U.S. patent application number 15/075432 was filed with the patent office on 2016-07-14 for system and process for retina phototherapy.
This patent application is currently assigned to Ojai Retinal Technology, LLC. The applicant listed for this patent is Ojai Retinal Technology, LLC. Invention is credited to Jeffrey K. Luttrull, Benjamin W. L. Margolis.
Application Number | 20160199227 15/075432 |
Document ID | / |
Family ID | 49622169 |
Filed Date | 2016-07-14 |
United States Patent
Application |
20160199227 |
Kind Code |
A1 |
Luttrull; Jeffrey K. ; et
al. |
July 14, 2016 |
SYSTEM AND PROCESS FOR RETINA PHOTOTHERAPY
Abstract
A system and process for treating retinal diseases includes
passing a plurality of radiant beams, i.e., laser light beams,
through an optical lens or mask to optically shape the beams. The
shaped beams are applied to at least a portion of the retina. Due
to the selected parameters of the beams--pulse length, power and
duty cycle--the beams can be applied to substantially the entire
retina, including the fovea, without damaging retinal or foveal
tissue, while still attaining the benefits of retinal phototherapy
or photostimulation.
Inventors: |
Luttrull; Jeffrey K.; (Ojai,
CA) ; Margolis; Benjamin W. L.; (Oakland,
CA) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
Ojai Retinal Technology, LLC |
Ojai |
CA |
US |
|
|
Assignee: |
Ojai Retinal Technology,
LLC
Ojai
CA
|
Family ID: |
49622169 |
Appl. No.: |
15/075432 |
Filed: |
March 21, 2016 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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13798523 |
Mar 13, 2013 |
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15075432 |
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13481124 |
May 25, 2012 |
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13798523 |
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Current U.S.
Class: |
606/4 |
Current CPC
Class: |
A61B 18/20 20130101;
A61F 2009/00897 20130101; A61F 9/00821 20130101; A61F 2009/00863
20130101; A61F 9/00823 20130101; A61F 2009/00844 20130101; A61F
2009/00885 20130101 |
International
Class: |
A61F 9/008 20060101
A61F009/008 |
Claims
1. A system for performing retinal phototherapy or
photostimulation, comprising: a laser console generating a
plurality of radiant beams, wherein each beam comprises a
predetermined wavelength, power, and duty cycle; an optical lens or
mask that the radiant beams pass through to optically shape the
beams; and a coaxial wide-field non-contact digital optical viewing
camera projecting the radiant beams to at least a portion of a
desired site for performing retinal phototherapy or
photostimulation.
2. The system of claim 1, including coupling the radiant beams into
a single output beam before performing the passing through the
optical lens or mask or projecting from the coaxial wide-field
non-contact digital optical viewing camera, wherein the passing and
projecting are performed using the single output beam.
3. The system of claim 2, wherein the single output beam projected
from the coaxial wide-field non-contact digital optical viewing
system is steered according to an offset pattern configured to
achieve complete coverage of the desired site for performing
retinal phototherapy or photostimulation for the wavelength of a
selected beam of the plurality of radiant beams.
4. The system of claim 3, wherein the single output beam projected
from the coaxial wide-field non-contact digital optical viewing
camera is steered according to the offset pattern so as to achieve
incomplete or overlapping coverage of the desired site for
performing retinal phototherapy or photostimulation for the
wavelengths of non-selected beams of the plurality of radiant
beams.
5. The system of claim 1, wherein each of the radiant beams from
the coaxial wide-field non-contact digital optical viewing camera
is projected sequentially to at least a portion of the desired site
for performing retinal phototherapy or photostimulation.
6. The system of claim 5, wherein each of the radiant beams
projected from the coaxial wide-field non-contact digital optical
viewing system is steered according to an offset pattern configured
to achieve complete coverage of the desired site for performing
retinal phototherapy or photostimulation for each wavelength of
each of the radiant beams.
7. The system of claim 6, wherein each of the radiant beams
projected from the coaxial wide-field non-contact digital optical
viewing camera is steered according to the offset pattern so as to
result in identical coverage of the desired site for performing
retinal phototherapy or photostimulation for each wavelength and
exclude simultaneous contact of the desired site for performing
retinal phototherapy or photostimulation by multiple radiant
beams.
8. The system of claim 1, including separate optical lenses or
masks configured so as to optically shape each radiant beam
according to its wavelength so as to produce each beam in a single
predetermined pattern.
9. The system of claim 1, including a diaphragm adjusted on an iris
aperture so as to block the radiant beams from an outer perimeter
portion of the retina, wherein the radiant beam is transmitted to
an inner central portion of the desired site for performing retinal
phototherapy or photostimulation.
10. The system of claim 1, including a liquid crystal display array
configured on a grid aperture so as to block the radiant beams from
one or more selective grid portions of the desired site for
performing retinal phototherapy or photostimulation and transmit
the radiant beams to any unblocked portions of the desired site for
performing retinal phototherapy or photostimulation.
11. The system of claim 1, further comprising a fundus image of the
desired site for performing retinal phototherapy or
photostimulation displayed parallel to or superimposed over a
result image from a retinal diagnostic modality.
12. The system of claim 1, wherein the optical lens or mask
includes diffractive optics to generate a plurality of spots from
the beams, and wherein the plurality of spots are projected from
the coaxial wide-field non-contact digital optical viewing camera
to at least a portion of the desired site for performing retinal
phototherapy or photostimulation.
13. A process for performing retinal phototherapy or
photostimulation, comprising the steps of: generating a therapeutic
laser exposure of one or more radiant beams that creates a true
subthreshold photocoagulation in retinal or foveal tissue of an
eye, wherein each of the radiant beams comprises a predetermined
wavelength, power, and duty cycle; passing the radiant beams
through optics to optically shape the radiant beams; and applying
the optically shaped radiant beams to at least a portion of the
retina, including the fovea.
14. The process of claim 13, including the step of coupling the
radiant beams into a single output beam before performing the
passing or applying steps, wherein the passing and applying steps
are performed using the single output beam.
15. The process of claim 13, wherein the applying step comprises
the step of steering the single output beam according to an offset
pattern configured to achieve complete coverage of the retina for
the wavelength of a selected beam of the one or more radiant
beams.
16. The process of claim 13, wherein the applying step comprises
sequentially applying each of the radiant beams to the retina,
wherein the applying step comprises the step of steering each of
the radiant beams according to an offset pattern configured to
achieve complete coverage of the retina for each wavelength of each
of the one or more radiant beams.
17. The process of claim 16, wherein the steering step comprises
the step of steering each of the radiant beams according to the
offset pattern so as to result in identical coverage of the retina
for each wavelength and exclude simultaneous treatment of the
retina by multiple radiant beams.
18. The process of claim 13, wherein the passing step comprises
separately passing each of the one or more radiant beams through
separate optics for each of the radiant beams.
19. The process of claim 18, including the step of configuring the
separate optics so as to optically shape each of the radiant beams
according to its wavelength so as to produce each radiant beam in a
single predetermined pattern.
20. The process of claim 18, further comprising the step of
combining the optically shaped radiant beams into a single beam of
multiple wavelengths having a single predetermined pattern.
21. The process of claim 13, including the step of adjusting a
diaphragm on an iris aperture so as to block a portion of the
radiant beams from an outer perimeter portion of the retina and
transmit the radiant beams to an inner central portion of the
retina.
22. The process of claim 21, including the step of configuring a
liquid crystal display array on a grid aperture so as to block a
portion of the one or more radiant beams from one or more selective
grid portions of the retina and transmit the radiant beams to any
unblocked portions of the retina.
23. The process of claim 13, further comprising the step of
displaying a fundus image of the retina parallel to or superimposed
over a result image from a retinal diagnostic modality.
24. The process of claim 13, wherein the optics comprise an optical
lens or mask including diffractive optics to generate a plurality
of laser spots from the one or more radiant beams.
25. The process of claim 24, wherein the applying step comprises
simultaneously applying the plurality of laser spots to at least a
portion of the retina, including the fovea, wherein each of the
plurality of laser spots creates true subthreshold
photocoagulation.
Description
RELATED APPLICATIONS
[0001] This is a Continuation of U.S. application Ser. No.
