U.S. patent application number 16/693159 was filed with the patent office on 2020-05-21 for devices and methods for glaucoma treatment.
The applicant listed for this patent is GLAUKOS CORPORATION. Invention is credited to Thomas W. Burns, David Steven Haffner, Gregory T. Smedley, Hosheng Tu.
Application Number | 20200155349 16/693159 |
Document ID | / |
Family ID | 34193530 |
Filed Date | 2020-05-21 |
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United States Patent
Application |
20200155349 |
Kind Code |
A1 |
Haffner; David Steven ; et
al. |
May 21, 2020 |
DEVICES AND METHODS FOR GLAUCOMA TREATMENT
Abstract
Intraocular stents and applicators are disclosed for treating
glaucoma. The stents are configured to extend between the anterior
chamber of the eye and Schlemm's canal for enhancing outflow of
aqueous from the anterior chamber so as to reduce intraocular
pressure. The stents can have features for anchoring the stent into
Schlemm's canal as well as preventing the walls of Schlemm's canal
from closing the outlet of the stents. The applicators can be
steerable so as to make implantation easier. Additionally, the
applicators can be configured to hold a plurality of stents so that
multiple stents can be implanted through one incision without
removing the applicator from the incision between serial
implantations.
Inventors: |
Haffner; David Steven;
(Mission Viejo, CA) ; Smedley; Gregory T.; (Aliso
Viejo, CA) ; Tu; Hosheng; (Newport Beach, CA)
; Burns; Thomas W.; (Dana Point, CA) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
GLAUKOS CORPORATION |
San Clemente |
CA |
US |
|
|
Family ID: |
34193530 |
Appl. No.: |
16/693159 |
Filed: |
November 22, 2019 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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15464113 |
Mar 20, 2017 |
10485701 |
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16693159 |
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11836112 |
Aug 8, 2007 |
9597230 |
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15464113 |
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10634213 |
Aug 5, 2003 |
7867186 |
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11836112 |
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10118578 |
Apr 8, 2002 |
7135009 |
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10634213 |
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60451226 |
Feb 28, 2003 |
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60401166 |
Aug 5, 2002 |
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Current U.S.
Class: |
1/1 |
Current CPC
Class: |
A61F 9/00781
20130101 |
International
Class: |
A61F 9/007 20060101
A61F009/007 |
Claims
1.-42. (canceled)
43. An instrument for delivering multiple ocular implants for
treating an ophthalmic condition and dispensing the ocular implants
within an eye of a subject, the instrument comprising: an injection
sheath defining a lumen and comprising a distal holding section,
the distal-holding section sized to be introduced into the eye
through an incision in the eye; a plurality of ocular implants
positioned in the lumen, each of said implants adapted to convey
aqueous humour from an anterior chamber of the eye to a fluid
outflow path of the eye so as to reduce elevated intraocular
pressure, each of said implants comprising a waist portion sized to
bypass a trabecular mesh disposed between the anterior chamber and
the fluid outflow path,; wherein a length of the waist portion is
less than 400 .mu.m; a trocar extending through each of the
plurality of implants, wherein a distal tip of said trocar is
sufficiently sharp to cut through the trabecular mesh; and a
holding member disposed between a pair of immediately adjacent
implants of the plurality of implants, wherein the holding member
is disposed on the trocar.
44. The instrument of claim 43, further comprising: a handle
attached to the injection sheath; a stent delivery button disposed
on the handle; and an actuator, wherein the stent delivery button
is configured to cause the actuator to discharge, from the
insertion sheath, one implant at a time.
45. The instrument of claim 43, wherein each of said implants
further comprises a central lumen and one or more side-ports, the
central lumen extending from a proximal-most surface of a proximal
head to a distal-most surface of to distal tapered base portion,
each of the one or more side-ports extending between the central
lumen and an outer surface of the distal tapered base portion.
46. The instrument of claim 45, wherein the trocar extends through
a central lumen of each of said implants.
47. The instrument of claim 43, wherein the implants are arranged
in series within the lumen.
48. The instrument of claim 43, wherein each of the plurality of
implants is slidably mounted on the trocar.
49. The instrument of claim 44, wherein the actuator is configured
to slide at least one of the implants off of the trocar.
50. The instrument of claim 44, wherein the actuator comprises a
pusher adapted for evenly pushing each of the plurality of
implants, one at a time, out of the insertion sheath.
51. The instrument of claim 50, wherein the pusher is connected
with the stent delivery button, the actuator being configured to
move the pusher a predetermined distance each time the stent
delivery button is pressed.
52. The instrument of claim 43, wherein the holding member is
elastically deformable.
53. An instrument for delivering multiple ocular implants for
treating an ophthalmic condition and dispensing the ocular implants
within an eye of a subject, the instrument comprising: an insertion
sheath defining a lumen, a distal portion of the insertion sheath
sized to be introduced into the eye through an incision in the eye;
a trocar disposed in said lumen, said trocar comprising a distal
tip having a cutting end sufficiently sharp to cut through eye
tissue; and a plurality of biocompatible ocular implants positioned
in the lumen and mounted on the trocar, each of said implants
adapted to convey aqueous humour from an anterior chamber of the
eye to a fluid outflow path of the eye so as to reduce elevated
intraocular pressure, wherein the trocar comprises a holding member
disposed between a pair of immediately adjacent implants of the
plurality of biocompatible ocular implants.
54. The instrument of claim 53, further comprising: a handle
attached to the injection sheath; a stent delivery button disposed
on the handle; and an actuator, wherein the stent delivery button
is configured to cause the actuator to discharge, from the
insertion sheath, one implant at a time.
55. The instrument of claim 53, wherein each of said implants
further comprises a central lumen and one or more side-ports, the
central lumen extending from a proximal-most surface of a head to a
distal-most surface of a base portion, each of the one or more
side-ports extending between the central lumen and an outer surface
of the base portion.
56. The instrument of claim 54, wherein the actuator comprises a
pusher adapted for evenly pushing each of the plurality of
implants, one at a time, out of the insertion sheath.
57. The instrument of claim 56, wherein the pusher is connected
with the stent delivery button, the actuator being configured to
move the pusher a predetermined distance each time the stent
delivery button is pressed.
58. The instrument of claim 53, wherein the holding member is
elastically deformable.
59. An instrument for delivering multiple ocular implants for
treating an ophthalmic condition and dispensing the ocular implants
within an eye of a subject, the instrument comprising: an injection
sheath defining a lumen, a distal portion of said injection sheath
sized to be introduced into an anterior chamber of the eye; a
trocar disposed in said lumen, said trocar comprising a distal tip
being configured to penetrate through trabecular mesh of the eye;
and a plurality of ocular implants mounted on the trocar and
positioned in the distal portion of the injection sheath, wherein
the trocar comprises a holding member positioned between each
adjacent pair of the plurality of ocular implants, wherein each of
said implants is adapted to convey aqueous humour from an anterior
chamber of the eye to a fluid outflow path of the eye so as to
reduce elevated intraocular pressure.
60. The instrument of claim 59, further comprising: a handle
attached to the injection sheath; a stent delivery button disposed
on the handle; and an actuator, wherein the stent delivery button
is configured to cause the actuator to discharge, from the
insertion sheath, one implant at a time.
61. The instrument of claim 60, wherein the actuator comprises a
pusher adapted for evenly pushing each of the plurality of
implants, one at a time, out of the insertion sheath.
62. The instrument of claim 59, wherein the holding member is
elastically deformable.
Description
CROSS REFERENCE TO RELATED APPLICATIONS
[0001] This application is a continuation application of U.S.
patent application Ser. No. 15/464,113, filed Mar. 20, 2017,
entitled "Devices and Methods for Glaucoma Treatment," which is a
continuation application of U.S. patent application Ser. No.
11/836,112, filed Aug. 8, 2007, entitled "Devices and Methods for
Glaucoma Treatment," which is a continuation application of U.S.
patent application Ser. No. 10/634,213, filed Aug. 5, 2003,
entitled "Devices and Methods for Glaucoma Treatment," now U.S.
Pat. No. 7,867,186, issued Nov. 11, 2011, which is a
continuation-in-part (CIP) application of U.S. patent application
Ser. No. 10/118,578, filed Apr. 8, 2002, entitled "Glaucoma Stent
and Methods Thereof for Glaucoma Treatment," now U.S. Pat. No.
7,135,009 B2, issued Nov. 14, 2006, which claims the priority
benefits of U.S. Provisional Application No. 60/401,166 filed Aug.
5, 2002, entitled "Injectable Stent for Treating Glaucoma and
Methods of Use," and U.S. Provisional Application No. 60/451,226
filed Feb. 28, 2003, entitled "Special Features and Methods for
Glaucoma Treatment." The entireties of all of these priority
documents are hereby incorporated by reference.
BACKGROUND OF THE INVENTION
Field of the Invention
[0002] The present application relates generally to medical devices
and methods for reducing the intraocular pressure in an animal eye
and, more particularly, to shunt-type stenting devices for
permitting and/or enhancing aqueous outflow from the eye's anterior
chamber toward existing outflow pathways and associated methods
thereof for the treatment of glaucoma in general.
Description of the Related Art
[0003] The human eye is a specialized sensory organ capable of
light reception and able to receive visual images. The trabecular
meshwork serves as a drainage channel and is located in the
anterior chamber angle formed between the iris and the cornea. The
trabecular meshwork maintains a balanced pressure in the anterior
chamber of the eye by allowing aqueous humor to flow from the
anterior chamber.
[0004] About two percent of people in the United States have
glaucoma. Glaucoma is a group of eye diseases encompassing a broad
spectrum of clinical presentations, etiologies, and treatment
modalities. Glaucoma causes pathological changes in the optic
nerve, visible on the optic disk, and it causes corresponding
visual field loss, resulting in blindness if untreated. Lowering
intraocular pressure is the major treatment goal in all
glaucomas.
[0005] In glaucomas associated with an elevation in eye pressure
(intraocular hypertension), the source of resistance to outflow of
aqueous humor is mainly in the trabecular meshwork. The tissue of
the trabecular meshwork allows the aqueous humor ("aqueous") to
enter Schlemm's canal, which then empties into aqueous collector
channels in the posterior wall of Schlemm's canal and then into
aqueous veins, which form the episcleral venous system. Aqueous
humor is a transparent liquid that fills the region between the
cornea, at the front of the eye, and the lens. The aqueous humor is
continuously secreted by the ciliary body around the lens, so there
is an essentially constant flow of aqueous humor from the ciliary
body to the eye's anterior chamber. The anterior chamber pressure
is determined by a balance between the production of aqueous and
its exit through the trabecular meshwork (major route) or uveal
scleral outflow (minor route). The trabecular meshwork is located
between the outer rim of the iris and the back of the cornea, in
the anterior chamber angle. The portion of the trabecular meshwork
adjacent to Schlemm's canal (the juxtacanilicular meshwork) causes
most of the resistance to aqueous outflow.
[0006] Glaucoma is grossly classified into two categories:
closed-angle glaucoma, also known as "angle closure" glaucoma, and
open-angle glaucoma. Closed-angle glaucoma is caused by closure of
the anterior chamber angle by contact between the iris and the
inner surface of the trabecular meshwork. Closure of this
anatomical angle prevents normal drainage of aqueous humor from the
anterior chamber of the eye.
[0007] Open-angle glaucoma is any glaucoma in which the angle of
the anterior chamber remains open, but the exit of aqueous through
the trabecular meshwork is diminished. The exact cause for
diminished filtration is unknown for most cases of open-angle
glaucoma. Primary open-angle glaucoma is the most common of the
glaucomas, and it is often asymptomatic in the early to moderately
advanced stage. Patients may suffer substantial, irreversible
vision loss prior to diagnosis and treatment. However, there are
secondary open-angle glaucomas which may include edema or swelling
of the trabecular spaces (e.g., from corticosteroid use), abnormal
pigment dispersion, or diseases such as hyperthyroidism that
produce vascular congestion.
