comprising BSS. In some embodiments, the irrigation connector 32 and/or the aspiration connector 34 may be marked or color coded to be easily distinguished from each other. With the shaft 12 tip tilted down, the handpiece apparatus 10 is placed (with the clean out chamber/transparent cover 36 in place) and the clean out chamber/transparent cover 36 is held in place. The BSS is injected until the BSS leaves the suction connector 34. The syringe is removed and the irrigation connector 32 and suction connector 34 are connected together. The irrigation and aspiration connectors may be configured (e.g., male and female luer fittings) to connect directly to one another in this manner.

4. A clear corneal incision was performed using a scalpel.

5. Viscoelastic is injected into the anterior chamber to expand its volume and maintain its volume during the procedure. The anterior chamber volume must be reestablished and maintained according to this procedure for continuing the procedure.

7. The clean out chamber/transparent cover 36 is carefully removed from the device 10 so that the shaft 12 components do not contact the clean out chamber.

8. The raised indicator 30 on the handpiece device 10 corresponds to and is directed to the direction of rotation of the distal member 14 and should remain perpendicular to the corneal incision.

9. The shaft 12 and distal member 14 are inserted through a corneal incision and into the anterior chamber of a patient's eye.

10. The distal member 14 is advanced toward the TM opposite the incision. An oblique view of the TM is established and the member is continued to be advanced until its smooth bottom surface B contacts the TM.

11. The TM is pierced with a pointed forward tip 16 so that the distal member 14 enters the Schlemm tube while avoiding damage to the posterior wall.

12. The distal member 14 is then advanced along the Schlemm tube in a direction intended to cut the TM. Examples of which are shown in fig. 7 and 11 and discussed more fully below. As the distal member 14 is advanced in a forward direction through the Schlemm tube, the smooth bottom surface B of the distal member 14 should only exert minimal pressure against the back wall of the Schlemm tube.

13. As the TM is resected, backflow of blood or an atrioventricular blood from the collection channel may occur. Viscoelastics and/or BSS may be used to improve visualization according to manipulation techniques known in the ophthalmic art.

14. Once the TM tissue strip has been cut and separated, such tissue can be manually grasped and removed using micro-forceps according to operating techniques known in the ophthalmic art.

14. Shaft 12 and distal member 14 are gently removed from the corneal incision following the same directional procedure as with raised indicator 30 during insertion.

15. at the end of the procedure, it is recommended to remove any viscoelastics that may be used completely using standard I/a procedures to avoid post-operative pressure spikes.

when performing a surgical procedure without active irrigation and aspiration, it is to be understood that the device 10 depicted in fig. 1 may alternatively be provided without the irrigation connector 32 and associated tubing to the handpiece, and without the aspiration connector 34 and associated tubing to the handpiece. Furthermore, the device 10 may optionally also be arranged such that the outer flushing pipe 26 does not have a flushing opening 28. For this alternative of the device 10, the surgical procedure described above under the second option can be performed without performing step 3, thus contributing to simplicity of use and reducing surgical time.

To insert the device 10, the incision into the anterior chamber may be about 180 degrees (e.g., about diametrically opposed) from the portion of the Schlemm's canal from which the operator intends to cut the TM tissue. Such a location of the incision allows the shaft 12 and distal member 14 to be advanced centrally across the anterior chamber of the eye to a treatment portion at an angle of about 180 degrees relative to the incision (e.g., if the incision is temporary, the treatment portion is the nasal cavity-the most commonly employed surgical method).

using this method, it is important that the forward tip 16 of the distal member 14 be in the proper orientation relative to the shaft 12 to allow for penetration of the TM by the forward tip 16, as well as the ability to facilitate advancement of the distal member 14 of the device 10 into and along the Schlemm tube. Further, this arrangement may provide for removal of the TM from the desired treatment portion by advancing the distal member 14 first in one direction (e.g., clockwise) and then in the other direction (e.g., counterclockwise) through the Schlemm tube.

as identified in fig. 3, the longitudinal axis LAX may protrude through the shaft 12. The linear transverse axis TAX may project tangentially to the bottom surface B at the front tip 16, as shown. The angle a1 between the longitudinal axis LAX and the transverse axis TAX may be about 85 degrees for optimal surgical utility. This allows one single device to perform both clockwise and counterclockwise TM removal relative to the entry point of the incision into the anterior chamber. If the angle A1 ranges between about 70 and 100 degrees, it will generally have good clinical utility in most eyes. However, as long as the angle a1 is from about 30 degrees to about 120 degrees, certain clinical utility may be maintained.