13/798,523, filed Mar. 13, 2013, which is a Continuation-in-Part of
U.S. application Ser. No. 13/481,124, filed May 25, 2012.
FIELD OF THE INVENTION
[0002] The present invention generally relates to phototherapy or
photostimulation of biological tissue, such as laser retinal
photocoagulation therapy. More particularly, the present invention
is directed to a system and process for treating retinal diseases
and disorders by using harmless, subthreshold phototherapy or
photostimulation of the retina.
BACKGROUND OF THE INVENTION
[0003] Complications of diabetic retinopathy remain a leading cause
of vision loss in people under sixty years of age. Diabetic macular
edema is the most common cause of legal blindness in this patient
group. Diabetes mellitus, the cause of diabetic retinopathy, and
thus diabetic macular edema, is increasing in incidence and
prevalence worldwide, becoming epidemic not only in the developed
world, but in the developing world as well. Diabetic retinopathy
may begin to appear in persons with Type I (insulin-dependent)
diabetes within three to five years of disease onset. The
prevalence of diabetic retinopathy increases with duration of
disease. By ten years, 14%-25% of patients will have diabetic
macular edema. By twenty years, nearly 100% will have some degree
of diabetic retinopathy. Untreated, patients with clinically
significant diabetic macular edema have a 32% three-year risk of
potentially disabling moderate visual loss.
[0004] Until the advent of thermal retinal photocoagulation, there
was generally no effective treatment for diabetic retinopathy.
Using photocoagulation to produce photothermal retinal burns as a
therapeutic maneuver was prompted by the observation that the
complications of diabetic retinopathy were often less severe in
eyes with preexisting retinal scarring from other causes. The Early
Treatment of Diabetic Retinopathy Study demonstrated the efficacy
of argon laser macular photocoagulation in the treatment of
diabetic macular edema. Full-thickness retinal laser burns in the
areas of retinal pathology were created, visible at the time of
treatment as white or gray retinal lesions ("suprathreshold"
retinal photocoagulation). With time, these lesions developed into
focal areas of chorioretinal scarring and progressive atrophy.
[0005] With visible endpoint photocoagulation, laser light
absorption heats pigmented tissues at the laser site. Heat
conduction spreads this temperature increase from the retinal
pigment epithelium and choroid to overlying non-pigmented and
adjacent unexposed tissues. Laser lesions become visible
immediately when damaged neural retina overlying the laser sight
loses its transparency and scatters white ophthalmoscopic light
back towards the observer.
[0006] There are different exposure thresholds for retinal lesions
that are haemorrhagic, ophthalmoscopically apparent, or
angiographically demonstrable. A "threshold" lesion is one that is
barely visible ophthalmoscopically at treatment time, a
"subthreshold" lesion is one that is not visible at treatment time,
and "suprathreshold" laser therapy is retinal photocoagulation
performed to a readily visible endpoint. Traditional retinal
photocoagulation treatment requires a visible endpoint either to
produce a "threshold" lesion or a "suprathreshold" lesion so as to
be readily visible and tracked. In fact, it has been believed that
actual tissue damage and scarring are necessary in order to create
the benefits of the procedure. The gray to white retinal burns
testify to the thermal retinal destruction inherent in conventional
threshold and suprathreshold photocoagulation. Photocoagulation has
been found to be an effective means of producing retinal scars, and
has become the technical standard for macular photocoagulation for
diabetic macular edema for nearly 50 years.
[0007] With reference now to FIG. 1, a diagrammatic view of an eye,
generally referred to by the reference number 10, is shown. When
using phototherapy, the laser light is passed through the patient's
cornea 12, pupil 14, and lens 16 and directed onto the retina 18.
The retina 18 is a thin tissue layer which captures light and
transforms it into the electrical signals for the brain. It has
many blood vessels, such as those referred to by reference number
20, to nourish it. Various retinal diseases and disorders, and
particularly vascular retinal diseases such as diabetic
retinopathy, are treated using conventional thermal retinal
photocoagulation, as discussed above. The fovea/macula region,
referred to by the reference number 22 in FIG. 1, is a portion of
the eye used for color vision and fine detail vision. The fovea is
at the center of the macula, where the concentration of the cells
needed for central vision is the highest. Although it is this area
where diseases such as age-related macular degeneration are so
damaging, this is the area where conventional photocoagulation
phototherapy cannot be used as damaging the cells in the foveal
area can significantly damage the patient's vision. Thus, with
current convention photocoagulation therapies, the foveal region is
avoided.
[0008] That iatrogenic retinal damage is necessary for effective
laser treatment of retinal vascular disease has been universally
accepted for almost five decades, and remains the prevailing
notion. Although providing a clear advantage compared to no
treatment, current retinal photocoagulation treatments, which
produce visible gray to white retinal burns and scarring, have
disadvantages and drawbacks. Conventional photocoagulation is often
painful. Local anesthesia, with its own attendant risks, may be
required. Alternatively, treatment may be divided into stages over
an extended period of time to minimize treatment pain and
post-operative inflammation. Transient reduction in visual acuity
is common following conventional photocoagulation.
[0009] In fact, thermal tissue damage may be the sole source of the
many potential complications of conventional photocoagulation which
may lead to immediate and late visual loss. Such complications
include inadvertent foveal burns, pre- and sub-retinal fibrosis,
choroidal neovascularization, and progressive expansion of laser
scars. Inflammation resulting from the tissue destruction may cause
or exacerbate macular edema, induced precipitous contraction of
fibrovascular proliferation with retinal detachment and vitreous
hemorrhage, and cause uveitis, serous choroidal detachment, angle
closure or hypotony. Some of these complications are rare, while
others, including treatment pain, progressive scar expansion,
visual field loss, transient visual loss and decreased night vision
are so common as to be accepted as inevitable side-effects of
conventional laser retinal photocoagulation. In fact, due to the
retinal damage inherent in conventional photocoagulation treatment,
it has been limited in density and in proximity to the fovea, where
the most visually disabling diabetic macular edema occurs.
[0010] Notwithstanding the risks and drawbacks, retinal
photocoagulation treatment, typically using a visible laser light,
is the current standard of care for proliferative diabetic
retinopathy, as well as other retinopathy and retinal diseases,
including diabetic macular edema and retinal venous occlusive
diseases which also respond well to retinal photocoagulation
treatment. In fact, retinal photocoagulation is the current
standard of care for many retinal diseases, including diabetic
retinopathy.
[0011] Another problem is that the treatment requires the
application of a large number of laser doses to the retina, which
can be tedious and time-consuming. Typically, such treatments call
for the application of each dose in the form of a laser beam spot
applied to the target tissue for a predetermined amount of time,
from a few hundred milliseconds to several seconds. Typically, the
laser spots range from 50-500 microns in diameter. Their laser
wavelength may be green, yellow, red or even infrared. It is not
uncommon for hundreds or even in excess of one thousand laser spots
to be necessary in order to fully treat the retina. The physician
is responsible for insuring that each laser beam spot is properly
positioned away from sensitive areas of the eye, such as the fovea,
that could result in permanent damage. Laying down a uniform
pattern is difficult and the pattern is typically more random than
geometric in distribution. Point-by-point treatment of a large
number of locations tends to be a lengthy procedure, which
frequently results in physician fatigue and patient discomfort.
[0012] U.S. Pat. No. 6,066,128, to Bahmanyar describes a method of
multi-spot laser application, in the form of retinal-destructive
laser photocoagulation, achieved by means of distribution of laser
irradiation through an array of multiple separate fiber optic
channels and micro lenses. While overcoming the disadvantages of a
point-by-point laser spot procedure, this method also has
drawbacks. However, a limitation of the Bahmanyar method is
differential degradation or breakage of the fiber optics or losses
due to splitting the laser source into multiple fibers, which can
lead to uneven, inefficient and/or suboptimal energy application.
Another limitation is the constraint on the size and density of the
individual laser spots inherent in the use of an optical system of
light transmission fibers in micro lens systems. The mechanical
constraint of dealing with fiber bundles can also lead to
limitations and difficulties focusing and aiming the multi-spot
array.