[0008] Current therapies for glaucoma are directed at decreasing
intraocular pressure. Medical therapy includes topical ophthalmic
drops or oral medications that reduce the production or increase
the outflow of aqueous. However, these drug therapies for glaucoma
are sometimes associated with significant side effects, such as
headache, blurred vision, allergic reactions, death from
cardiopulmonary complications, and potential interactions with
other drugs. When drug therapy fails, surgical therapy is used.
Surgical therapy for open-angle glaucoma consists of laser
trabeculoplasty, trabeculectomy, and implantation of aqueous shunts
after failure of trabeculectomy or if trabeculectomy is unlikely to
succeed. Trabeculectomy is a major surgery that is widely used and
is augmented with topically applied anticancer drugs, such as
5-flurouracil or mitomycin-C to decrease scarring and increase the
likelihood of surgical success.
[0009] Approximately 100,000 trabeculectomies are performed on
Medicare-age patients per year in the United States. This number
would likely increase if the morbidity associated with
trabeculectomy could be decreased. The current morbidity associated
with trabeculectomy consists of failure (10-15%); infection (a life
long risk of 2-5%); choroidal hemorrhage, a severe internal
hemorrhage from low intraocular pressure, resulting in visual loss
(1%); cataract formation; and hypotony maculopathy (potentially
reversible visual loss from low intraocular pressure).
[0010] For these reasons, surgeons have tried for decades to
develop a workable surgery for the trabecular meshwork.
[0011] The surgical techniques that have been tried and practiced
are goniotomy/trabeculotomy and other mechanical disruptions of the
trabecular meshwork, such as trabeculopuncture, goniophotoablation,
laser trabecular ablation, and goniocurretage. These are all major
operations and are briefly described below.
[0012] Goniotomy/Trabeculotomy: Goniotomy and trabeculotomy are
simple and directed techniques of microsurgical dissection with
mechanical disruption of the trabecular meshwork. These initially
had early favorable responses in the treatment of open-angle
glaucoma. However, long-term review of surgical results showed only
limited success in adults. In retrospect, these procedures probably
failed due to cellular repair and fibrosis mechanisms and a process
of "filling in." Filling in is a detrimental effect of collapsing
and closing in of the opening created in the trabecular meshwork.
Once the openings close, the pressure builds back up and the
surgery fails.
[0013] Trabeculopuncture: Q-switched Neodynium (Nd) YAG lasers also
have been investigated as an optically invasive technique for
creating full-thickness holes in trabecular meshwork. However, the
relatively small hole created by this trabeculopuncture technique
exhibits a filling-in effect and fails.
[0014] Goniophotoablation/Laser Trabecular Ablation:
Goniophotoablation is disclosed by Berlin in U.S. Pat. No.
4,846,172 and involves the use of an excimer laser to treat
glaucoma by ablating the trabecular meshwork. This was demonstrated
not to succeed by clinical trial. Hill et al. disclosed the use of
an Erbium:YAG laser to create full-thickness holes through
trabecular meshwork (Hill et al., Lasers in Surgery and Medicine
11:341-346, 1991). This technique was investigated in a primate
model and a limited human clinical trial at the University of
California, Irvine. Although morbidity was zero in both trials,
success rates did not warrant further human trials. Failure was
again from filling in of surgically created defects in the
trabecular meshwork by repair mechanisms. Neither of these is a
viable surgical technique for the treatment of glaucoma.
[0015] Goniocurretage: This is an ab interno (from the inside),
mechanically disruptive technique that uses an instrument similar
to a cyclodialysis spatula with a microcurrette at the tip. Initial
results were similar to trabeculotomy: it failed due to repair
mechanisms and a process of filling in.
[0016] Although trabeculectomy is the most commonly performed
filtering surgery, viscocanulostomy (VC) and non penetrating
trabeculectomy (NPT) are two new variations of filtering surgery.
These are ab externo (from the outside), major ocular procedures in
which Schlemm's canal is surgically exposed by making a large and
very deep scleral flap. In the VC procedure, Schlemm's canal is
cannulated and viscoelastic substance injected (which dilates
Schlemm's canal and the aqueous collector channels). In the NPT
procedure, the inner wall of Schlemm's canal is stripped off after
surgically exposing the canal.
[0017] Trabeculectomy, VC, and NPT involve the formation of an
opening or hole under the conjunctiva and scleral flap into the
anterior chamber, such that aqueous humor is drained onto the
surface of the eye or into the tissues located within the lateral
wall of the eye. These surgical operations are major procedures
with significant ocular morbidity. Where trabeculectomy, VC, and
NPT were thought to have a low chance for success in particular
cases, a number of implantable drainage devices have been used to
ensure that the desired filtration and outflow of aqueous humor
through the surgical opening will continue. The risk of placing a
glaucoma drainage device also includes hemorrhage, infection, and
diplopia (double vision).
[0018] All of the above surgeries and variations thereof have
numerous disadvantages and moderate success rates. They involve
substantial trauma to the eye and require great surgical skill in
creating a hole through the full thickness of the sclera into the
subconjunctival space. The procedures are generally performed in an
operating room and have a prolonged recovery time for vision.
[0019] The complications of existing filtration surgery have
prompted ophthalmic surgeons to find other approaches to lowering
intraocular pressure or treating tissue of trabecular meshwork.
[0020] The trabecular meshwork and juxtacanilicular tissue together
provide the majority of resistance to the outflow of aqueous and,
as such, are logical targets for tissue stimulation/rejuvenating or
shunting in the treatment of open-angle glaucoma. In addition,
minimal amounts of tissue are displaced and functions of the
existing physiologic outflow pathways are restored.
[0021] As reported in Arch. Ophthalm. (2000) 118:412, glaucoma
remains a leading cause of blindness, and filtration surgery
remains an effective, important option in controlling the disease.
However, modifying existing filtering surgery techniques in any
profound way to increase their effectiveness appears to have
reached a dead end. The article further states that the time has
come to search for new surgical approaches that may provide better
and safer care for patients with glaucoma.
[0022] Therefore, there is a great clinical need for an improved
method of treating glaucoma that is faster, safer, and less
expensive than currently available drug or surgical modalities. The
methods disclosed herein include ab interno and ab externo
procedures that involve non-flap operations. The method herein may
further comprise using an innovative stenting device.
SUMMARY OF THE INVENTION
[0023] The trabecular meshwork and juxtacanilicular tissue together
provide the majority of resistance to the outflow of aqueous and,
as such, are logical targets for the treatment of glaucoma. Various
embodiments of glaucoma devices and methods are disclosed herein
for treating glaucoma by an ab interno procedure or an ab externo
procedure, with respect to trabecular meshwork. The "ab interno"
procedure is herein intended to mean any procedure that creates an
opening from the anterior chamber through trabecular meshwork
outwardly toward Schlemm's canal or toward scleral/cornea wall.
This ab interno procedure may be initiated through the scleral wall
or cornea wall into the anterior chamber as a first step. The "ab
externo" procedure is herein intended to mean any procedure that
creates an opening on the scleral wall through trabecular meshwork
inwardly toward the anterior chamber. In most "ab externo"
procedures disclosed herein, an instrument is passed through or
contacts Schlemm's canal before entering trabecular meshwork and
approaching the anterior chamber. The trabecular meshwork can
generally be said to be bordered on one side by the anterior
chamber and on the other side by Schlemm's canal.
[0024] Glaucoma surgical morbidity would greatly decrease if one
were to bypass the focal resistance to outflow of aqueous only at
the point of resistance, and to utilize remaining, healthy aqueous
outflow mechanisms. This is in part because episcleral aqueous
humor exerts a backpressure that prevents intraocular pressure from
falling too low, and one could thereby avoid hypotony. Thus, such a
surgery would virtually eliminate the risk of hypotony-related
maculopathy and choroidal hemorrhage. Furthermore, visual recovery
would be very rapid, and the risk of infection would be very small,
reflecting a reduction in incidence from 2-5% to about 0.05%.
[0025] Copending U.S. application Ser. No. 09/549,350, filed Apr.
14, 2000, entitled APPARATUS AND METHOD FOR TREATING GLAUCOMA, and
copending U.S. application Ser. No. 09/704,276, filed Nov. 1, 2000,
entitled GLAUCOMA TREATMENT DEVICE, disclose devices and methods of
placing a trabecular shunt ab interno, i.e., from inside the
anterior chamber through the trabecular meshwork, into Schlemm's
canal. The entire contents of each one of these copending patent
applications are hereby incorporated by reference herein. This
application encompasses both ab interno and ab externo glaucoma
shunts or stents and methods thereof.
[0026] One technique performed in accordance with certain aspects
herein can be referred to generally as "trabecular bypass surgery."
Advantages of this type of surgery include lowering intraocular
pressure in a manner which is simple, effective, disease
site-specific, and can potentially be performed on an outpatient
basis.
[0027] Generally, trabecular bypass surgery (TBS) creates an
opening, a slit, or a hole through trabecular meshwork with minor
microsurgery. TBS has the advantage of a much lower risk of
choroidal hemorrhage and infection than prior techniques, and it
uses existing physiologic outflow mechanisms. In some aspects, this
surgery can potentially be performed under topical or local
anesthesia on an outpatient basis with rapid visual recovery. To
prevent "filling in" of the hole, a biocompatible elongated hollow
device is placed within the hole and serves as a stent. U.S. patent
application Ser. No. 09/549,350, filed Apr. 14, 2000 and the
corresponding WO PCT US 01/07398 filed Mar. 8, 2001, the entire
contents of which are hereby incorporated by reference herein,
disclose trabecular bypass surgery in details.
[0028] As described in U.S. patent application. Ser. No.
09/549,350, filed Apr. 14, 2000, and U.S. application Ser. No.
09/704,276, filed Nov. 1, 2000, a trabecular shunt or stent for
transporting aqueous humor is provided. The trabecular stent
includes a hollow, elongate tubular element, having an inlet
section and an outlet section. The outlet section may optionally
include two segments or elements, adapted to be positioned and
stabilized inside Schlemm's canal. In one embodiment, the device
appears as a "T" or an "L" shaped device.
[0029] In accordance with one aspect of at least one of the
inventions disclosed herein, a delivery apparatus (or "applicator")
is used for placing a trabecular stent through a trabecular
meshwork of an eye. Certain embodiments of such a delivery
apparatus are disclosed in copending U.S. application Ser. No.
10/101,548, filed Mar. 18, 2002, entitled APPLICATOR AND METHODS
FOR PLACING A TRABECULAR SHUNT FOR GLAUCOMA TREATMENT, and U.S.
Provisional Application No. 60/276,609, filed Mar. 16, 2001,
entitled APPLICATOR AND METHODS FOR PLACING A TRABECULAR SHUNT FOR
GLAUCOMA TREATMENT, the entire contents of each one of which are
hereby incorporated by reference herein.
[0030] The stent has an inlet section and an outlet section. The
delivery apparatus includes a handpiece, an elongate tip, a holder
and an actuator. The handpiece has a distal end and a proximal end.
The elongate tip is connected to the distal end of the handpiece.
The elongate tip has a distal portion and is configured to be
placed through a corneal incision and into an anterior chamber of
the eye. The holder is attached to the distal portion of the
elongate tip. The holder is configured to hold and release the
inlet section of the trabecular stent. The actuator is on the
handpiece and actuates the holder to release the inlet section of
the trabecular stent from the holder. When the trabecular stent is
deployed from the delivery apparatus into the eye, the outlet
section is positioned in substantially opposite directions inside
Schlemm's canal. In one embodiment, a deployment mechanism within
the delivery apparatus includes a push-pull type plunger.
[0031] Some aspects of at least one of the inventions disclosed
herein relate to devices for reducing intraocular pressure by
providing outflow of aqueous from an anterior chamber of an eye.
The device generally comprises an elongated tubular member and
cutting means. The tubular member is adapted for extending through
a trabecular meshwork of the eye. The tubular member generally
comprises a lumen having an inlet port and at least one outlet port
for providing a flow pathway. The cutting means is mechanically
connected to or is an integral part of the tubular member for
creating an incision in the trabecular meshwork for receiving at
least a portion of the tubular member.