If there is a bend or compound angle of the shaft 12 or any portion of the device 10 inserted into the eye, the angle perpendicular to the incision relative to the distal member 14 at the treatment site may desirably be about 90 degrees (despite intervening angles or bends), with clinical utility if this angle ranges from about 30 degrees to about 120 degrees.

With respect to proper sizing, it is desirable that the shaft 12 and distal member 14 be insertable through a minimum incision size. It will be appreciated that the present invention can be designed to use no irrigation and suction, potentially using a solid probe shaft and/or by other means. However, where I/A capability is included, this may limit the insertion size for adequate inflow and outflow by an incision of about 1.8 mm. However, if insertable through an incision of less than 2.8 mm, such a device would still have clinical utility (as such incision sizes are commonly used in cataract removal procedures).

Still with respect to proper sizing, it can be appreciated that when cutting the TM strip, the device will be guided down the Schlemm tube. In its natural state, the Schlemm tube has a primary lumen width of about 350 microns or about 0.014 inches. In addition, the tube lumen is non-circular and decreases in height substantially (typically described as about 25-50 microns or.001-. 002 inches).

To properly size the device's component features, it will be appreciated that the TM forming the anterior wall of the Schlemm's canal exhibits a high degree of elasticity, and the posterior scleral wall of the Schlemm's canal is much less elastic, but deformable. These factors need to be considered in order to size the features of the tip of the device, as the pointed tip will be used to enter into the lumen of the Schlemm tube as the member is advanced and help guide the member down the lumen of the Schlemm tube.

One important sizing factor is the overall width of the member in the direction of its advancement along the Schlemm tube. Although the TM is elastic, the tip of the member must be insertable into the lumen of the Schlemm tube as it advances, along with the portion of the member between the tip and the point where the tissue cutting blades on the beveled side edge cause the TM to be cut, and must be advanceable.

Figure 4 shows front and side views of the tip of the device.

Referring to the illustrations of fig. 4, 4A, and 4B, the forward-most portion of distal member 14 may have a first width W1. Width W1 may be about 230 microns (0.009 inches). For good clinical utility, this width W1 can vary between about 150 and 300 microns (0.006-0.012 inches), and some clinical utility can be maintained between 50-500 microns (0.002-0.020 inches), taking into account the elasticity and deformation of Schlemm's tube.

When the leading tip 16 pierces the TM and the distal member 14 is advanced into the Schlemm tube, the posterior wall of the Schlemm tube will be juxtaposed with the bottom surface B. As the distal member 14 is advanced through the Schlemm tube, the TM tissue will be advanced over and up the sloped portion of the edge 20, and the edge 20 will thereby cut the TM tissue strip.

With particular reference to fig. 4B, as distal member 14 is advanced through the Schlemm tube, TM tissue will generally span over rim 20 along axis BAX as the rim is tilted. The angle a2 shown between transverse axis TAX and axis BAX depends on the angle of inclination of each edge 20. The right edge 20R and the left edge 20L may be inclined at the same or different angles a 2. In the particular non-limiting example shown, the two edges 20 are inclined at the same angle a2, which is preferably about 35 to 40 degrees, as shown in fig. 3, as this will place the TM in tension over a reasonably short distance along the path 20 of the member so that the length of the member can be kept compact. However, it is reasonable to assume that angle a2 may provide good clinical utility over a range of about 30 to 50 degrees, and maintain some clinical utility over a range between about 20 to 70 degrees.