[0013] U.S. Patent Publication 2010/0152716 A1 to Previn describes
a different system to apply destructive laser irradiation to the
retina using a large retinal laser spot with a speckle pattern,
oscillated at a high frequency to homogenize the laser irradiance
throughout the spot. However, a problem with this method is the
uneven heat buildup, with higher tissue temperatures likely to
occur toward the center of the large spot. This is aggravated by
uneven heat dissipation by the ocular circulation resulting in more
efficient cooling towards the margins of the large spot compared to
the center. That is, the speckle pattern being oscillated at a high
frequency can cause the laser spots to be overlapping or so close
to one another that heat builds up and undesirable tissue damage
occurs. Previn's speckle technique achieves averaging of point
laser exposure within the larger exposure via the random
fluctuations of the speckle pattern. However, such averaging
results from some point exposures being more intense than others,
whereas some areas within the exposure area may end with
insufficient laser exposure, whereas other areas will receive
excessive laser exposure. In fact, Previn specifically notes the
risk of excessive exposure or exposure of sensitive areas, such as
the fovea, which should be avoided with this system. Although these
excessively exposed spots may result in retinal damage, Previn's
invention is explicitly intended to apply damaging retinal
photocoagulation to the retina, other than the sensitive area such
as the fovea.
[0014] However, all conventional retinal photocoagulation
treatments, including those described by Previn and Bahmanyar,
create visible endpoint laser photocoagulation in the form of gray
to white retinal burns and lesions, as discussed above. Recently,
the inventor has discovered that subthreshold photocoagulation in
which no visible tissue damage or laser lesions were detectable by
any known means including ophthalmoscopy; infrared, color, red-free
or autofluorescence fundus photography in standard or retro-mode;
intravenous fundus fluorescein or indocyanine green
angiographically, or Spectral-domain optical coherence tomography
at the time of treatment or any time thereafter has produced
similar beneficial results and treatment without many of the
drawbacks and complications resulting from conventional visible
threshold and suprathreshold photocoagulation treatments. It has
been determined that with the proper operating parameters,
subthreshold photocoagulation treatment can be, and may ideally be,
applied to the entire retina, including sensitive areas such as the
fovea, without visible tissue damage or the resulting drawbacks or
complications of conventional visible retinal photocoagulation
treatments. Moreover, by desiring to treat the entire retina, or
confluently treat portions of the retina, laborious and
time-consuming point-by-point laser spot therapy can be avoided. In
addition, the inefficiencies and inaccuracies inherent to invisible
endpoint laser treatment resulting in suboptimal tissue target
coverage can also be avoided.
SUMMARY OF THE INVENTION
[0015] The present invention resides in a process and system for
treating retinal diseases and disorders by means of harmless,
subthreshold photocoagulation phototherapy. Although the present
invention is particularly useful in treating diabetic retinopathy,
including diabetic macular edema, it will be understood that the
present invention also applies to all other retinal conditions,
including but not limited to retinal venous occlusive diseases and
idiopathic central serous chorioretinopathy, proliferative diabetic
retinopathy, and retinal macroaneurysm as reported, which respond
well to traditional retinal photocoagulation treatments; but having
potential application as preventative and rejuvenative in disorders
such as genetic diseases and age-related macular degeneration and
others.
[0016] The present invention is directed a process for performing
retinal phototherapy or photostimulation. The process includes
generating a plurality of radiant beams, such as micropulsed laser
light beams, passing the beams through an optical lens or mask to
optically shape the beams, and applying the beams to at least a
portion of the retina, possibly including at least a portion of the
fovea. Each beam has a predetermined wavelength, power, and duty
cycle.
[0017] The process may include coupling the beams into a single
output beam before performing the passing or applying steps. The
passing and applying steps are then performed using the single
output beam. The applying step includes steering the single output
beam according to an offset pattern configured to achieve complete
coverage of the retina for the wavelength of a selected beam of the
plurality of beams. The steering step also includes steering the
single output beam according to the offset pattern so as to achieve
incomplete or overlapping coverage of the retina for the
wavelengths of non-selected beams.
[0018] Alternatively, the applying step may involve sequentially
applying each of the radiant beams to at least a portion of the
retina. In this case, the applying step involves steering each of
the radiant beams according to an offset pattern configured to
achieve complete coverage of the retina for each wavelength of each
of the radiant beams. The steering step also includes steering each
of the radiant beams according to the offset pattern so as to
result in identical coverage of the retina for each wavelength and
exclude simultaneous treatment of the retina by multiple radiant
beams.
[0019] The passing step may include separately passing each of the
radiant beams through separate optical lenses or masks for each
radiant beam. Each of the separate optical lenses or masks is
configured so as to optically shape each radiant beam according to
its wavelength so as to produce each beam in a single predetermined
pattern. In this case, the single predetermined pattern is the same
for each beam. The optically shaped beams are combined into a
single beam of multiple wavelengths having a single predetermined
pattern. The single beam of multiple wavelengths is steered
according to an offset pattern configured to achieve complete
coverage of the retina for the single predetermined pattern.
[0020] The process for performing retinal phototherapy or
photostimulation may also involve generating a radiant beam,
passing the beam through an optical lens or mask to optically shape
the beam, directing the beam through an aperture configured to
selectively transmit or block the beam, and applying the beam to at
least a portion of the retina, including at least a portion of the
fovea, according to the configuration of the aperture. The beam has
a predetermined wavelength, power, and duty cycle.
[0021] The optical lens or mask may include diffractive optics to
generate a plurality of spots from the beams. Similarly, the
optical lens or mask may include a plurality of fiber optic wires
to generate the plurality of spots. A person of ordinary skill in
the art will understand that after a beam is passed through
diffractive optics or other device for generating spots, the beam
comprises a plurality of spots. Thus, the applying step, while
stating that it is applying a beam to the retina, that beam is made
up of a plurality of spots resulting from the diffraction and not a
single continuous beam. The remainder of this description will
refer to the applying step as applying beams, wherein each beam
comprises a plurality of spots to the extent the beam was passed
through diffractive optics. The applying step includes applying the
plurality of beams to at least a portion of the retina.
[0022] The aperture may be included in the process using a single
beam or plurality of beams. The aperture may comprise an iris
aperture or a grid aperture. Either process may include adjusting a
diaphragm on the iris aperture so as to block the radiant beams
from an outer perimeter portion of the retina and transmit the
radiant beam to an inner central portion of the retina.
[0023] Alternatively, a liquid crystal display array on the grid
aperture may be configured so as to block the radiant beams from
one or more selective grid portions of the retina and transmit the
radiant beams to any unblocked portions of the retina. The grid
aperture may be used to selectively block the beam/beams so as to
attenuate areas of peak power or to prevent treatment of scar
tissue on the retina. The aperture may also be used to selectively
transmit the beam/beams to disease markers on the retina.
[0024] The process may also include the step of displaying a fundus
image of the patient's retina parallel to or superimposed over a
result image from a retinal diagnostic modality. This parallel or
superimposed display may facilitate determination of areas to block
or not block during the applying step.
[0025] The process may also include the step of archiving a fundus
image of the retina before, during and/or after the applying step.
One may also recording treatment parameters of the applying step,
including graphically noting areas of treatment application or
treatment exclusion.
[0026] In accordance with the present invention, a system for
treating retinal diseases and disorders comprises a laser producing
a radiant beam. In a particularly preferred embodiment, the radiant
beam is a light beam having an infrared wavelength, such as between
750 nm-1300 nm, and preferably approximately 810 nm. The light beam
has an intensity of between 100-590 watts per square centimeter,
and preferably approximately 350 watts per square centimeter. The
exposure envelope of the laser is generally 500 milliseconds or
less. The laser has a duty cycle of less than 10%, and typically
approximately 5% or less. The micropulse frequency is preferably
500 Hz.
[0027] An optical lens or mask optically shapes the light beam from
the laser into a geometric object or pattern. For example, the
optical lens or mask, such as a diffraction grating or plurality of
fiber optics, produces a simultaneous pattern of spaced apart laser
spots.
[0028] An optical scanning mechanism controllably directs the light
beam object or pattern onto the retina. The light beam geometric
object or pattern is incrementally moved a sufficient distance from
where the light beam was previously applied to the retina, to avoid
tissue damage, prior to reapplying the light beam to the
retina.