[0032] In one embodiment, a self-trephining glaucoma stent is
provided for reducing and/or balancing intraocular pressure in an
eye. The stent generally comprises a snorkel and a curved blade.
The snorkel generally comprises an upper seat for stabilizing said
stent within the eye, a shank and a lumen. The shank is
mechanically connected to the seat and is adapted for extending
through a trabecular meshwork of the eye. The lumen extends through
the snorkel and has at least one inlet flow port and at least one
outlet flow port. The blade is mechanically connected to the
snorkel. The blade generally comprises a cutting tip proximate a
distal-most point of the blade for making an incision in the
trabecular meshwork for receiving the shank.
[0033] Some aspects of at least one of the inventions disclosed
herein relate to methods of implanting a trabecular stent device in
an eye. In one embodiment, the device has a snorkel mechanically
connected to a blade. The blade is advanced through a trabecular
meshwork of the eye to cut the trabecular meshwork and form an
incision therein. At least a portion of the snorkel is inserted in
the incision to implant the device in the eye.
[0034] Some aspects provide a self-trephining glaucoma stent and
methods thereof which advantageously allow for a "one-step"
procedure in which the incision and placement of the stent are
accomplished by a single device and operation. This desirably
allows for a faster, safer, and less expensive surgical procedure.
In any of the embodiments, fiducial markings, indicia, or the like
and/or positioning of the stent device in a preloaded applicator
may be used for proper orientation and alignment of the device
during implantation.
[0035] Among the advantages of trabecular bypass surgery is its
simplicity. The microsurgery may potentially be performed on an
outpatient basis with rapid visual recovery and greatly decreased
morbidity. There is a lower risk of infection and choroidal
hemorrhage, and there is a faster recovery, than with previous
techniques.
[0036] Some aspects of at least one of the inventions disclosed
herein relate to a medical device system for treating glaucoma of
an eye comprising using OCT (optical coherence tomography) as an
imaging and locating system for trabecular stent placement. In one
embodiment, the procedure would first be set up with triangulation
or some means to reliably establish the implant location in x, y,
and z coordinates by using OCT within a few microns, most
preferably in a non-invasive, non-contact manner. Having acquired
the target space or location, the trabecular stent device would
then be injected into place either via an ab interno procedure or
an ab externo procedure. An article by Hoerauf et al. (Greafe's
Arch Clin Exp Ophthalmol 2000; 238:8-18 published by
Springer-Verlag), entire contents of which are incorporated herein
by reference, discloses a slit-lamp adapted optical coherence
tomography of the anterior segment.
[0037] Some aspects of at least one of the inventions disclosed
herein relate to a `foldable` stent wherein the size of the stent
is reduced in order to place it through a yet smaller ocular
entrance wound, as small as half or less than the size of the
unfolded stent. The smallest size wound is important to aid in
recovery, to prevent complications, and to minimize the preparation
and extent of the surgical environment. In another embodiment, the
device is positioned through the trabecular meshwork in an ab
externo or ab interno procedure. Reliable visualization (OCT, UBM,
gonioscope, electromagnetic or other means) is a key enabler for
micro precision surgery such as a trabecular bypass surgery using a
microstent.
[0038] Some aspects of at least one of the inventions disclosed
herein relate to a medical device system with trephining
capability, wherein a cutting mechanism is on or as part of the
applicator for purposes of making the hole in trabecular meshwork
for stent insertion. In one aspect, a cutting tip may protrude
through the lumen of the stent. In another, the tip extends down
the side of the snorkel without entering the lumen. In still
another, the tip either passes through the lumen or down the side
and further extends to the tip of the stent that is the leading
edge during insertion. In one embodiment, the cutting tip can be
designed to retract after making the incision but before insertion
of the stent into Schlemm's canal if it interferes with the
insertion operation. It could also be retracted after insertion of
the stent into Schlemm's canal.
[0039] Some aspects of at least one of the inventions disclosed
herein provide an implant for treating glaucoma, the implant having
a longitudinal implant axis, and comprising an outflow portion
through which a portion of the longitudinal implant axis passes,
the outflow portion shaped and sized to be (a) introduced into
Schlemm's canal with the portion of the longitudinal implant axis
at an angle to Schlemm's canal; and (b) received with Schlemm's
canal regardless of the rotational orientation of the outflow
portion about the portion of the longitudinal implant axis during
the introduction; and an inflow portion in fluid communication with
the outflow portion, the inflow portion configured to permit
communication of fluid from the anterior chamber of the eye to the
outflow portion.
[0040] Some aspects of at least one of the inventions disclosed
herein provide an implant for treating glaucoma, comprising: an
outflow portion, sized and shaped to be received within Schlemm's
canal, the outflow portion comprising: an outflow portion base
having an outflow opening and at least one standoff member disposed
to space the outflow opening from a wall of Schlemm's canal, such
that the opening is unobstructed by the canal wall.
[0041] Some aspects of at least one of the inventions disclosed
herein provide an implant for treating glaucoma, the implant having
a longitudinal implant axis and comprising: a first portion at a
first end of the longitudinal implant axis, the first portion sized
and configured to reside in Schlemm's canal, such that the first
portion has a maximum dimension along a longitudinal axis of
Schlemm's canal that is not substantially greater than a dimension
of the first portion that runs perpendicular to both the
longitudinal axis of Schlemm's canal and to the longitudinal
implant axis; and a second portion at a second end of the
longitudinal implant axis, the second portion configured to provide
fluid communication between the anterior chamber and the first
portion.
[0042] Some aspects of at least one of the inventions disclosed
herein provide an implant for treating glaucoma, comprising: an
outflow portion, sized and shaped to be received within Schlemm's
canal; an inflow portion in fluid communication with the outflow
portion, the inflow portion configured to be disposed in the
anterior chamber of the eye; and a central portion extending
between the inflow and outflow portions; the outflow portion having
a diameter that is no more than three times the diameter of the
central portion.
[0043] In accordance with one embodiment of at least one of the
inventions disclosed herein, an implant for treating glaucoma is
provided. The implant includes a longitudinal implant axis, and
comprises an outflow portion through which said longitudinal
implant axis passes. The outflow portion is shaped and sized to be
introduced into Schlemm's canal with the portion of the
longitudinal implant axis at an angle to Schlemm's canal. The
outflow portion is also shaped and sized to be received within
Schlemm's canal regardless of a rotational orientation of the
outflow portion about said longitudinal implant axis during said
introduction. The implant also comprises an inflow portion
configured to permit communication of fluid from the anterior
chamber of the eye to the outflow portion.
[0044] In accordance with another embodiment of at least one of the
inventions disclosed herein, an implant for treating glaucoma is
provided. The implant comprises an outflow portion, sized and
shaped to be received within Schlemm's canal. The outflow portion
comprises an outflow portion base having an outflow opening and at
least one standoff member disposed to space said outflow opening
from a wall of Schlemm's canal, such that said outflow opening is
unobstructed by said canal wall.
[0045] In accordance with a further embodiment of at least one of
the inventions disclosed herein, an implant for treating glaucoma
is provided The implant includes a longitudinal implant axis and
comprises a first portion at a first end of said longitudinal
implant axis. The first portion is sized and configured to reside
in Schlemm's canal, such that said first portion has a maximum
dimension along a longitudinal axis of Schlemm's canal that is not
substantially greater than a dimension of the first portion that
runs perpendicular to both said longitudinal axis of Schlemm's
canal and to said longitudinal implant axis. A second portion at a
second end of said longitudinal implant axis is configured to
provide fluid communication between the anterior chamber and said
first portion.
[0046] In accordance with yet another embodiment of at least one of
the inventions disclosed herein, an implant for treating glaucoma
comprises an outflow portion, sized and shaped to be received
within Schlemm's canal. An inflow portion is in fluid communication
with said outflow portion, the inflow portion configured to be
disposed in the anterior chamber of the eye. A central portion
extending between the inflow and outflow portions. The outflow
portion having a diameter that is no more than three times the
diameter of the central portion.
[0047] In accordance with yet another embodiment of at least one of
the inventions disclosed herein, an instrument for delivering
implants for treating an ophthalmic condition is provided. The
instrument comprises an elongate body sized to be introduced into
an eye through an incision in the eye. A plurality of implants are
positioned in the elongate body. The elongate body further
comprises an actuator that serially dispenses the implants from the
elongate body for implanting in eye tissue.
[0048] In accordance with another embodiment of at least one of the
inventions disclosed herein, a method of implanting a plurality of
implants for treating glaucoma is provided. The method includes
inserting an instrument into an eye through an incision, utilizing
the instrument to deliver a first implant through a wall of
Schlemm's canal at a first location, and utilizing the instrument
to deliver a second implant through a wall of Schlemm's canal at a
second location, without removing the instrument from the eye
between the deliveries of said implants.
[0049] In accordance with yet another embodiment of at least one of
the inventions disclosed herein, a method of implanting a plurality
of implants for treating glaucoma is provided. The method includes
inserting an instrument into an eye through an incision, utilizing
the instrument to deliver a first implant through a wall of
Schlemm's canal at a first location, and utilizing the instrument
to deliver a second implant through a wall of Schlemm's canal at a
second location, wherein the locations are determined from
morphological data on collector channel locations.
[0050] In accordance with yet another embodiment of at least one of
the inventions disclosed herein, a method of implanting a plurality
of implants for treating glaucoma is provided. The method comprises
inserting an instrument into an eye through an incision, utilizing
the instrument to deliver a first implant through a wall of
Schlemm's canal at a first location, and utilizing said instrument
to deliver a second implant through a wall of Schlemm's canal at a
second location. The locations are determined by imaging collector
channel locations.
[0051] In accordance with a further embodiment of at least one of
the inventions disclosed herein, a method of implanting a plurality
of implants for treating glaucoma is provided. The method comprises
inserting an instrument into an eye through an incision, utilizing
the instrument to deliver a first implant through a wall of
Schlemm's canal at a first location, and utilizing said instrument
to deliver a second implant through a wall of Schlemm's canal at a
second location. The locations are angularly spaced along Schlemm's
canal by at least 20 degrees.
[0052] In accordance with yet another embodiment of at least one of
the inventions disclosed herein, a method of implanting a plurality
of implants for treating glaucoma is provided. The method comprises
inserting an instrument into an eye through an incision, utilizing
the instrument to deliver a first implant through a wall of
Schlemm's canal at a first location, utilizing the instrument to
deliver a second implant through a wall of Schlemm's canal at a
second location. The first and second locations are substantially
at collector channels.
[0053] In accordance with another embodiment of at least one of the
inventions disclosed herein, a method of implanting a plurality of
implants for treating glaucoma is provided. The method comprises
inserting an instrument into an eye through an incision, utilizing
the instrument to deliver a first implant through a wall of
Schlemm's canal at a first location, and utilizing said instrument
to deliver a second implant through a wall of Schlemm's canal at a
second location. The implants have different flow
characteristics.
[0054] In accordance with yet another embodiment of at least one of
the inventions disclosed herein, a method of implanting a plurality
of implants for treating glaucoma is provided. The method comprises
inserting an instrument into an eye through an incision, utilizing
the instrument to deliver a first implant into the posterior
segment of the eye, and utilizing the instrument to deliver a
second implant into the posterior segment of the eye at a second
location. The instrument is not removed from the eye between said
deliveries of the implants.
[0055] In accordance with a further embodiment of at least one of
the inventions disclosed herein, a method of implanting a plurality
of implants for treating glaucoma is provided. The method comprises
serially dispensing a plurality of preloaded implants from an
instrument into eye tissue at a respective plurality of locations
within the eye.
[0056] For purposes of summarizing, certain aspects, advantages and
novel features of the inventions disclosed herein have been
described herein above. Of course, it is to be understood that not
necessarily all such advantages may be achieved in accordance with
any particular embodiment. Thus, the inventions may be embodied or
carried out in a manner that achieves or optimizes one advantage or
group of advantages as taught or suggested herein without
necessarily achieving other advantages as may be taught or
suggested herein.
[0057] These and other embodiments of the inventions will become
apparent to those skilled in the art from the following detailed
description of exemplary embodiments having reference to the
attached figures, the inventions not being limited to any
particular preferred embodiment(s) disclosed.