As the TM tissue advances over the rim 20, the tilting of the rim will cause the TM tissue to lift away from the posterior wall of the Schlemm tube. Meanwhile, in embodiments where the width between the edges (e.g., W1, W2, W3) becomes wider, such widening may also pull or stretch the TM tissue laterally as it advances over the edge 20. As the TM advances over the top surface of the tip, and up the angled tissue-cutting blades 20, this separation between the TM and the back wall of the Schlemm tube, as well as the lateral widening between the edges (in embodiments where the width between the edges becomes wider), stretches the TM, causing the TM to open up by both tissue-cutting blades 20, thus forming a TM strip. In embodiments in which the tissue cutting blades 20 are generally spaced apart by a distance W2, the TM stripes cut by the blades will be approximately the width W2 (the distance between the tissue cutting blades 20). However, the actual width of the TM strip that is cut will be different than W2 due to the stretching effect of the TM during cutting. As shown in fig. 5-6D, some embodiments of device 10 may have a distal member 14a on which distal member 14a edge 20 has a sharpened, beveled, serrated, stepped, roughened, or otherwise configured area 21 to enhance or facilitate cutting of TM tissue. In the non-limiting example shown, these regions 21R, 21L are of a saw-toothed configuration and are formed on the inclined portions of the two edges 20R and 20L. It is understood that in some embodiments and/or for certain applications, such region(s) 21 may be present on only one of edges 20R or 20L, and/or differently configured regions 21 may be present on the opposite edge.

Furthermore, as can be particularly appreciated from the displays of fig. 5A and 6A-6D, in the example shown, the edges 20R, 20L may be non-planar and may rotate or curl as they progress in the rearward direction. Fig. 5A shows only the edge 20 of the device of fig. 5 without the adjacent structure. Fig. 6A-6D show transverse cross-sectional views through spaced apart locations a-A, B-B, C-C and D-D of fig. 6. From these views, it can be readily appreciated that in this example, the edges are non-parallel and actually rotate or curl as they progress in the rearward direction. At a location near the anterior tip 16, the edges may be vertical or near vertical and converge at the anterior end to form a sharp or blunt point on the anterior tip 16 that is capable of penetrating through TM tissue, as explained above. As identified in fig. 5A, an angle a3 is defined between each edge 20 and the horizontal transverse plane. As the rim 20 progresses rearward, its height gradually increases and rotates inward, as shown in the cross-sectional views of fig. 6B and 6C. As identified on fig. 5A, at a location rearward of angle A3 (e.g., at a point where edge 20 begins to tilt), edge 20 is at an angle a4 with respect to horizontal, such angle a4 being greater than angle A3. As the edge progresses further back, it rotates or curls further to a height above the horizontal, as can be seen in the cross-section of fig. 6D. As identified on fig. 5A, at a location rearward of angle a4 (e.g., at about the midpoint of the sloped portion of edge 20), angle a5 is disposed relative to horizontal, such angle a5 being greater than angle a4, and in this example greater than 180 degrees.

The entire step or distal member 14 may be formed of a constant thickness of metal or other suitable material. In particular, the thickness of the walls forming the sole B of the distal member 14 may remain constant without increasing and without any upwardly sloping or planar ramps in the region extending rearwardly from the forward or distal tip 16 to the rear or proximal side of the foot or distal member 14. In use, as shown in fig. 7, as distal member 14 is advanced through the Schlemm tube, TM tissue will pass over the non-planar, progressively rotating edge 20 and bridge or hang across open lumen 18 until edge 20 (with or without optional cutting surface 21) forms a cut or cut in the TM tissue. In embodiments utilizing suction, the resulting transversely cut or cut TM tissue strip may then be suctioned from the lumen 18 into the open distal end of the tube 24.

The described components of the device may be manufactured by cutting a tube with an appropriate pattern that allows for the subsequent formation of the tip feature.

As shown in fig. 3A, the distal member 14 of the device 10 may be manufactured by cutting (e.g., laser cutting) and then bending the distal portion of the tube 24 to form the desired features of the distal member 14. As part of this cutting of the tube 24, the tissue cutting edge 20, with or without the cutting surface 21, may be formed simultaneously with the cutting, or by secondary machining relative to the cutting tube (either before or after forming the member from the cutting tube).