[0029] The light beam is applied to at least a portion of the
retina, such as at eighteen to fifty-five times the American
National Standards Institute (ANSI) maximum permissible exposure
(MPE) level. Given the parameters of the generated laser light
beam, including the pulse length, power, and duty cycle, no visible
laser lesions or tissue damage is detectable ophthalmoscopically or
angiographically or to any currently known means after treatment,
allowing the entire retina, including the fovea, to be treated
without damaging retinal or foveal tissue while still providing the
benefits of photocoagulation treatment.
[0030] Other features and advantages of the present invention will
become apparent from the following more detailed description, taken
in conjunction with the accompanying drawings, which illustrate, by
way of example, the principles of the invention.
BRIEF DESCRIPTION OF THE DRAWINGS
[0031] The accompanying drawings illustrate the invention. In such
drawings:
[0032] FIG. 1 is a cross-sectional diagrammatic view of a human
eye;
[0033] FIGS. 2A-2F are graphic representations of the effective
surface area of various modes of retinal laser treatment;
[0034] FIG. 3 is a diagrammatic view illustrating a system used for
treating a retinal disease or disorder in accordance with the
present invention;
[0035] FIG. 4 is a diagrammatic view of an exemplary optical lens
or mask used to generate a geometric pattern, in accordance with
the present invention;
[0036] FIG. 5 is a top plan view of an optical scanning mechanism,
used in accordance with the present invention;
[0037] FIG. 6 is a partially exploded view of the optical scanning
mechanism of FIG. 5, illustrating the various component parts
thereof;
[0038] FIG. 7 illustrates controlled offset of exposure of an
exemplary geometric pattern grid of laser spots to treat the retina
in accordance with the present invention;
[0039] FIG. 8 is a diagrammatic view illustrating the units of a
geometric object in the form of a line controllably scanned to
treat an area of the retina in accordance with the present
invention;
[0040] FIG. 9 is a diagrammatic view similar to FIG. 8, but
illustrating the geometric line or bar rotated to treat an area of
the retina;
[0041] FIG. 10 is an illustration of a cross-sectional view of a
diseased human retina before treatment with the present
invention;
[0042] FIG. 11 is a cross-sectional view similar to FIG. 10,
illustrating the portion of the retina after treatment using the
present invention;
[0043] FIG. 12 is a diagrammatic view illustrating an alternate
embodiment of a system used for treating a retinal disease or
disorder in accordance with the present invention;
[0044] FIG. 13 is a diagrammatic view illustrating yet another
alternate embodiment of a system used for treating a retinal
disease or disorder in accordance with the present invention;
[0045] FIG. 14 is a front view of a camera including an iris
aperture of the present invention; and
[0046] FIG. 15 is a front view of a camera including an LCD
aperture of the present invention.
DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS
[0047] The present invention relates to a system and process for
treating retinal diseases, including vascular retinal diseases such
as diabetic retinopathy and diabetic macular edema, by means of
predetermined parameters producing harmless, true subthreshold
photocoagulation. The inventor's finding that retinal laser
treatment that does not cause any laser-induced retinal damage, but
can be at least as effective as conventional retinal
photocoagulation is contrary to conventional thinking and
practice.
[0048] Conventional thinking assumes that the physician must
intentionally create retinal damage as a prerequisite to
therapeutically effective treatment. With reference to FIG. 2,
FIGS. 2A-2F are graphic representations of the effective surface
area of various modes of retinal laser treatment for retinal
vascular disease. The gray background represents the retina 30
which is unaffected by the laser treatment. The black areas 32 are
areas of the retina which are destroyed by conventional laser
techniques. The lighter gray or white areas 34 represent the areas
of the retina affected by the laser, but not destroyed.
[0049] FIG. 2A illustrates the therapeutic effect of conventional
argon laser retinal photocoagulation. The therapeutic effects
attributed to laser-induced thermal retinal destruction include
reduced metabolic demand, debulking of diseased retina, increased
intraocular oxygen tension and ultra production of vasoactive
cytokines, including vascular endothelial growth factor (VEGF).
[0050] With reference to FIG. 2B, increasing the burn intensity of
the traditional laser burn is shown. It will be seen that the
burned and damaged tissue area 32 is larger, which has resulted in
a larger "halo effect" of heated, but undamaged, surrounding tissue
34. Laboratory studies have shown that increased burn intensity is
associated with an enhanced therapeutic effect, but hampered by
increased loss of functional retina and inflammation. However, with
reference to FIG. 2C, when the intensity of the conventional argon
laser photocoagulation is reduced, the area of the retina 34
affected by the laser but not destroyed is also reduced, which may
explain the inferior clinical results from
lower-intensity/lower-density or "mild" argon laser grid
photocoagulation compared to higher-intensity/higher-density
treatment, as illustrated in FIG. 2B.
[0051] With reference to FIG. 2D, it has been found that
low-fluence photocoagulation with short-pulse continuous wave laser
photocoagulation, also known as selective retinal therapy, produces
minimal optical and lateral spread of laser photothermal tissue
effects, to the extent that the area of the retina affected by the
laser but not destroyed is minimal to nonexistent. Thus, despite
damage or complete ablation of the directly treated retina 30, the
rim of the therapeutically affected and surviving tissue is scant
or absent. This explains the recent reports finding superiority of
conventional argon laser photocoagulation over PASCAL for diabetic
retinopathy.
[0052] However, the inventor has shown that such thermal retinal
damage is unnecessary and questioned whether it accounts for the
benefits of the conventional laser treatments. Instead, the
inventor has surmised that the therapeutic alterations in the
retinal pigment epithelium (RPE) cytokine production elicited by
conventional photocoagulation comes from cells at the margins of
traditional laser burns, affected but not killed by the laser
exposure, referred to by the reference number 34 in FIG. 2.
[0053] FIG. 2E represents the use of a low-intensity and
low-density laser, such as a micropulsed diode laser. This creates
subthreshold retinal photocoagulation, shown by the reference
number 34, without any visible burn areas 32. All areas of the
retinal pigment epithelium exposed to the laser irradiation are
preserved, and available to contribute therapeutically.
[0054] The subthreshold retinal photocoagulation is defined as
retinal laser applications biomicroscopically invisible at the time
of treatment. Unfortunately, the term has often been used in the
art to describe several different clinical scenarios reflecting
widely varying degrees of laser-induced thermal retinal damage. The
use of the term "subthreshold" falls into three categories
reflecting common usage and the historical and morphological
evolution of reduced-intensity photocoagulation for retinal
vascular disease toward truly invisible phototherapy which the
invention embodies.
[0055] "Classical subthreshold" for photocoagulation describes the
early attempts at laser intensity reduction using conventional
continuous argon, krypton, and diode lasers. Although the retinal
burns were notably less obvious than the conventional "threshold"
(photocoagulation confined to the outer retina and thus less
visible at time of treatment) or even milder "suprathreshold"
(full-thickness retinal photocoagulation generally easily visible
at the time of treatment), the lesions of "classical" subthreshold
photocoagulation were uniformly visible both clinically and by
fundus fluorescein angiography (FFA) at the time of treatment and
thereafter.
[0056] "Clinical subthreshold" photocoagulation describes the next
epiphany of evolution of laser-induced retinal damage reduction,
describing a lower-intensity but persistently damaging retinal
photocoagulation using either a micropulsed laser or short-pulsed
continuous wave laser that better confine the damage to the outer
retina and retinal pigmentation epithelium. In "clinical"
subthreshold photocoagulation, the laser lesions may in fact be
ophthalmoscopically invisible at the time of treatment, however, as
laser-induced retinal damage remains the intended point of
treatment, laser lesions are produced which generally become
increasingly clinically visible with time, and many, if not all,
laser lesions can be seen by FFA, fundus autofluorescence
photography (FAF), and/or spectral-domain (SD) optical coherence
tomography (OCT) at the time of treatment and thereafter.
[0057] "True" subthreshold photocoagulation, as a result of the
present invention, is invisible and includes laser treatment
non-discernible by any other known means such as FFA, FAF, or even
SD-OCT. "True subthreshold" photocoagulation is therefore defined
as a laser treatment which produces absolutely no retinal damage
detectable by any means at the time of treatment or any time
thereafter by known means of detection. As such, with the absence
of lesions and other tissue damage and destruction, FIGS. 2E and 2F
represent the result of "true", invisible subthreshold
photocoagulation.