BRIEF DESCRIPTION OF THE DRAWINGS
[0058] Certain preferred embodiments and modifications thereof will
become apparent to those skilled in the art from the detailed
description herein having reference to the figures that follow, of
which:
[0059] FIG. 1 is a coronal cross-sectional view of an eye;
[0060] FIG. 2 is an enlarged cross-sectional view of an anterior
chamber angle of the eye of FIG. 1 with a trabecular stent;
[0061] FIG. 3 is a schematic and partial sectional view of an eye
illustrating an implanted glaucoma stent in accordance with one
embodiment of at least one of the inventions disclosed herein;
[0062] FIG. 4 is a side elevational view of the stent of FIG.
3;
[0063] FIG. 5 is a top plan view of the stent of FIG. 3;
[0064] FIG. 6 is a bottom plan view of the stent of FIG. 3;
[0065] FIG. 7 is a front elevational view of the stent of FIG. 3
(along line 7-7 of FIG. 4);
[0066] FIG. 8 is a rear elevational view of the stent of FIG. 3
(along line 8-8 of FIG. 4);
[0067] FIG. 9 is an enlarged top plan view of a forward end of the
stent of FIG. 3;
[0068] FIG. 10 is a top plan view of a modification of an inlet end
of the stent of
[0069] FIG. 3;
[0070] FIG. 11 is a top plan view of another modification of the
inlet end of the stent of FIG. 3;
[0071] FIG. 12 is a top plan view of yet another modification of
the inlet end of the stent of FIG. 3;
[0072] FIG. 13 is a top plan view of still another modification of
the inlet end of the stent of FIG. 3;
[0073] FIG. 14 is schematic and partial sectional view of an eye
illustrating a modification of the implanted glaucoma stent of FIG.
3;
[0074] FIG. 15 is a schematic and partial sectional view of an eye
illustrating a further modification of the implanted glaucoma stent
of FIG. 3;
[0075] FIG. 16 is a side elevational view of yet another
modification of the glaucoma stent of FIG. 3;
[0076] FIG. 17 is a top plan view of the stent of FIG. 16;
[0077] FIG. 18 is a bottom plan view of the stent of FIG. 16;
[0078] FIG. 19 is a front elevational view along line 19-19 of FIG.
16;
[0079] FIG. 20 is a rear elevational view along line 20-20 of FIG.
16;
[0080] FIG. 21 is a side elevation view of still another
modification of the glaucoma stent of FIG. 3;
[0081] FIG. 22 is a top plan view of the stent of FIG. 21;
[0082] FIG. 23 is a bottom plan view of the stent of FIG. 21;
[0083] FIG. 24 is a front elevational view along line 24-24 of FIG.
21;
[0084] FIG. 25 is a rear elevational view along line 25-25 of FIG.
21;
[0085] FIG. 26 is a front elevational view of a modification of the
glaucoma stent illustrated in FIG. 3;
[0086] FIG. 27 is a right side elevational view of the stents
illustrated in FIG. 26 as viewed along the line 27-27;
[0087] FIG. 28 is a right side elevational view of the glaucoma
stent illustrated in FIG. 26, as viewed along the line 28-28;
[0088] FIG. 29 is a schematic and partial sectional view of an eye
illustrating a temporal implantation of a glaucoma stent using a
delivery apparatus having features and advantages in accordance
with at least one of the inventions disclosed herein;
[0089] FIG. 30 is an oblique elevational view of an articulating
arm stent delivery/retrieval apparatus having features and
advantages in accordance with an embodiment of at least one of the
inventions disclosed herein;
[0090] FIG. 31 is a schematic and partial sectional view of a
portion of an eye and illustrating an implantation of a glaucoma
stent using a delivery apparatus extending through the anterior
chamber of the eye;
[0091] FIG. 32 is a schematic and partial sectional view of a
Schlemm's canal and trabecular meshwork of an eye with another
glaucoma stent extending from the anterior chamber of the eye,
through the trabecular meshwork, and into a rear wall of the
Schlemm's canal;
[0092] FIG. 33 is an enlarged cross-sectional view of a distal
portion of the stent illustrated in FIG. 32;
[0093] FIG. 34 is a schematic and partial sectional view of the eye
of FIG. 32 and a side elevational view of a modification of the
stent illustrated in FIG. 32;
[0094] FIG. 35 is a schematic and partial sectional view of the eye
illustrated in FIG. 32, and a side elevational view of a
photomodification of the stent illustrated in FIG. 32;
[0095] FIG. 36 is a schematic and partial sectional view of the eye
illustrated in FIG. 32, and a side elevational view of another
modification of the stent of FIG. 32;
[0096] FIG. 37 is a schematic and partial sectional view of the eye
illustrated in FIG. 32, and a side elevational view of a further
modification of the implant illustrated in FIG. 32;
[0097] FIG. 38 is a schematic and partial sectional view of the eye
illustrated in FIG. 32 and a side elevational view of another
modification of the stent illustrated in FIG. 32;
[0098] FIG. 39 is a schematic and partial sectional view of the eye
illustrated in FIG. 32, and a side elevational view of the further
modification of the implant illustrated in FIG. 32;
[0099] FIG. 40 is a schematic and partial sectional view of the eye
illustrated in FIG. 32, and a side elevational view of yet another
modification of the stent illustrated in FIG. 32;
[0100] FIG. 41 is a schematic and partial sectional view of an eye
and the side elevational view of yet another modification of the
stent illustrated in FIG. 32;
[0101] FIG. 42 is a schematic and partial sectional view of the eye
illustrated in FIG. 32, and a side elevational view of yet another
modification of the implant illustrated in FIG. 32;
[0102] FIG. 43 is an enlarged schematic and partial cross-sectional
view of an anterior chamber angle of an eye having a valve stent
implanted therein;
[0103] FIG. 44 is an enlarged cross-sectional view of an anterior
chamber angle of an eye including an osmotic membrane device
implanted therein;
[0104] FIG. 45 is an enlarged cross-sectional view of an anterior
chamber angle of an eye illustrating an implantation of a glaucoma
stent using an ab externo procedure;
[0105] FIG. 46 is a schematic and partial sectional view of the eye
illustrated in FIG. 32 and a side elevational view of another
modification of the implant illustrated in FIG.
[0106] 32;
[0107] FIG. 47 is an enlarged schematic and partial sectional view
of the eye illustrated in FIG. 32 and including a drug release
device implanted therein;
[0108] FIG. 48 is a flow diagram illustrating a method for treating
glaucoma;
[0109] FIG. 49A is an enlarged schematic illustration showing an
anterior chamber, trabecular meshwork and a Schlemm's canal of an
eye and an oblique elevational view of yet another modification of
the stent illustrated in FIG. 32;
[0110] FIG. 49B is an oblique elevational view of a modification of
the stent illustrated in FIG. 49A;
[0111] FIG. 49C is a side elevational view of another modification
of the stent illustrated in FIG. 49A;
[0112] FIG. 50A is a cross-sectional view of the eye portion
showing anatomically the trabecular meshwork, Schlemm's canal and
one collector duct;
[0113] FIG. 50B is a cross-sectional view of FIG. 50A with a
portion of a stent mechanically inserted into one of the collector
ducts;
[0114] FIG. 51A is a side elevational view of a stent delivery
applicator with a steerable distal section for multiple stent
deployment;
[0115] FIG. 51B is a schematic and partial sectional view of the
distal section of the stent delivery applicator of FIG. 51A;
[0116] FIG. 51C is a cross-sectional view, section 1-1 of FIG.
51B;
[0117] FIG. 51D is an oblique side elevational view of the
steerable section of the delivery applicator illustrated in FIG.
51A and including an optional ultrasonically enabled distal
end;
[0118] FIG. 52A is a partial sectional and side elevational view of
a distal section of a modification of the stent delivery applicator
illustrated in FIG. 51A;
[0119] FIG. 52B is a partial sectional and side elevational view of
a distal section of the stent delivery applicator illustrated in
FIG. 51A having been inserted through a trabecular meshwork with
the stent disposed within the distal section;
[0120] FIG. 52C is a partial sectional and side elevational view of
a distal section of the stent delivery applicator illustrated in
FIG. 51A having been inserted through a trabecular meshwork and
after the sheath of the distal portion has been withdrawn;
[0121] FIG. 52D is a partial sectional and side elevational view of
a distal section of the stent delivery applicator illustrated in
FIG. 51A having been inserted through a trabecular meshwork, and
after the sheath and a cutting member have been withdrawn;
[0122] FIG. 53 is an oblique side elevational and partial sectional
view of a further modification of the stent illustrated in FIG.
32;
[0123] FIG. 54A is a sectional view of yet another modification of
the stent delivery applicator illustrated in FIG. 51A;
[0124] FIG. 54B is an enlarged sectional view of a distal end of
the applicator illustrated in FIG. 54A and including two implants
disposed over a trocar of the device, this portion being identified
by the circle 2-2 in FIG. 54A;
[0125] FIG. 54C is a sectional view of the applicator device taken
along section line 3-3 of FIG. 54A.
DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS
[0126] The preferred embodiments described herein relate
particularly to surgical and therapeutic treatment of glaucoma
through reduction of intraocular pressure and/or stimulation of the
trabecular meshwork tissue. While the description sets forth
various embodiment-specific details, it will be appreciated that
the description is illustrative only and should not be construed in
any way as limiting the invention. Furthermore, various
applications of the inventions disclosed herein, and modifications
thereto, which may occur to those who are skilled in the art, are
also encompassed by the general concepts described herein.
[0127] FIG. 1 is a cross-sectional view of an eye 10. FIG. 2 is an
enlarged sectional view of the eye showing the relative anatomical
locations of a trabecular meshwork 21, an anterior chamber 20, and
a Schlemm's canal 22. A sclera 11 is a thick collagenous tissue
which covers the entire eye 10 except a portion which is covered by
a cornea 12.
[0128] With reference to FIGS. 1 and 2, the cornea 12 is a thin
transparent tissue that focuses and transmits light into the eye
and through a pupil 14, which is a circular hole in the center of
an iris 13 (colored portion of the eye). The cornea 12 merges into
the sclera 11 at a juncture referred to as a limbus 15. A ciliary
body 16 extends along the interior of the sclera 11 and is
coextensive with a choroid 17. The choroid 17 is a vascular layer
of the eye 10, located between the sclera 11 and a retina 18. An
optic nerve 19 transmits visual information to the brain and is the
anatomic structure that is progressively destroyed by glaucoma.
[0129] With continued reference to FIGS. 1 and 2, the anterior
chamber 20 of the eye 10, which is bound anteriorly by the cornea
12 and posteriorly by the iris 13 and a lens 26, is filled with
aqueous humor (hereinafter referred to as "aqueous"). Aqueous is
produced primarily by the ciliary body 16, then moves anteriorly
through the pupil 14 and reaches an anterior chamber angle 25,
formed between the iris 13 and the cornea 12.
[0130] As best illustrated by the drawing of FIG. 2, in a normal
eye, aqueous is removed from the anterior chamber 20 through the
trabecular meshwork 21. Aqueous passes through the trabecular
meshwork 21 into Schlemm's canal 22 and thereafter through a
plurality of collector ducts and aqueous veins 23, which merge with
blood-carrying veins, and into systemic venous circulation.
Intraocular pressure is maintained by an intricate balance between
secretion and outflow of aqueous in the manner described above.
Glaucoma is, in most cases, characterized by an excessive buildup
of aqueous in the anterior chamber 20 which leads to an increase in
intraocular pressure. Fluids are relatively incompressible, and
thus intraocular pressure is distributed relatively uniformly
throughout the eye 10.
[0131] As shown in FIG. 2, the trabecular meshwork 21 is adjacent a
small portion of the sclera 11. Exterior to the sclera 11 is a
conjunctiva 24. Traditional procedures that create a hole or
opening for implanting a device through the tissues of the
conjunctiva 24 and sclera 11 involve extensive surgery, as compared
to surgery for implanting a device, as described herein, which
ultimately resides entirely within the confines of the sclera 11
and cornea 12. A trabecular stent 229 can be placed bypassing the
trabecular meshwork 21 with a proximal terminal 227 exposed to
anterior chamber 20 and a distal terminal 228 exposed to Schlemm's
canal 22.