When forming the tip, as can be seen in fig. 3, the support members 25 may be formed and interconnected to enhance the strength of the distal member 14 in its formed configuration. It will be appreciated that there are many alternative cutting patterns for the tube, including or not including features such as support members or any particular configuration thereof, which may be used to cut and form the member features of the current device.

The invention thus far described is indicative of examples of preferred configurations and their sizing and preferred orientations and ranges. There are additional variations that are part of this disclosure that provide functional utility.

Fig. 8-11 show another embodiment of the device 10 b. In this embodiment, the device 10b can have the same construction as described above with respect to the first embodiment 10A, except that this device 10b has a different distal member 14 b. In this device 10B, the distal member 14B has a base B, a front tip 58, a rim 56, and a wing member 62, the wing member 62 having an open area 64 behind the wing member 62.

Alternatively, this device 10b (or any other device of the invention including the first embodiment 10) may include an indicator 50 positioned above the wing member 62. The indicator 50 may have a tip 52 directly aligned with a front tip 58. As can be appreciated from fig. 11, during use, pointer 60 remains above the TM tissue, and is thus readily visible to the operating surgeon, even though forward tip 58 and a portion of wing 62 may be obscured by virtue of being below the TM tissue. The surgeon may then use the indicator 50 to confirm the exact direction in which the forward tip 58 is advanced through the Schlemm's canal.

The edge 56 forms an angled tissue cutting surface on the front of the wing member 62. Optionally, as can be seen in fig. 10, the modified distal member 14c may include a portion or region of the edge 56 that is sharpened, beveled, serrated, or otherwise configured to form a cutting region 62 (alt), which cutting region 62 (alt) facilitates cutting of tissue as it is advanced thereover.

It will be appreciated that such tip configurations may be formed from a tubular structure using a cutting pattern, as shown in fig. 9. As shown in fig. 9, the distal portion of tube 24 is cut such that features of distal member 14b can be formed. As part of this cutting of the tube 24, an optional tissue cutting area or surface 62 (alt) may be formed on the wing members 62, as shown in fig. 10, and/or such tissue cutting blades may be formed by secondary machining relative to the cutting tube (either before or after forming the tip from the cutting tube).

An illustration of the device is depicted in fig. 11, with distal member 14b, with wing member 62 and indicator 50 advanced through the Schlemm tube. As shown in fig. 11, the optional indicator 50 provides a visual indication of the direction of the inferior tip as it is advanced along the Schlemm tube. The arrows in fig. 11 show the superimposed irrigation and aspiration flows. In this non-limiting example, the manner in which the selectable indicator 50 is configured is only one example of the manner in which the selectable indicator may be configured, and all selectable configurations of indicators or direction indicators are intended to be included in this disclosure.

During an internal procedure for forming an opening in the TM of the eye, anterior tip 58 may be inserted through the TM and into the Schlemm's canal below the TM with indicator 50 held above the TM. Foot or distal member 14b or 14c is then advanced through the Schlemm tube with TM tissue cut by edges 56R and 56L in the forward direction of wing member 62.

It should be understood that while the present invention has been described above with reference to certain examples or embodiments thereof, various additions, deletions, alterations and modifications may be made to those described examples and embodiments without departing from the intended spirit and scope of the invention. For example, any element, step, component, part, ingredient, reactant, part, or portion of one embodiment or example can be incorporated into or used with another embodiment or example, unless otherwise specified or unless the circumstance would render the embodiment or example unsuitable for its intended purpose. Further, where steps of a method or process have been described or listed in a particular order, the order of such steps may be changed unless otherwise specified or unless the case would render the embodiment or example unsuitable for its intended purpose. Additionally, an element, step, component, part, ingredient, reactant, part, or portion of any invention or example described herein can optionally be present or used in the absence or substantial absence of any other element, step, component, ingredient, reactant, part, or portion, unless stated otherwise. All reasonable additions, deletions, modifications and alterations should be considered equivalents of the described examples and embodiments, and are intended to be included within the scope of the appended claims.