[0058] Various parameters have been determined to achieve "true"
subthreshold or "low-intensity" effective photocoagulation. These
include providing sufficient power to produce effective treatment
retinal laser exposure, but not too high to create tissue damage or
destruction. True subthreshold laser applications can be applied
singly or to create a geometric object or pattern of any size and
configuration to minimize heat accumulation, but assure uniform
heat distribution as well as maximizing heat dissipation such as by
using a low duty cycle. The inventor has discovered how to achieve
therapeutically effective and harmless true subthreshold retinal
laser treatment. The inventor has also discovered that placement of
true subthreshold laser applications confluently and contiguously
to the retinal surface improves and maximizes the therapeutic
benefits of treatment without harm or retinal damage.
[0059] The American Standards Institute (ANSI) has developed
standards for safe workplace laser exposure based on the
combination of theoretical and empirical data. The "maximum
permissible exposure" (MPE) is the safety level, set at
approximately 1/10.sup.th of the laser exposure level expected to
produce biological effects. At a laser exposure level of 1 times
MPE, absolute safety would be expected and retinal exposure to
laser radiation at this level would be expected to have no biologic
affect. Based on ANSI data, a 50% of some risk of suffering a
barely visible (threshold) retinal burn is generally encountered at
10 times MPE for conventional continuous wave laser exposure. For a
low-duty cycle micropulsed laser exposure of the same power, the
risk of threshold retinal burn is approximately 100 times MPE.
Thus, the therapeutic range--the interval of doing nothing at all
and the 50% of some likelihood of producing a threshold retinal
burn--for low-duty cycle micropulsed laser irradiation is 10 times
wider than for continuous wave laser irradiation with the same
energy. It has been determined that safe and effective subthreshold
photocoagulation using a low-duty cycle micropulsed diode laser is
between 18 times and 55 times MPE, such as with a preferred laser
exposure to the retina at 47 times MPE for a near-infrared 810 nm
diode laser. At this level, the inventor has observed that there is
therapeutic effectiveness with no retinal damage whatsoever.
[0060] It has been found that the intensity or power of a low-duty
cycle 810 nm laser beam between 100 watts to 590 watts per square
centimeter is effective yet safe. A particularly preferred
intensity or power of the laser light beam is approximately 250-350
watts per square centimeter for an 810 nm micropulsed diode
laser.
[0061] Power limitations in current micropulsed diode lasers
require fairly long exposure duration. The longer the laser
exposure, the more important the center-spot heat dissipating
ability toward the unexposed tissue at the margins of the laser
spot and toward the underlying choriocapillaris. Thus, the radiant
beam of an 810 nm diode laser should have an exposure envelope
duration of 500 milliseconds or less, and preferably approximately
100-300 milliseconds. Of course, if micropulsed diode lasers become
more powerful, the exposure duration will be lessened
accordingly.
[0062] Another parameter of the present invention is the duty cycle
(the frequency of the train of micropulses, or the length of the
thermal relaxation time in between consecutive pulses). It has been
found that the use of a 10% duty cycle or higher adjusted to
deliver micropulsed laser at similar irradiance at similar MPE
levels significantly increase the risk of lethal cell injury,
particularly in darker fundi. However, duty cycles less than 10%,
and preferably approximately 5% duty cycle (or less) demonstrated
adequate thermal rise and treatment at the level of the RPE cell to
stimulate a biologic response, but remained below the level
expected to produce lethal cell injury, even in darkly pigmented
fundi. Moreover, if the duty cycle is less than 5%, the exposure
envelope duration in some instances can exceed 500
milliseconds.
[0063] In a particularly preferred embodiment, the use of small
retinal laser spots is used. This is due to the fact that larger
spots can contribute to uneven heat distribution and insufficient
heat dissipation within the large retinal laser spot, potentially
causing tissue damage or even tissue destruction towards the center
of the larger laser spot. In this usage, "small" would generally
apply to retinal spots less than 3 mm in diameter. However, the
smaller the retinal spot, the more ideal the heat dissipation and
uniform energy application becomes. Thus, at the power intensity
and exposure duration described above, small spots, such as 25-300
micrometers in diameter, or small geometric lines or other objects
are preferred so as to maximize even heat distribution and heat
dissipation to avoid tissue damage.
[0064] Thus, the following key parameters have been found in order
to create harmless, "true" subthreshold photocoagulation in
accordance with the present invention: a) a low (preferably 5% or
less) duty cycle; b) a small spot size to minimize heat
accumulation and assure uniform heat distribution within a given
laser spot so as to maximize heat dissipation; c) sufficient power
to produce retinal laser exposures of between 18 times-55 times MPE
producing an RPE temperature rise of 7.degree. C.-14.degree. C.;
and retinal irradiance of between 100-590 W/cm.sup.2.
[0065] Using the foregoing parameters, a harmless, "true"
subthreshold photocoagulation phototherapy treatment can be
attained which has been found to produce the benefits of
conventional photocoagulation phototherapy, but avoid the drawbacks
and complications of conventional phototherapy. In fact, "true"
subthreshold photocoagulation phototherapy in accordance with the
present invention enables the physician to apply a
"low-intensity/high-density" phototherapy treatment, such as
illustrated in FIG. 2F, and treat the entire retina, including
sensitive areas such as the macula and even the fovea without
creating visual loss or other damage. As indicated above, using
conventional phototherapies, the entire retina, and particularly
the fovea, cannot be treated as it will create vision loss due to
the tissue damage in sensitive areas.
[0066] Conventional retina-damaging laser treatment is limited in
treatment density, requiring subtotal treatment of the retina,
including subtotal treatment of the particular areas of retinal
abnormality. However, recent studies demonstrate that eyes in
diabetics may have diffuse retinal abnormalities without otherwise
clinically visible diabetic retinopathy, and eyes with localized
areas of clinically identifiable abnormality, such as diabetic
macular edema or central serous chorioretinopathy, often have total
retinal dysfunction detectable only by retinal function testing.
The ability of the invention to harmlessly treat the entire retina
thus allows, for the first time, both preventative and therapeutic
treatment of eyes with retinal disease completely rather than
locally or subtotally; and early treatment prior to the
manifestation of clinical retinal disease and visual loss.
[0067] As discussed above, it is conventional thinking that tissue
damage and lesions must be created in order to have a therapeutic
effect. However, the inventor has found that this simply is not the
case. In the absence of laser-induced retinal damage, there is no
loss of functional retinal tissue and no inflammatory response to
treatment. Adverse treatment effects are thus completely eliminated
and functional retina preserved rather than sacrificed. This may
yield superior visual acuity results compared to conventional
photocoagulation treatment.
[0068] The present invention spares the neurosensory retina and is
selectively absorbed by the RPE. Current theories of the
pathogenesis of retinal vascular disease especially implicate
cytokines, potent extra cellular vasoactive factors produced by the
RPE, as important mediators of retinal vascular disease. The
present invention both selectively targets and avoids lethal
buildup within RPE. Thus, with the present invention the capacity
for the treated RPE to participate in a therapeutic response is
preserved and even enhanced rather than eliminated as a result
their destruction of the RPE in conventional photocoagulation
therapies.
[0069] It has been noted that the clinical effects of cytokines may
follow a "U-shaped curve" where small physiologic changes in
cytokine production, denoted by the left side of curve, may have
large clinical effects comparable to high-dose (pharmacologic)
therapy (denoted by the right side of the curve). Using sublethal
laser exposures in accordance with the present invention may be
working on the left side of the curve where the treatment response
may approximate more of an "on/off" phenomenon rather than a
dose-response. This might explain the clinical effectiveness of the
present invention observed at low reported irradiances. This is
also consistent with clinical experience and in-vitro studies of
laser-tissue interaction, wherein increasing irradiance may simply
increase the risk of thermal retinal damage without improving the
therapeutic effect.
[0070] With reference again to FIG. 2, the invisible, true
subthreshold photocoagulation phototherapy maximizes the
therapeutic recruitment of the RPE through the concept of "maximize
the affected surface area", in that all areas of RPE exposed to the
laser irradiation are preserved, and available to contribute
therapeutically. As discussed above with respect to FIG. 2, it is
believed that conventional therapy creates a therapeutic ring
around the burned or damaged tissue areas, whereas the present
invention creates a therapeutic area without any burned or
otherwise destroyed tissue.