[0132] FIG. 3 schematically illustrates the use of one embodiment
of a trabecular stenting device 30 for establishing an outflow
pathway, passing through the trabecular meshwork 21, described in
greater detail below. FIGS. 4-9 are different views of the stent
30. Advantageously, and as discussed in further detail later
herein, the self-trephining-stent allows a one-step procedure to
make an incision in the trabecular mesh 21 and place the stent or
implant 30 at the desired or predetermined position within the eye
10. Desirably, this facilitates and simplifies the overall surgical
procedure.
[0133] In the illustrated embodiment of FIGS. 3-9, the shunt or
stent 30 generally comprises an inlet portion or "snorkel" 32 and a
main body portion or blade 34. The snorkel 32 and blade 34 are
mechanically connected to or in mechanical communication with one
another. A generally longitudinal axis 36 extends along the stent
30 and/or the body portion 34.
[0134] In the illustrated embodiment of FIGS. 3-9, the stent 30
comprises an integral unit. In modified embodiments, the stent 30
may comprise an assembly of individual pieces or components. For
example, the stent 30 may comprise an assembly of the snorkel 32
and blade 34.
[0135] In the illustrated embodiment of FIGS. 3-9, the snorkel 32
is in the form of a generally elongate tubular member and generally
comprises an upper seat, head or cap portion 38, a shank portion 40
and a lumen or passage 42 extending therethrough. The seat 38 is
mechanically connected to or in mechanical communication with the
shank 40 which is also mechanically connected to or in mechanical
communication with the blade 34. longitudinal axis 43 extends along
the snorkel 32 and/or the lumen 42.
[0136] In the illustrated embodiment of FIGS. 3-9, the seat 38 is
generally circular in shape and has an upper surface 44 and a lower
surface 46 which, as shown in FIG. 3, abuts or rests against the
trabecular meshwork 21 to stabilize the glaucoma stent 30 within
the eye 10. In modified embodiments, the seat 38 may efficaciously
be shaped in other suitable manners, as required or desired, giving
due consideration to the goals of stabilizing the glaucoma stent 30
within the eye 10 and/or of achieving one or more of the benefits
and advantages as taught or suggested herein. For example, the seat
38 may be shaped in other polygonal or non-polygonal shapes and/or
comprise one or more ridges which extend radially outwards, among
other suitable retention devices.
[0137] In the illustrated embodiment of FIGS. 3-9, and as best seen
in the top view of FIG. 5, the seat top surface 44 comprises
fiducial marks or indicia 48. These marks or indicia 48 facilitate
and ensure proper orientation and alignment of the stent 30 when
implanted in the eye 10. The marks or indicia 48 may comprise
visual differentiation means such as color contrast or be in the
form of ribs, grooves, or the like. Alternatively, or in addition,
the marks 48 may provide tactile sensory feedback to the surgeon by
incorporating a radiopaque detectable or ultrasound imaginable
substrate at about the mark 48. Also, the seat 38 and/or the seat
top surface 44 may be configured in predetermined shapes aligned
with the blade 34 and/or longitudinal axis 36 to provide for proper
orientation of the stent device 30 within the eye 10. For example,
the seat top surface 44 may be oval or ellipsoidal (FIG. 10),
rectangular (FIG. 11), hexagonal (FIG. 12), among other suitable
shapes (e.g. FIG. 13).
[0138] In the illustrated embodiment of FIGS. 3-9, and as indicated
above, the seat bottom surface 46 abuts or rests against the
trabecular meshwork 21 to stabilize and retain the glaucoma stent
30 within the eye 10. For stabilization purposes, the seat bottom
surface 46 may comprise a studded surface, a ribbed surface, a
surface with pillars, a textured surface, or the like.
[0139] In the illustrated embodiment of FIGS. 3-9, the snorkel
shank 40 is generally cylindrical in shape. With the stent 30
implanted, as shown in FIG. 3, the shank 40 is generally positioned
in an incision or cavity 50 formed in the trabecular meshwork 21 by
the self-trephining stent 30. Advantageously, and as discussed
further below, this single step of forming the cavity 50 by the
stent 30 itself and placing the stent 30 in the desired position
facilitates and expedites the overall surgical procedure. In
modified embodiments, the snorkel shank 40 may efficaciously be
shaped in other suitable manners, as required or desired. For
example, the shank 40 may be in the shape of other polygonal or
non-polygonal shapes, such as, oval, ellipsoidal, and the like.
[0140] In the illustrated embodiment of FIGS. 3-9, and as best seen
in FIG. 3, the shank 40 has an outer surface 52 in contact with the
trabecular meshwork 21 surrounding the cavity 50. For stabilization
purposes, the shank outer surface 52 may comprise a studded
surface, a ribbed surface, a surface with pillars, a textured
surface, or the like.
[0141] In the illustrated embodiment of FIGS. 3-9, the snorkel
lumen 42 has an inlet port, opening or orifice 54 at the seat top
surface 44 and an outlet port, opening or orifice 56 at the
junction of the shank 40 and blade 34. The lumen 42 is generally
cylindrical in shape, that is, it has a generally circular
cross-section, and its ports 54, 56 are generally circular in
shape. In modified embodiments, the lumen 42 and ports 54, 56 may
be efficaciously shaped in other manners, as required or desired,
giving due consideration to the goals of providing sufficient
aqueous outflow and/or of achieving one or more of the benefits and
advantages as taught or suggested herein. For example, the lumen 42
and/or one or both ports 54, 56 may be shaped in the form of ovals,
ellipsoids, and the like, or the lumen 42 may have a tapered or
stepped configuration.
[0142] Referring in particular to FIG. 3, aqueous from the anterior
chamber 20 flows into the lumen 42 through the inlet port 54 (as
generally indicated by arrow 58) and out of the outlet port 56 and
into Schlemm's canal 22 (as generally indicated by arrows 60) to
lower and/or balance the intraocular pressure (IOP). In another
embodiment, as discussed in further detail below, one or more of
the outlet ports may be configured to face in the general direction
of the stent longitudinal axis 36. In modified embodiments, the
snorkel 32 may comprise more than one lumen, as needed or desired,
to facilitate multiple aqueous outflow transportation into
Schlemm's canal 22.
[0143] In the illustrated embodiment of FIGS. 3-9, the blade
longitudinal axis 36 and the snorkel longitudinal axis 43 are
generally perpendicular to one another. Stated differently, the
projections of the axes 36, 43 on a common plane which is not
perpendicular to either of the axes 36, 43 intersect at 90.degree..
The blade longitudinal axis 36 and the snorkel longitudinal axis 43
may intersect one another or may be offset from one another.
[0144] In the illustrated embodiment of FIGS. 3-9, the main body
portion or blade 34 is a generally curved elongated sheet- or
plate-like structure with an upper curved surface 62 and a lower
curved surface 64 which defines a trough or open face channel 66.
The perimeter of the blade 34 is generally defined by a curved
proximal edge 68 proximate to the snorkel 32, a curved distal edge
70 spaced from the proximal edge 68 by a pair of generally straight
lateral edges 72, 74. The first lateral edge 72 extends beyond the
second lateral edge 74 and intersects with the distal edge 70 at a
distal-most point 76 of the blade 34. Preferably, the blade 34
defines a blade cutting tip 78.
[0145] In the illustrated embodiment of FIGS. 3-9, and as shown in
the enlarged view of FIG. 9, the cutting tip 78 comprises a first
cutting edge 80 on the distal edge 70 and a second cutting edge 82
on the lateral edge 72. The cutting edges 80, 82 preferably extend
from the distal-most point 76 of the blade 34 and comprise at least
a respective portion of the distal edge 70 and lateral edge 72. The
respective cutting edges 80, 82 are formed at the sharp edges of
respective beveled or tapered surfaces 84, 86. In one embodiment,
the remainder of the distal edge 70 and lateral edge 72 are dull or
rounded. In one embodiment, the tip 78 proximate to the distal-most
end 76 is curved slightly inwards, as indicated generally by the
arrow 88 in FIG. 5 and arrow 88 (pointed perpendicular and into the
plane of the paper) in FIG. 9, relative to the adjacent curvature
of the blade 34.
[0146] In modified embodiments, suitable cutting edges may be
provided on selected portions of one or more selected blade edges
68, 70, 72, 74 with efficacy, as needed or desired, giving due
consideration to the goals of providing suitable cutting means on
the stent 30 for effectively cutting through the trabecular
meshwork 21 (FIG. 3) and/or of achieving one or more of the
benefits and advantages as taught or suggested herein.
[0147] Referring in particular to FIG. 9, in one embodiment, the
ratio between the lengths of the cutting edges 80, 82 is about 2:1.
In another embodiment, the ratio between the lengths of the cutting
edges 80, 82 is about 1:1. In yet another embodiment, the ratio
between the lengths of the cutting edges 80, 82 is about 1:2. In
modified embodiments, the lengths of the cutting edges 80, 82 may
be efficaciously selected in other manners, as required or desired,
giving due consideration to the goals of providing suitable cutting
means on the stent 30 for effectively cutting through the
trabecular meshwork 21 (FIG. 3) and/or of achieving one or more of
the benefits and advantages as taught or suggested herein.
[0148] Still referring in particular to FIG. 9, in one embodiment,
the ratio between the lengths of the cutting edges 80, 82 is in the
range from about 2:1 to about 1:2. In another embodiment, the ratio
between the lengths of the cutting edges 80, 82 is in the range
from about 5:1 to about 1:5. In yet another embodiment, the ratio
between the lengths of the cutting edges 80, 82 is in the range
from about 10:1 to about 1:10. In modified embodiments, the lengths
of the cutting edges 80, 82 may be efficaciously selected in other
manners, as required or desired, giving due consideration to the
goals of providing suitable cutting means on the stent 30 for
effectively cutting through the trabecular meshwork 21 (FIG. 3)
and/or of achieving one or more of the benefits and advantages as
taught or suggested herein.
[0149] As shown in the top view of FIG. 9, the cutting edge 80
(and/or the distal end 70) and the cutting edge 82 (and/or the
lateral edge 72) intersect at an angle .theta.. Stated differently,
.theta. is the angle between the projections of the cutting edge 80
(and/or the distal end 70) and the cutting edge 82 (and/or the
lateral edge 72) on a common plane which is not perpendicular to
either of these edges.
[0150] Referring to in particular to FIG. 9, in one embodiment, the
angle .theta. is about 50.degree.. In another embodiment, the angle
.theta. is in the range from about 40.degree. to about 60.degree..
In yet another embodiment, the angle .theta. is in the range from
about 30.degree. to about 70.degree.. In modified embodiments, the
angle .theta. may be efficaciously selected in other manners, as
required or desired, giving due consideration to the goals of
providing suitable cutting means on the stent 30 for effectively
cutting through the trabecular meshwork 21 (FIG. 3) and/or of
achieving one or more of the benefits and advantages as taught or
suggested herein.
[0151] The stent 30 of the embodiments disclosed herein can be
dimensioned in a wide variety of manners. Referring in particular
to FIG. 3, the depth of Schlemm's canal 22 is typically about less
than 400 microns (.mu.m). Accordingly, the stunt blade 34 is
dimensioned so that the height of the blade 34 (referred to as H41
in FIG. 4) is typically less than about 400 .mu.m. The snorkel
shank 40 is dimensioned so that it has a length (referred to as
L.sub.41 in FIG. 4) typically in the range from about 150 .mu.m to
about 400 .mu.m which is roughly the typical range of the thickness
of the trabecular meshwork 21.
[0152] Of course, as the skilled artisan will appreciate, that with
the stent 30 implanted, the blade 34 may rest at any suitable
position within Schlemm's canal 22. For example, the blade 34 may
be adjacent to a front wall 90 of Schlemm's canal 22 (as shown in
FIG. 3), or adjacent to a back wall 92 of Schlemm's canal 22, or at
some intermediate location therebetween, as needed or desired.