[0071] In another departure from conventional retinal
photocoagulation, a low red to infrared laser light beam, such as
from an 810 nm micropulsed diode laser, is used instead of an argon
laser. It has been found that the 810 nm diode laser is minimally
absorbed and negligibly scattered by intraretinal blood, cataract,
vitreous hemorrhage and even severely edematous neurosensory
retina. Differences in fundus coloration result primarily from
differences in choroid pigmentation, and less of variation of the
target RPE. Treatment in accordance with the present invention is
thus simplified, requiring no adjustment in laser parameters for
variations in macular thickening, intraretinal hemorrhage, and
media opacity such as cataracts or fundus pigmentation, reducing
the risk of error.
[0072] However, it is contemplated that the present invention could
be utilized with micropulsed emissions of other wavelengths, such
as the recently available 577 nm yellow and 532 nm green lasers,
and others. The higher energies and different tissue absorption
characteristic of shorter wavelength lasers may increase retinal
burn risk, effectively narrowing the therapeutic window. In
addition, the shorter wavelengths are more scattered by opaque
ocular media, retinal hemorrhage and macular edema, potentially
limiting usefulness and increasing the risk of retinal damage in
certain clinical settings. Thus, a low red to infrared laser light
beam is still preferred.
[0073] In fact, low power red and near-infrared laser exposure is
known to positively affect many cell types, particularly
normalizing the behavior of cells and pathological environments,
such as diabetes, through a variety of intracellular
photo-acceptors. Cell function, in cytokine expression, is
normalized and inflammation reduced. By normalizing function of the
viable RPE cells, the invention may induce changes in the
expression of multiple factors physiologically as opposed to drug
therapy that typically narrowly targets only a few post-cellular
factors pharmacologically. The laser-induced physiologic alteration
of RPE cytokine expression may account for the slower onset but
long lasting benefits using the present invention. Furthermore, use
of a physiologically invisible infrared or near-infrared laser
wavelength is perceived as comfortable by the patient, and does not
cause reactive pupillary constriction, allowing visualization of
the ocular fundus and treatment of the retina to be performed
without pharmacologic dilation of the patient pupil. This also
eliminates the temporary of visual disability typically lasting
many hours following pharmacologic pupillary dilation currently
required for treatment with conventional laser photocoagulation.
Currently, patient eye movement is a concern not only for creating
the pattern of laser spots to treat the intended area, but also
could result in exposure of conventional therapy to sensitive areas
of the eye, such as the fovea, resulting in loss of vision or other
complications.
[0074] With reference now to FIG. 3, a schematic diagram is shown
of a system for realizing the process of the present invention. The
system, generally referred to by the reference number 40, includes
a laser console 42, such as for example the 810 nm near infrared
micropulsed diode laser in the preferred embodiment. The laser
generates a laser light beam which is passed through an optical
lens or mask, or a plurality of optical lenses and/or masks 44 as
needed. The laser projector optics 44 pass the shaped light beam to
a coaxial wide-field non-contact digital optical viewing
system/camera 46 for projecting the laser beam light onto the eye
48 of the patient. It will be understood that the box labeled 46
can represent both the laser beam projector as well as a viewing
system/camera, which might in reality comprise two different
components in use. The viewing system/camera 46 provides feedback
to a display monitor 50, which may also include the necessary
computerized hardware, data input and controls, etc. for
manipulating the laser 42, the optics 44, and/or the
projection/viewing components 46.
[0075] As discussed above, current treatment requires the
application of a large number of individual laser beam spots
applied to the target tissue to be treated. These can number in the
hundreds or even thousands for the desired treatment area. This is
very time intensive and laborious.
[0076] With reference now to FIG. 4, in one embodiment, the laser
light beam 52 is passed through a collimator lens 54 and then
through a mask 56. In a particularly preferred embodiment, the mask
56 comprises a diffraction grating. The mask/diffraction grating 56
produces a geometric object, or more typically a geometric pattern
of simultaneously produced multiple laser spots or other geometric
objects. This is represented by the multiple laser light beams
labeled with reference number 58. Alternatively, the multiple laser
spots may be generated by a plurality of fiber optic wires. Either
method of generating laser spots allows for the creation of a very
large number of laser spots simultaneously over a very wide
treatment field, such as consisting of the entire retina. In fact,
a very high number of laser spots, perhaps numbering in the
hundreds even thousands or more could cover the entire ocular
fundus and entire retina, including the macula and fovea, retinal
blood vessels and optic nerve. The intent of the process in the
present invention is to better ensure complete and total coverage
and treatment, sparing none of the retina by the laser so as to
improve vision.
[0077] Using optical features with a feature size on par with the
wavelength of the laser employed, for example using a diffraction
grating, it is possible to take advantage of quantum mechanical
effects which permits simultaneous application of a very large
number of laser spots for a very large target area. The individual
spots produced by such diffraction gratings are all of a similar
optical geometry to the input beam, with minimal power variation
for each spot. The result is a plurality of laser spots with
adequate irradiance to produce harmless yet effective treatment
application, simultaneously over a large target area. The present
invention also contemplates the use of other geometric objects and
patterns generated by other diffractive optical elements.
[0078] The laser light passing through the mask 56 diffracts,
producing a periodic pattern a distance away from the mask 56,
shown by the laser beams labeled 58 in FIG. 4. The single laser
beam 52 has thus been formed into hundreds or even thousands of
individual laser beams 58 so as to create the desired pattern of
spots or other geometric objects. These laser beams 58 may be
passed through additional lenses, collimators, etc. 60 and 62 in
order to convey the laser beams and form the desired pattern on the
patient's retina. Such additional lenses, collimators, etc. 60 and
62 can further transform and redirect the laser beams 58 as
needed.
[0079] Arbitrary patterns can be constructed by controlling the
shape, spacing and pattern of the optical mask 56. The pattern and
exposure spots can be created and modified arbitrarily as desired
according to application requirements by experts in the field of
optical engineering. Photolithographic techniques, especially those
developed in the field of semiconductor manufacturing, can be used
to create the simultaneous geometric pattern of spots or other
objects.
[0080] Typically, the system of the present invention incorporates
a guidance system to ensure complete and total retinal treatment
with retinal photostimulation. As the treatment method of the
present invention is harmless, the entire retina, including the
fovea and even optical nerve, can be treated. Moreover, protection
against accidental visual loss by accidental patient movement is
not a concern. Instead, patient movement would mainly affect the
guidance in tracking of the application of the laser light to
ensure adequate coverage. Fixation/tracking/registration systems
consisting of a fixation target, tracking mechanism, and linked to
system operation are common in many ophthalmic diagnostic systems
and can be incorporated into the present invention.
[0081] With reference now to FIGS. 5 and 6, in a particularly
preferred embodiment, the geometric pattern of simultaneous laser
spots is sequentially offset so as to achieve confluent and
complete treatment of the retinal surface. Although a segment of
the retina can be treated in accordance with the present invention,
more ideally the entire retina will be treated with one treatment.
This is done in a time-saving manner by placing hundreds to
thousands of spots over the entire ocular fundus at once. This
pattern of simultaneous spots is scanned, shifted, or redirected as
an entire array sequentially, so as to cover the entire retina.
[0082] This can be done in a controlled manner using an optical
scanning mechanism 64 such as that illustrated in FIGS. 5 and 6.
FIGS. 5 and 6 illustrate an optical scanning mechanism 64 in the
form of a MEMS mirror, having a base 66 with electronically
actuated controllers 68 and 70 which serve to tilt and pan the
mirror 72 as electricity is applied and removed thereto. Applying
electricity to the controller 68 and 70 causes the mirror 72 to
move, and thus the simultaneous pattern of laser spots or other
geometric objects reflected thereon to move accordingly on the
retina of the patient. This can be done, for example, in an
automated fashion using electronic software program to adjust the
optical scanning mechanism 64 until complete coverage of the
retina, or at least the portion of the retina desired to be
treated, is exposed to the phototherapy. The optical scanning
mechanism may also be a small beam diameter scanning galvo mirror
system, or similar system, such as that
[0083] distributed by Thorlabs. Such a system is capable of
scanning the lasers in the desired offsetting pattern.
[0084] Since the parameters of the present invention dictate that
the applied radiant energy or laser light is not destructive or
damaging, the geometric pattern of laser spots, for example, can be
overlapped without creating any damage. However, in a particularly
preferred embodiment, as illustrated in FIG. 7, the pattern of
spots are offset at each exposure so as to create space between the
immediately previous exposure to allow heat dissipation and prevent
the possibility of heat damage or tissue destruction. Thus, as
illustrated in FIG. 7, the pattern, illustrated for exemplary
purposes as a grid of sixteen spots, is offset each exposure such
that the laser spots occupy a different space than previous
exposures. It will be understood that this occurs until the entire
retina, the preferred methodology, has received phototherapy, or
until the desired effect is attained. This can be done, for
example, by applying electrostatic torque to a micromachined
mirror, as illustrated in FIGS. 5 and 6. By combining the use of
small retina laser spots separated by exposure free areas, prevents
heat accumulation, and grids with a large number of spots per side,
it is possible to atraumatically and invisibly treat large target
areas with short exposure durations far more rapidly than is
possible with current technologies.
[0085] By rapidly and sequentially repeating redirection or
offsetting of the entire simultaneously applied grid array of spots
or geometric objects, complete coverage of the target, such as a
human retina, can be achieved rapidly without thermal tissue
injury. This offsetting can be determined algorithmically to ensure
the fastest treatment time and least risk of damage due to thermal
tissue, depending on laser parameters and desired application. The
following has been modeled using the Fraunhoffer Approximation.
With a mask having a nine by nine square lattice, with an aperture
radius 9 .mu.m, an aperture spacing of 600 .mu.m, using a 890 nm
wavelength laser, with a mask-lens separation of 75 mm, and
secondary mask size of 2.5 mm by 2.5 mm, the following parameters
will yield a grid having nineteen spots per side separated by 133
.mu.m with a spot size radius of 6 .mu.m. The number of exposures
"m" required to treat (cover confluently with small spot
applications) given desired area side-length "A", given output
pattern spots per square side "n", separation between spots "R",
spot radius "r" and desired square side length to treat area "A",
can be given by the following formula:
m = A nR floor ( R 2 r ) 2 ##EQU00001##
[0086] With the foregoing setup, one can calculate the number of
operations m needed to treat different field areas of exposure. For
example, a 3 mm.times.3 mm area, which is useful for treatments,
would require 98 offsetting operations, requiring a treatment time
of approximately thirty seconds. Another example would be a 3
cm.times.3 cm area, representing the entire human retinal surface.
For such a large treatment area, a much larger secondary mask size
of 25 mm by 25 mm could be used, yielding a treatment grid of 190
spots per side separated by 133 .mu.m with a spot size radius of 6
.mu.m. Since the secondary mask size was increased by the same
factor as the desired treatment area, the number of offsetting
operations of approximately 98, and thus treatment time of
approximately thirty seconds, is constant. These treatment times
represent at least ten to thirty times reduction in treatment times
compared to current methods of sequential individual laser spot
applications. Field sizes of 3 mm would, for example, allow
treatment of the entire human macula in a single exposure, useful
for treatment of common blinding conditions such as diabetic
macular edema and age-related macular degeneration. Performing the
entire 98 sequential offsettings would ensure entire coverage of
the macula.
[0087] Of course, the number and size of retinal spots produced in
a simultaneous pattern array can be easily and highly varied such
that the number of sequential offsetting operations required to
complete treatment can be easily adjusted depending on the
therapeutic requirements of the given application.
[0088] Furthermore, by virtue of the small apertures employed in
the diffraction grating or mask, quantum mechanical behavior may be
observed which allows for arbitrary distribution of the laser input
energy. This would allow for the generation of any arbitrary
geometric shapes or patterns, such as a plurality of spots in grid
pattern, lines, or any other desired pattern. Other methods of
generating geometric shapes or patterns, such as using multiple
fiber optical fibers or microlenses, could also be used in the
present invention. Time savings from the use of simultaneous
projection of geometric shapes or patterns permits the treatment
fields of novel size, such as the 1.2 cm 2 area to accomplish
whole-retinal treatment, in a clinical setting.
[0089] With reference now to FIG. 8, instead of a geometric pattern
of small laser spots, the present invention contemplates use of
other geometric objects or patterns. For example, a single line 74
of laser light, formed by the continuously or by means of a series
of closely spaced spots, can be created. An offsetting optical
scanning mechanism can be used to sequentially scan the line over
an area, illustrated by the downward arrow in FIG. 8.
[0090] With reference now to FIG. 9, the same geometric object of a
line 74 can be rotated, as illustrated by the arrows, so as to
create a circular field of phototherapy. The potential negative of
this approach, however, is that the central area will be repeatedly
exposed, and could reach unacceptable temperatures. This could be
overcome, however, by increasing the time between exposures, or
creating a gap in the line such that the central area is not
exposed.
[0091] With reference again to FIG. 3, due to the unique
characteristics of the present invention, allowing a single set of
optimized laser parameters, which are not significantly influenced
by media opacity, retinal thickening, or fundus pigmentation, a
simplified user interface is permitted. While the operating
controls could be presented and function in many different ways,
the system permits a very simplified user interface that might
employ only two control functions. That is, an "activate" button,
wherein a single depression of this button while in "standby" would
actuate and initiate treatment. A depression of this button during
treatment would allow for premature halting of the treatment, and a
return to "standby" mode. The activity of the machine could be
identified and displayed, such as by an LED adjacent to or within
the button. A second controlled function could be a "field size"
knob. A single depression of this button could program the unit to
produce, for example, a 3 mm focal or a "macular" field spot. A
second depression of this knob could program the unit to produce a
6 mm or "posterior pole" spot. A third depression of this knob
could program the unit to produce a "pan retinal" or approximately
160.degree.-220.degree. panoramic retinal spot or coverage area.
Manual turning of this knob could produce various spot field sizes
therebetween. Within each field size, the density and intensity of
treatment would be identical. Variation of the field size would be
produced by optical or mechanical masking or apertures, such as the
iris or LCD apertures described below.
[0092] Fixation software could monitor the displayed image of the
ocular fundus. Prior to initiating treatment of a fundus landmark,
such as the optic nerve, or any part or feature of either eye of
the patient (assuming orthophoria), could be marked by the operator
on the display screen. Treatment could be initiated and the
software would monitor the fundus image or any other
image-registered to any part of either eye of the patient (assuming
orthophoria) to ensure adequate fixation. A break in fixation would
automatically interrupt treatment. Treatment would automatically
resume toward completion as soon as fixation was established. At
the conclusion of treatment, determined by completion of confluent
delivery of the desired laser energy to the target, the unit would
automatically terminate exposure and default to the "on" or
"standby" mode. Due to unique properties of this treatment,
fixation interruption would not cause harm or risk patient injury,
but only prolong the treatment session.
[0093] With reference now to FIGS. 10 and 11, spectral-domain OCT
imaging is shown in FIG. 10 of the macular and foveal area of the
retina before treatment with the present invention. FIG. 11 is of
the optical coherence tomography (OCT) image of the same macula and
fovea after treatment using the present invention, using a 131
micrometer retinal spot, 5% duty cycle, 0.3 second pulse duration,
0.9 watt peak power placed throughout the area of macular
thickening, including the fovea. It will be noted that the enlarged
dark area to the left of the fovea depression (representing the
pathologic retinal thickening of diabetic macular edema) is absent,
as well as the fact that there is an absence of any laser-induced
retinal damage. Such treatment simply would not be attainable with
conventional techniques.
[0094] The laser could be projected via a wide field non-contact
lens to the ocular fundus. Customized direction of the laser fields
or particular target or area of the ocular fundus other than the
central area could be accomplished by an operator joy stick or
eccentric patient gaze. The laser delivery optics could be coupled
coaxially to a wide field non-contact digital ocular fundus viewing
system. The image of the ocular fundus produced could be displayed
on a video monitor visible to the laser operator. Maintenance of a
clear and focused image of the ocular fundus could be facilitated
by a joy stick on the camera assembly manually directed by the
operator. Alternatively, addition of a target registration and
tracking system to the camera software would result in a completely
automated treatment system.