Also, the snorkel shank 40 may extend into Schlemm's canal 22. The
length of the snorkel shank 40 and/or the dimensions of the blade
34 may be efficaciously adjusted to achieve the desired implant
positioning.
[0153] The trabecular stenting device 30 (FIGS. 3-9) of the
exemplary embodiment may be manufactured or fabricated by a wide
variety of techniques. These include, without limitation, molding,
thermo-forming, or other micro-machining techniques, among other
suitable techniques.
[0154] The trabecular stenting device 30 preferably comprises a
biocompatible material such that inflammation arising due to
irritation between the outer surface of the device 30 and the
surrounding tissue is minimized. Biocompatible materials which may
be used for the device 30 preferably include, but are not limited
to, titanium, titanium alloys, medical grade silicone, e.g.,
Silastic.TM., available from Dow Coming Corporation of Midland,
Mich.; and polyurethane, e.g., Pellethane.TM., also available from
Dow Corning Corporation.
[0155] In other embodiments, the stent device 30 may comprise other
types of biocompatible material, such as, by way of example,
polyvinyl alcohol, polyvinyl pyrolidone, collagen, heparinized
collagen, polytetrafluoroethylene, expanded
polytetrafluoroethylene, fluorinated polymer, fluorinated
elastomer, flexible fused silica, polyolefin, polyester,
polysilicon, and/or a mixture of the aforementioned biocompatible
materials, and the like. In still other embodiments, composite
biocompatible material may be used, wherein a surface material may
be used in addition to one or more of the aforementioned materials.
For example, such a surface material may include
polytetrafluoroethylene (PTFE) (such as Teflon.TM.), polyimide,
hydrogel, heparin, therapeutic drugs (such as beta-adrenergic
antagonists and other anti-glaucoma drugs, or antibiotics), and the
like.
[0156] In an exemplary embodiment of the trabecular meshwork
surgery, the patient is placed in the supine position, prepped,
draped and anesthetized as necessary. A small (less than about 1
mm) incision, which may be self sealing can then be made through
the cornea 12. The corneal incision can be made in a number of
ways, for example, by using a micro-knife, among other tools.
[0157] An applicator or delivery apparatus is used to advance the
glaucoma stent 30 through the corneal incision and to the
trabecular meshwork 21. Some embodiments of such a delivery
apparatus are disclosed in copending U.S. application Ser. No.
10/101,548, filed Mar. 18, 2002, entitled APPLICATOR AND METHODS
FOR PLACING A TRABECULAR SHUNT FOR GLAUCOMA TREATMENT, and U.S.
Provisional Application No. 60/276,609, filed Mar. 16, 2001,
entitled APPLICATOR AND METHODS FOR PLACING A TRABECULAR SHUNT FOR
GLAUCOMA TREATMENT, the entire contents of each one of which are
hereby incorporated by reference herein. Some embodiments of a
delivery apparatus are also described in further detail below.
Gonioscopic, microscopic, or endoscopic guidance can be used during
the trabecular meshwork surgery.
[0158] With the device 30 held by the delivery apparatus, the blade
34 of the device 30 is used to cut and/or displace the material of
the trabecular meshwork 21. The snorkel shank 40 can also
facilitate in removal of this material during implantation. The
delivery apparatus is withdrawn once the device 30 has been
implanted in the eye 10. As shown in FIG. 3, the snorkel seat 38
can rest on a top surface 94 of the trabecular meshwork 21 with the
snorkel shank 40 extending through the cavity 50 (created by the
device 30) in the trabecular meshwork 21, and with the blade 34
extending inside Schlemm's canal 22.
[0159] Advantageously, the embodiments of the self-trephining stent
device 30 allow for a "one-step" procedure to make an incision in
the trabecular meshwork and to implant the stent in the proper
orientation and alignment within the eye to allow outflow of
aqueous from the anterior chamber through the stent and into
Schlemm's canal to lower and/or balance the intraocular pressure
(IOP). Desirably, this provides for a faster, safer, and less
expensive surgical procedure.
[0160] Many complications can arise in trabecular meshwork
surgeries, wherein a knife is first used to create an incision in
the trabecular meshwork, followed by removal of the knife and
subsequent installation of the stent. For instance, the knife may
cause some bleeding which clouds up the surgical site. This may
require more effort and time to clean the surgical site prior to
placement of the stent. Moreover, this may cause the intraocular
pressure (IOP) to rise or to fall undesirably. Thus, undesirably,
such a multiple step procedure may demand crisis management which
slows down the surgery, makes it less safe, and more expensive.
[0161] FIG. 14 is a simplified partial view of an eye 10
illustrating the implantation of a self-trephining glaucoma stent
device 30a having features and advantages in accordance with one
embodiment. The stent 30a is generally similar to the stent 30 of
FIGS. 3-9 except that its snorkel 32a comprises a longer shank 40a
which extends into Schlemm's canal 22 and a lumen 42a which
bifurcates into two output channels 45a.
[0162] In the illustrated embodiment of FIG. 14, the shank 40a
terminates at the blade 34. Aqueous flows from the anterior chamber
20 into the lumen 42a through an inlet port 54a (as generally
indicated by arrow 58a). Aqueous then flows through the output
channels 45a and out of respective outlet ports 56a and into
Schlemm's canal 22 (as generally indicated by arrows 60a). The
outlet channels 45a extend radially outwards in generally opposed
directions and the outlet ports 56a are configured to face in the
general direction of the stent longitudinal axis 36 so that they
open into Schlemm's canal 22 and are in proper orientation to allow
aqueous outflow into Schlemm's canal 22 for lowering and/or
balancing the intraocular pressure (IOP). As indicated above,
fiducial marks or indicia and/or predetermined shapes of the
snorkel seat 38 allow for proper orientation of the blade 34 and
also the output channels 45a and respective ports 56a within
Schlemm's canal.
[0163] In the illustrated embodiment of FIG. 14, two outflow
channels 45a are provided. In another embodiment, only one outflow
channel 45a is provided. In yet another embodiment, more than two
outflow channels 45a are provided. In modified embodiments, the
lumen 42a may extend all the way through to the blade 34 and
provide an outlet port as discussed above with reference to the
embodiment of FIGS. 3-9.
[0164] FIG. 15 is a simplified partial view of an eye 10
illustrating the implantation of a self-trephining glaucoma stent
device 30b having features and advantages in accordance with one
embodiment. The stent 30b is generally similar to the stent 30 of
FIGS. 3-9 except that its snorkel 32b comprises a longer shank 40b
which extends into Schlemm's canal 22 and a lumen 42b which
bifurcates into two output channels 45b.
[0165] In the illustrated embodiment of FIG. 15, the shank 40b
extends through the blade 34. Aqueous flows from the anterior
chamber 20 into the lumen 42b through an inlet port 54b (as
generally indicated by arrow 58b). Aqueous then flows through the
output channels 45b and out of respective outlet ports 56b and into
Schlemm's canal 22 (as generally indicated by arrows 60b). The
outlet channels 45b extend radially outwards in generally opposed
directions and the outlet ports 56b are configured to face in the
general direction of the stent longitudinal axis 36 so that they
open into Schlemm's canal 22 and are in proper orientation to allow
aqueous outflow into Schlemm's canal 22 for lowering and/or
balancing the intraocular pressure (IOP). As indicated above,
fiducial marks or indicia and/or predetermined shapes of the
snorkel seat 38 allow for proper orientation of the blade 34 and
also the output channels 45b and respective ports 56b within
Schlemm's canal.
[0166] In the illustrated embodiment of FIG. 15, two outflow
channels 45b are provided. In another embodiment, only one outflow
channel 45b is provided. In yet another embodiment, more than two
outflow channels 45b are provided. In modified embodiments, the
lumen 42b may extend all the way through to the blade 34 and
provide an outlet port as discussed above with reference to the
embodiment of FIGS. 3-9.
[0167] FIGS. 16-20 show different views of a self-trephining
glaucoma stent device 30c having features and advantages in
accordance with one embodiment. The stent 30c is generally similar
to the stent 30 of FIGS. 3-9 except that it has a modified blade
configuration. The stent 30c comprises a blade 34c which is a
generally curved elongated sheet- or plate-like structure with an
upper curved surface 62c and a lower curved surface 64c which
defines a trough or open face channel 66c. The perimeter of the
blade 34c is generally defined by a curved proximal edge 68c
proximate to the snorkel 32, a curved distal edge 70c spaced from
the proximal edge 68c by a pair of generally straight lateral edges
72c, 74c which are generally parallel to one another and have about
the same length.
[0168] In the illustrated embodiment of FIGS. 16-20, the blade 34c
comprises a cutting tip 78c. The cutting tip 78c preferably
includes cutting edges formed on selected portions of the distal
edge 70c and adjacent portions of the lateral edges 72c, 74c for
cutting through the trabecular meshwork for placement of the
snorkel 32. The cutting edges are sharp edges of beveled or tapered
surfaces as discussed above in reference to FIG. 9. The embodiment
of FIGS. 16-20 may be efficaciously modified to incorporate the
snorkel configuration of the embodiments of FIGS. 14 and 15.
[0169] FIGS. 21-25 show different views of a self-trephining
glaucoma stent device 30d having features and advantages in
accordance with one embodiment. The stent 30d is generally similar
to the stent 30 of FIGS. 3-9 except that it has a modified blade
configuration. The stent 30d comprises a blade 34d which is a
generally curved elongated sheet- or plate-like structure with an
upper curved surface 62d and a lower curved surface 64d which
defines a trough or open face channel 66d. The perimeter of the
blade 34d is generally defined by a curved proximal edge 68d
proximate to the snorkel 32, a pair of inwardly converging curved
distal edges 70d', 70d'' spaced from the proximal edge 68d by a
pair of generally straight respective lateral edges 72d, 74d which
are generally parallel to one another and have about the same
length. The distal edges 70d', 70d'' intersect at a distal-most
point 76d of the blade 34d proximate a blade cutting tip 78d.
[0170] In the illustrated embodiment of FIGS. 21-25, the cutting
tip 78d preferably includes cutting edges formed on the distal
edges 70d', 70d'' and extending from the distal-most point 76d of
the blade 34d. In one embodiment, the cutting edges extend along
only a portion of respective distal edges 70d', 70d.'' In another
embodiment, the cutting edges extend along substantially the entire
length of respective distal edges 70d', 70d.'' In yet another
embodiment, at least portions of the lateral edges 72d, 74d
proximate to respective distal edges 70d', 70d'' have cutting
edges. In a further embodiment, the tip 78d proximate to the
distal-most end 76d is curved slightly inwards, as indicated
generally by the arrow 88d in FIG. 21 and arrow 88d (pointed
perpendicular and into the plane of the paper) in FIG. 22, relative
to the adjacent curvature of the blade 34d.
[0171] In the embodiment of FIGS. 21-25, the cutting edges are
sharp edges of beveled or tapered surfaces as discussed above in
reference to FIG. 9. The embodiment of FIGS. 21-25 may be
efficaciously modified to incorporate the snorkel configuration of
the embodiments of FIGS. 14 and 15.
[0172] FIGS. 26-28 show different views of a self-trephining
glaucoma stent device 30e having features and advantages in
accordance with one embodiment. The stent device 30e generally
comprises a snorkel 32e mechanically connected to or in mechanical
communication with a blade or cutting tip 34e. The snorkel 32e has
a seat, head or cap portion 38e mechanically connected to or in
mechanical communication with a shank 40e, as discussed above. The
shank 40e has a distal end or base 47e. The snorkel 32e further has
a lumen 42e which bifurcates into a pair of outlet channels 45e, as
discussed above in connection with FIGS. 14 and 15. Other lumen and
inlet and outlet port configurations as taught or suggested herein
may also be efficaciously used, as needed or desired.
[0173] In the illustrated embodiment of FIGS. 26-28, the blade 34e
extends downwardly and outwardly from the shank distal end 47e. The
blade 34e is angled relative to a generally longitudinal axis 43e
of the snorkel 32e, as best seen in FIGS. 27 and 28. The blade 34e
has a distal-most point 76e. The blade or cutting tip 34e has a
pair of side edges 70e', 70e,'' including cutting edges,
terminating at the distal-most point 76e, as best seen in FIG. 26.
In one embodiment, the cutting edges are sharp edges of beveled or
tapered surfaces as discussed above in reference to FIG. 9.
[0174] Referring to FIGS. 26-28, in one embodiment, the blade 34e
includes cutting edges formed on the edges 70e', 70e'' and
extending from the distal-most point 76e of the blade 34d. In one
embodiment, the cutting edges extend along only a portion of
respective distal edges 70e', 70e.'' In another embodiment, the
cutting edges extend along substantially the entire length of
respective distal edges 70e', 70e.'' In yet another embodiment, the
blade or cutting tip 34e comprises a bent tip of needle, for
example, a 30 gauge needle.
[0175] In general, any of the blade configurations disclosed herein
may be used in conjunction with any of the snorkel configurations
disclosed herein or incorporated by reference herein to provide a
self-trephining glaucoma stent device for making an incision in the
trabecular meshwork for receiving the corresponding snorkel to
provide a pathway for aqueous outflow from the eye anterior chamber
to Schlemm's canal, thereby effectively lowering and/or balancing
the intraocular pressure (IOP). The self-trephining ability of the
device, advantageously, allows for a "one-step" procedure in which
the incision and placement of the snorkel are accomplished by a
single device and operation. In any of the embodiments, fiducial
markings or indicia, and/or preselected configuration of the
snorkel seat, and/or positioning of the stent device in a preloaded
applicator may be used for proper orientation and alignment of the
device during implantation.
[0176] In many cases, a surgeon works from a temporal incision when
performing cataract or goniometry surgery. FIG. 29 illustrates a
temporal implant procedure, wherein a delivery apparatus or
"applicator" 100 having a curved tip 102 is used to deliver a stent
30 to a temporal side 27 of the eye 10. An incision 28 is made in
the cornea 10, as discussed above. The apparatus 100 is then used
to introduce the stent 30 through the incision 28 and implant it
within the eye 10.
[0177] Still referring in particular to FIG. 29, in one embodiment,
a similarly curved instrument would be used to make the incision
through the trabecular meshwork 21. In other embodiments, a
self-trephining stent device 30 may be used to make this incision
through the trabecular meshwork 21, as discussed above. The
temporal implantation procedure illustrated in FIG. 29 may be
employed with the any of the various stent embodiments taught or
suggested herein.
[0178] FIG. 30 illustrates one embodiment of an apparatus
comprising an articulating stent applicator or retrieval device
100a. In this embodiment, a proximal arm 106 is attached to a
distal arm 108 at a joint 112. This joint 112 is movable such that
an angle formed between the proximal arm 106 and the distal arm 108
can change. One or more claws 114 can extend from the distal arm
108, in the case of a stent retrieval device. Similarly, this
articulation mechanism may be used for the trabecular stent
applicator, and thus the articulating applicator or retrieval
device 100a may be either an applicator for the trabecular stent, a
retrieval device, or both, in various embodiments. The embodiment
of FIG. 30 may be employed with the any of the various stent
embodiments taught or suggested herein.
[0179] FIG. 31 shows another illustrative method for placing any of
the various stent embodiments taught or suggested herein at the
implant site within the eye 10. A delivery apparatus 100b generally
comprises a syringe portion 116 and a cannula portion 118. The
distal section of the cannula 118 has at least one irrigating hole
120 and a distal space 122 for holding the stent device 30. The
proximal end 124 of the lumen of the distal space 122 is sealed
from the remaining lumen of the cannula portion 118. The delivery
apparatus of FIG. 30 may be employed with the any of the various
stent embodiments taught or suggested herein.
[0180] In one aspect of the invention, a delivery apparatus (or
"applicator") is used for placing a trabecular stent through a
trabecular meshwork of an eye. Certain embodiments of such a
delivery apparatus are disclosed in copending U.S. application Ser.
No. 10/101,548, filed Mar. 18, 2002, entitled APPLICATOR AND
METHODS FOR PLACING A TRABECULAR SHUNT FOR GLAUCOMA TREATMENT, and
U.S. Provisional Application No. 60/276,609, filed Mar. 16, 2001,
entitled APPLICATOR AND METHODS FOR PLACING A TRABECULAR SHUNT FOR
GLAUCOMA TREATMENT, the entire contents of each one of which are
hereby incorporated by reference herein.
[0181] The stent has an inlet section and an outlet section. The
delivery apparatus includes a handpiece, an elongate tip, a holder
and an actuator. The handpiece has a distal end and a proximal end.
The elongate tip is connected to the distal end of the handpiece.
The elongate tip has a distal portion and is configured to be
placed through a corneal incision and into an anterior chamber of
the eye. The holder is attached to the distal portion of the
elongate tip. The holder is configured to hold and release the
inlet section of the trabecular stent. The actuator is on the
handpiece and actuates the holder to release the inlet section of
the trabecular stent from the holder. When the trabecular stent is
deployed from the delivery apparatus into the eye, the outlet
section is positioned in substantially opposite directions inside
Schlemm's canal. In one embodiment, a deployment mechanism within
the delivery apparatus includes a push-pull type plunger.
[0182] In some embodiments, the holder comprises a clamp. In some
embodiments, the apparatus further comprises a spring within the
handpiece that is configured to be loaded when the stent is being
held by the holder, the spring being at least partially unloaded
upon actuating the actuator, allowing for release of the stent from
the holder.
[0183] In various embodiments, the clamp comprises a plurality of
claws configured to exert a clamping force onto the inlet section
of the stent. The holder may also comprise a plurality of
flanges.
[0184] In some embodiments, the distal portion of the elongate tip
is made of a flexible material. This can be a flexible wire. The
distal portion can have a deflection range, preferably of about 45
degrees from the long axis of the handpiece.
[0185] The delivery apparatus can further comprise an irrigation
port in the elongate tip.
[0186] Some aspects include a method of placing a trabecular stent
through a trabecular meshwork of an eye, the stent having an inlet
section and an outlet section, including advancing a delivery
apparatus holding the trabecular stent through an anterior chamber
of the eye and into the trabecular meshwork, placing part of the
stent through the trabecular meshwork and into a Schlemm's canal of
the eye; and releasing the stent from the delivery apparatus.
[0187] In various embodiments, the method includes using a delivery
apparatus that comprises a handpiece having a distal end and a
proximal end; an elongate tip connected to the distal end of the
handpiece, the elongate tip having a distal portion and being
configured to be placed through a corneal incision and into an
anterior chamber of the eye; a holder attached to the distal
portion of the elongate tip, the holder configured to hold and
release the inlet section of the trabecular stent; and an actuator
on the handpiece that actuates the holder to release the inlet
section of the trabecular stent from the holder.
[0188] In one aspect, the trabecular stent is removably attached to
a delivery apparatus (also known as "applicator"). When the
trabecular stent is deployed from the delivery apparatus into the
eye, the outlet section is positioned in substantially opposite
directions inside Schlemm's canal. In one embodiment, a deployment
mechanism within the delivery apparatus includes a push-pull type
plunger. In some embodiments, the delivery applicator may be a
guidewire, an expandable basket, an inflatable balloon, or the
like.
Screw/Barb Anchored Stent
[0189] FIGS. 32 and 33 illustrate a glaucoma stent device 30f
having features and advantages in accordance with one embodiment.
This embodiment of the trabecular stent 30f includes a barbed or
threaded screw-like extension or pin 126 with barbs 128 for
anchoring. The barbed pin 126 extends from a distal or base portion
130 of the stent 30f.
[0190] In use, the stent 30f (FIG. 32) is advanced through the
trabecular meshwork 21 and across Schlemm's canal 22. The barbed
(or threaded) extension 126 penetrates into the back wall 92 of
Schlemm's canal 22 up to the shoulder or base 130 that then rests
on the back wall 92 of the canal 22. The combination of a shoulder
130 and a barbed pin 126 of a particular length limits the
penetration depth of the barbed pin 126 to a predetermined or
preselected distance. In one embodiment, the length of the pin 126
is about 0.5 mm or less. Advantageously, this barbed configuration
provides a secure anchoring of the stent 30f. As discussed above,
correct orientation of the stent 30f is ensured by appropriate
fiducial marks, indicia or the like and by positioning of the stent
in a preloaded applicator.
[0191] Referring to FIG. 32, the aqueous flows from the anterior
chamber 20, through the lumen 42f, then out through two side-ports
56f to be directed in both directions along Schlemm's canal 22.
Alternatively, flow could be directed in only one direction through
a single side-port 56f. In other embodiments, more then two outlet
ports 56f, for example, six to eight ports (like a pin wheel
configuration), may be efficaciously used, as needed or
desired.
[0192] Still referring to FIG. 32, in one embodiment, the stent 30f
is inserted through a previously made incision in the trabecular
meshwork 21. In other embodiments, the stent 30f may be combined
with any of the blade configurations taught or suggested herein to
provide self-trephining capability. In these cases, the incision
through the trabecular meshwork 21 is made by the self-trephining
stent device which has a blade at its base or proximate to the
base.
Deeply Threaded Stent
[0193] FIG. 34 illustrates a glaucoma stent device 30g having
features and advantages in accordance with one embodiment. The
stent 30g has a head or seat 38g and a shank or main body portion
40g with a base or distal end 132. This embodiment of the
trabecular stent 30g includes a deep thread 134 (with threads 136)
on the main body 40g of the stent 30g below the head 38g. The
threads may or may not extend all the way to the base 132.
[0194] In use, the stent 30g (FIG. 34) is advanced through the
meshwork 21 through a rotating motion, as with a conventional
screw. Advantageously, the deep threads 136 provide retention and
stabilization of the stent 30g in the trabecular meshwork 21.
[0195] Referring to FIG. 34, the aqueous flows from the anterior
chamber 20, through the lumen 42g, then out through two side-ports
56g to be directed in both directions along Schlemm's canal 22.
Alternatively, flow could be directed in only one direction through
a single side-port 56g. In other embodiments, more then two outlet
ports 56g may be efficaciously used, as needed or desired.
[0196] One suitable applicator or delivery apparatus for this stent
30g (FIG. 34) includes a preset rotation, for example, via a wound
torsion spring or the like. The rotation is initiated by a release
trigger on the applicator. A final twist of the applicator by the
surgeon and observation of suitable fiducial marks, indicia or the
like ensure proper alignment of the side ports 56g with Schlemm's
canal 22.
[0197] Referring to FIG. 34, in one embodiment, the stent 30g is
inserted through a previously made incision in the trabecular
meshwork 21. In other embodiments, the stent 30g may be combined
with any of the blade configurations taught or suggested herein to
provide self-trephining capability. In these cases, the incision
through the trabecular meshwork 21 is made by the self-trephining
stent device which has a blade at its base or proximate to the
base.
Rivet Style Stent
[0198] FIG. 35 illustrates a glaucoma stent device 30h having
features and advantages in accordance with one embodiment. The
stent has a base or distal end 138. This embodiment of the
trabecular stent 30h has a pair of flexible ribs 140. In the unused
state, the ribs are initially generally straight (that is, extend
in the general direction of arrow 142).
[0199] Referring to FIG. 35, upon insertion of the stent 30h
through the trabecular meshwork 21, the ends 144 of respective ribs
140 of the stent 30h come to rest on the back wall 92 of Schlemm's
canal 22. Further advancement of the stent 30h causes the ribs 140
to deform to the bent shape as shown in the drawing of FIG. 35. The
ribs 140 are designed to first buckle near the base 138 of the
stent 30h. Then the buckling point moves up the ribs 140 as the
shank part 40h of the stent 30h is further advanced through the
trabecular meshwork 21.
[0200] The lumen 42h (FIG. 35) in the stent 30h is a simple
straight hole. The aqueous flows from the anterior chamber 20,
through the lumen 42h, then out around the ribs 140 to the
collector channels further along Schlemm's canal 22 in either
direction.