[0095] A fixation image could be coaxially displayed to the patient
to facilitate ocular alignment. This image would change in shape
and size, color, intensity, blink or oscillation rate or other
regular or continuous modification during treatment to avoid
photoreceptor exhaustion, patient fatigue and facilitate good
fixation.
[0096] The field of photobiology reveals that different biologic
effects may be achieved by exposing target tissues to lasers of
different wavelengths. The same may also be achieved by
consecutively applying multiple lasers of either different or the
same wavelength in sequence with variable time periods of
separation and/or with different irradiant energies. The present
invention anticipates the use of multiple laser, light or radiant
wavelengths (or modes) applied simultaneously or in sequence to
maximize or customize the desired treatment effects. This method
also minimizes potential detrimental effects. The following
description identifies two optical methods of providing
simultaneous or sequential application of multiple wavelengths.
[0097] FIG. 12 illustrates diagrammatically a system which couples
multiple light sources into the pattern-generating optical
subassembly described above. Specifically, this system 40' is
similar to the system 40 described in FIG. 3 above. The primary
differences between the alternate system 40' and the earlier
described system 40 is the inclusion of a plurality of laser
consoles 42, the outputs of which are each fed into a fiber coupler
76. The fiber coupler produces a single output that is passed into
the laser projector optics 44 as described in the earlier system.
The coupling of the plurality of laser consoles 42 into a single
optical fiber is achieved with a fiber coupler 76 as is known in
the art. Other known mechanisms for combining multiple light
sources are available and may be used to replace the fiber coupler
described herein.
[0098] In this system 40' the multiple light sources 42 follow a
similar path as described in the earlier system 40, i.e.,
collimated, diffracted, recollimated, and directed into the retina
with a steering mechanism. In this alternate system 40' the
diffractive element must function differently than described
earlier depending upon the wavelength of light passing through,
which results in a slightly varying pattern. The variation is
linear with the wavelength of the light source being diffracted. In
general, the difference in the diffraction angles is small enough
that the different, overlapping patterns may be directed along the
same optical path through the steering mechanism 46 to the retina
48 for treatment. The slight difference in the diffraction angles
will affect how the steering pattern achieves coverage of the
retina.
[0099] Since the resulting pattern will vary slightly for each
wavelength, a sequential offsetting to achieve complete coverage
will be different for each wavelength. This sequential offsetting
can be accomplished in two modes. In the first mode, all
wavelengths of light are applied simultaneously without identical
coverage. An offsetting steering pattern to achieve complete
coverage for one of the multiple wavelengths is used. Thus, while
the light of the selected wavelength achieves complete coverage of
the retina, the application of the other wavelengths achieves
either incomplete or overlapping coverage of the retina. The second
mode sequentially applies each light source of a varying wavelength
with the proper steering pattern to achieve complete coverage of
the retina for that particular wavelength. This mode excludes the
possibility of simultaneous treatment using multiple wavelengths,
but allows the optical method to achieve identical coverage for
each wavelength. This avoids either incomplete or overlapping
coverage for any of the optical wavelengths.
[0100] These modes may also be mixed and matched. For example, two
wavelengths may be applied simultaneously with one wavelength
achieving complete coverage and the other achieving incomplete or
overlapping coverage, followed by a third wavelength applied
sequentially and achieving complete coverage.
[0101] FIG. 13 illustrates diagrammatically yet another alternate
embodiment of the inventive system 40''. This system 40'' is
configured generally the same as the system 40 depicted in FIG. 3.
The main difference resides in the inclusion of multiple
pattern-generating subassembly channels tuned to a specific
wavelength of the light source. Multiple laser consoles 42 are
arranged in parallel with each one leading directly into its own
laser projector optics 44. The laser projector optics of each
channel 80a, 80b, 80c comprise a collimator 54, mask or diffraction
grating 56 and recollimators 60, 62 as described in connection with
FIG. 4 above--the entire set of optics tuned for the specific
wavelength generated by the corresponding laser console 42. The
output from each set of optics 44 is then directed to a beam
splitter 78 for combination with the other wavelengths. It is known
by those skilled in the art that a beam splitter used in reverse
can be used to combine multiple beams of light into a single
output.
[0102] The combined channel output from the final beam splitter 78c
is then directed through the camera 46 which applies a steering
mechanism to allow for complete coverage of the retina 48.
[0103] In this system 40'' the optical elements for each channel
are tuned to produce the exact specified pattern for that channel's
wavelength. Consequently, when all channels are combined and
properly aligned a single steering pattern may be used to achieve
complete coverage of the retina for all wavelengths.
[0104] The system 40'' may use as many channels 80a, 80b, 80c, etc.
and beam splitters 78a, 78b, 78c, etc. as there are wavelengths of
light being used in the treatment.
[0105] Implementation of the system 40'' may take advantage of
different symmetries to reduce the number of alignment constraints.
For example, the proposed grid patterns are periodic in two
dimensions and steered in two dimensions to achieve complete
coverage. As a result, if the patterns for each channel are
identical as specified, the actual pattern of each channel would
not need to be aligned for the same steering pattern to achieve
complete coverage for all wavelengths. Each channel would only need
to be aligned optically to achieve an efficient combination.
[0106] In system 40'', each channel begins with a light source 42,
which could be from an optical fiber as in other embodiments of the
pattern-generating subassembly. This light source 42 is directed to
the optical assembly 44 for collimation, diffraction, recollimation
and directed into the beam splitter which combines the channel with
the main output.
[0107] The invention described herein is generally safe for
panretinal and/or trans-foveal treatment. However, it is possible
that a user, i.e., surgeon, preparing to limit treatment to a
particular area of the retina where disease markers are located or
to prevent treatment in a particular area with darker pigmentation,
such as from scar tissue. In this case, the camera 46 may be fitted
with an iris aperture 82 configured to selectively widen or narrow
the opening through which the light is directed into the eye 48 of
the patient. FIG. 14 illustrates an opening 84 on a camera 46
fitted with such an iris aperture 82. Alternatively, the iris
aperture 82 may be replaced or supplemented by a liquid crystal
display (LCD) 86. The LCD 86 acts as a dynamic aperture by allowing
each pixel in the display to either transmit or block the light
passing through it. Such an LCD 86 is depicted in FIG. 15.
[0108] Preferably, any one of the inventive systems 40, 40', 40''
includes a display on a user interface with a live image of the
retina as seen through the camera 46. The user interface may
include an overlay of this live image of the retina to select areas
where the treatment light will be limited or excluded by the iris
aperture 82 and/or the LCD 86. The user may draw an outline on the
live image as on a touch screen and then select for either the
inside or the outside of that outline to have limited or excluded
coverage.
[0109] By way of example, if the user identifies scar tissue on the
retina that should be excluded from treatment, the user would draw
an outline around the scar tissue and then mark the interior of
that outline for exclusion from the laser treatment. The control
system and user interface 50 would then send the proper control
signal to the LCD 86 to block the projected treatment light through
the pixels over the selected scar tissue. The LCD 86 provides an
added benefit of being useful for attenuating regions of the
projected pattern. This feature may be used to limit the peak power
output of certain spots within the pattern. Limiting the peak power
of certain spots in the pattern with the highest power output can
be used to make the treatment power more uniform across the
retina.
[0110] Although the present invention is particularly suited for
treatment of retinal diseases, such as diabetic retinopathy and
macular edema, it is contemplated that it could be used for other
diseases as well. The system and process of the present invention
could target the trabecular mesh work as treatment for glaucoma,
accomplished by another customized treatment field template. It is
contemplated by the present invention that the system and concepts
of the present invention be applied to phototherapy treatment of
other tissues, such as, but not limited to, the gastrointestinal or
respiratory mucosa, delivered endoscopically, for other
purposes.
[0111] In addition, the results or images from other retinal
diagnostic modalities, such as OCT, retinal angiography, or
autofluoresence photography, might be displayed in parallel or by
superimposition on the display image of the patient's fundus to
guide, aid or otherwise facilitate the treatment. This parallel or
superimposition of images can facilitate identification of disease,
injury or scar tissue on the retina.
[0112] Although several embodiments have been described in detail
for purposes of illustration, various modifications may be made
without departing from the scope and spirit of the invention.
Accordingly, the invention is not to be limited, except as by the
appended claims.
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