[0201] Referring to FIG. 35, in one embodiment, the stent 30h is
inserted through a previously made incision in the trabecular
meshwork 21. In other embodiments, the stent 30h may be combined
with any of the blade configurations taught or suggested herein to
provide self-trephining capability. In these cases, the incision
through the trabecular meshwork 21 is made by the self-trephining
stent device which has a blade at its base or proximate to the
base.
Grommet Style Stent
[0202] FIG. 36 illustrates a glaucoma stent device 30i having
features and advantages in accordance with one embodiment. This
embodiment of the trabecular stent 30i includes a head or seat 38i,
a tapered base portion 146 and an intermediate narrower waist
portion or shank 40i.
[0203] In use, the stent 30i (FIG. 36) is advanced through the
trabecular meshwork 21 and the base 146 is pushed into Schlemm's
canal 22. The stent 30i is pushed slightly further, if necessary,
until the meshwork 21 stretched by the tapered base 146 relaxes
back and then contracts to engage the smaller diameter portion
waist 40i of the stent 30i. Advantageously, the combination of the
larger diameter head or seat 38i and base 146 of the stent 30i
constrains undesirable stent movement. As discussed above, correct
orientation of the stent 30i is ensured by appropriate fiducial
marks, indicia or the like and by positioning of the stent in a
preloaded applicator.
[0204] Referring to FIG. 36, the aqueous flows from the anterior
chamber 20, through the lumen 42i, then out through two side-ports
56i to be directed in both directions along Schlemm's canal 22.
Alternatively, flow could be directed in only one direction through
a single side-port 56i. In other embodiments, more then two outlet
ports 56i may be efficaciously used, as needed or desired.
[0205] Still referring to FIG. 36, in one embodiment, the stent 30i
is inserted through a previously made incision in the trabecular
meshwork 21. In other embodiments, the stent 30i may be combined
with any of the blade configurations taught or suggested herein to
provide self-trephining capability. In these cases, the incision
through the trabecular meshwork 21 is made by the self-trephining
stent device which has a blade at its base or proximate to the
base.
Biointeractive Stent
[0206] FIG. 37 illustrates a glaucoma stent device 30j having
features and advantages in accordance with one embodiment. This
embodiment of the trabecular stent 30j utilizes a region of
biointeractive material 148 that provides a site for the trabecular
meshwork 21 to firmly grip the stent 30j by ingrowth of the tissue
into the biointeractive material 148. As shown in FIG. 37,
preferably the biointeractive layer 148 is applied to those
surfaces of the stent 30j which would abut against or come in
contact with the trabecular meshwork 21.
[0207] In one embodiment, the biointeractive layer 148 (FIG. 37)
may be a region of enhanced porosity with a growth promoting
chemical. In one embodiment, a type of bio-glue 150 that dissolves
over time is used to hold the stent secure during the time between
insertion and sufficient ingrowth for stabilization. As discussed
above, correct orientation of the stent 30j is ensured by
appropriate fiducial marks, indicia or the like and by positioning
of the stent in a preloaded applicator.
[0208] Referring to FIG. 37, the aqueous flows from the anterior
chamber 20, through the lumen 42j, then out through two side-ports
56j to be directed in both directions along Schlemm's canal 22.
Alternatively, flow could be directed in only one direction through
a single side-port 56j. In other embodiments, more then two outlet
ports 56j may be efficaciously used, as needed or desired.
[0209] Still referring to FIG. 37, in one embodiment, the stent 30j
is inserted through a previously made incision in the trabecular
meshwork 21. In other embodiments, the stent 30j may be combined
with any of the blade configurations taught or suggested herein to
provide self-trephining capability. In these cases, the incision
through the trabecular meshwork 21 is made by the self-trephining
stent device which has a blade at its base or proximate to the
base.
Glued or Welded Stent
[0210] FIG. 38 illustrates a glaucoma stent device 30k having
features and advantages in accordance with one embodiment. This
embodiment of the trabecular stent 30k is secured in place by using
a permanent (non-dissolving) bio-glue 152 or a "welding" process
(e.g. heat) to form a weld 152. The stent 30k has a head or seat
38k and a lower surface 46k.
[0211] The stent 30k is advanced through the trabecular meshwork 21
until the head or seat 38k comes to rest on the trabecular meshwork
21, that is, the head lower surface 46k abuts against the
trabecular meshwork 21, and the glue or weld 152 is applied or
formed therebetween, as shown in FIG. 38. As discussed above,
correct orientation of the stent 30k is ensured by appropriate
fiducial marks, indicia or the like and by positioning of the stent
in a preloaded applicator.
[0212] Referring to FIG. 38, the aqueous flows from the anterior
chamber 20, through the lumen 42k, then out through two side-ports
56k to be directed in both directions along Schlemm's canal 22.
Alternatively, flow could be directed in only one direction through
a single side-port 56k. In other embodiments, more then two outlet
ports 56k may be efficaciously used, as needed or desired.
[0213] Still referring to FIG. 38, in one embodiment, the stent 30k
is inserted through a previously made incision in the trabecular
meshwork 21. In other embodiments, the stent 30k may be combined
with any of the blade configurations taught or suggested herein to
provide self-trephining capability. In these cases, the incision
through the trabecular meshwork 21 is made by the self-trephining
stent device which has a blade at its base or proximate to the
base.
Hydrophilic Latching Stent
[0214] FIG. 39 illustrates a glaucoma stent device 30m having
features and advantages in accordance with one embodiment. This
embodiment of the trabecular stent 30m is fabricated from a
hydrophilic material that expands with absorption of water.
Desirably, this would enable the device 30m to be inserted through
a smaller incision in the trabecular meshwork 21. The subsequent
expansion (illustrated by the smaller arrows 154) of the stent 30m
would advantageously enable it to latch in place in the trabecular
meshwork 21. As discussed above, correct orientation of the stent
30m is ensured by appropriate fiducial marks, indicia or the like
and by positioning of the stent in a preloaded applicator.
[0215] Referring to FIG. 39, the aqueous flows from the anterior
chamber 20, through the lumen 42m, then out through two side-ports
56m to be directed in both directions along Schlemm's canal 22.
Alternatively, flow could be directed in only one direction through
a single side-port 56m. In other embodiments, more then two outlet
ports 56m may be efficaciously used, as needed or desired.
[0216] Still referring to FIG. 39, in one embodiment, the stent 30m
is inserted through a previously made incision in the trabecular
meshwork 21. In other embodiments, the stent 30m may be combined
with any of the blade configurations taught or suggested herein to
provide self-trephining capability. In these cases, the incision
through the trabecular meshwork 21 is made by the self-trephining
stent device which has a blade at its base or proximate to the
base.
Photodynamic Stent
[0217] FIG. 40 illustrates a glaucoma stent device 30n having
features and advantages in accordance with one embodiment. This
embodiment of the trabecular stent 30n is fabricated from a
photodynamic material that expands on exposure to light.
[0218] It is commonly known that there is a diurnal variation in
the aqueous humor production by the eye--it is higher during the
day than it is at night. The lumen 42n of the stent 30n responds to
light entering the cornea during the day by expanding and allowing
higher flow of aqueous through the lumen 42n and into Schlemm's
canal 22. This expansion is generally indicated by the smaller
arrows 156 (FIG. 40) which show the lumen 42n (and ports) expanding
or opening in response to light stimulus. (The light or radiation
energy E is generally given by E=h.nu., where h is Planck's
constant and .nu. is the frequency of the light provided.) At
night, in darkness, the lumen diameter decreases and reduces the
flow allowed through the lumen 42n. In one embodiment, an
excitation wavelength that is different from that commonly
encountered is provided on an as-needed basis to provide higher
flow of aqueous to Schlemm's canal 22.
[0219] This photodynamic implementation is shown in FIG. 40 for the
self-latching style of stent 30n, but can be efficaciously used
with any of the other stent embodiments, as needed or desired. As
discussed above, correct orientation of the stent 30n is ensured by
appropriate fiducial marks, indicia or the like and by positioning
of the stent in a preloaded applicator.
[0220] Referring to FIG. 40, the aqueous flows from the anterior
chamber 20, through the lumen 42n, then out through two side-ports
56n to be directed in both directions along Schlemm's canal 22.
Alternatively, flow could be directed in only one direction through
a single side-port 56n. In other embodiments, more then two outlet
ports 56n may be efficaciously used, as needed or desired.
[0221] Still referring to FIG. 40, in one embodiment, the stent 30n
is inserted through a previously made incision in the trabecular
meshwork 21. In other embodiments, the stent 30n may be combined
with any of the blade configurations taught or suggested herein to
provide self-trephining capability. In these cases, the incision
through the trabecular meshwork 21 is made by the self-trephining
stent device which has a blade at its base or proximate to the
base.
Collector Channel Alignment Stent
[0222] FIG. 41 illustrates a glaucoma stent device 30p having
features and advantages in accordance with one embodiment. This
figure depicts an embodiment of a stent 30p that directs aqueous
from the anterior chamber 20 directly into a collector channel 29
which empties into aqueous veins. The stent 30p has a base or
distal end 160.
[0223] In the illustrated embodiment of FIG. 41, a removable
alignment pin 158 is utilized to align the stent lumen 42p with the
collector channel 29. In use, the pin 158 extends through the stent
lumen 42p and protrudes through the base 160 and extends into the
collector channel 29 to center and/or align the stent 30p over the
collector channel 29. The stent 30p is then pressed firmly against
the back wall 92 of Schlemm's canal 22. A permanent bio-glue 162 is
used between the stent base and the back wall 92 of Schlemm's canal
22 to seat and securely hold the stent 30p in place. Once
positioned, the pin 158 is withdrawn from the lumen 42p to allow
the aqueous to flow directly from the anterior chamber 20 into the
collector duct 29. The collector ducts are nominally 20 to 100
micrometers (.mu.m) in diameter and are visualized with a suitable
microscopy method (such as ultrasound biomicroscopy (UBM)) or laser
imaging to provide guidance for placement of the stent 30p.
[0224] Referring to FIG. 41, in one embodiment, the stent 30p is
inserted through a previously made incision in the trabecular
meshwork 21. In other embodiments, the stent 30p may be combined
with any of the blade configurations taught or suggested herein to
provide self-trephining capability. In these cases, the incision
through the trabecular meshwork 21 is made by the self-trephining
stent device which has a blade at its base or proximate to the
base.
Barbed Stent (Anterior Chamber to Collector Channel)
[0225] FIG. 42 illustrates a glaucoma stent device 30q having
features and advantages in accordance with one embodiment. This
figure depicts an embodiment of a stent 30q that directs aqueous
from the anterior chamber 20 directly into a collector channel 29
which empties into aqueous veins. The stent 30q has a base or
distal end 166 and the channel 29 has wall(s) 164.
[0226] In the illustrated embodiment of FIG. 42, a barbed,
small-diameter extension or pin 168 on the stent base 166 is guided
into the collector channel 29 and anchors on the wall(s) 164 of the
channel 29. The pin 168 has barbs 170 which advantageously provide
anchoring of the stent 30q. The collector ducts 29 are nominally 20
to 100 micrometers (.mu.m) in diameter and are visualized with a
suitable microscopy method (such as ultrasound biomicroscopy (UBM))
or laser imaging to provide guidance for placement of the
stent.
[0227] Referring to FIG. 42, in one embodiment, the stent 30q is
inserted through a previously made incision in the trabecular
meshwork 21. In other embodiments, the stent 30q may be combined
with any of the blade configurations taught or suggested herein to
provide self-trephining capability. In these cases, the incision
through the trabecular meshwork 21 is made by the self-trephining
stent device which has a blade at its base or proximate to the
base.
Valved Tube Stent (Anterior Chamber to Choroid)
[0228] FIG. 43 illustrates a valved tube stent device 30r having
features and advantages in accordance with one embodiment. This is
an embodiment of a stent 30r that provides a channel for flow
between the anterior chamber 20 and the highly vascular choroid 17.
Clinically, the choroid 17 can be at pressures lower than those
desired for the eye 10. Therefore, this stent 30r includes a valve
with an opening pressure equal to the desired pressure difference
between the choroid 17 and the anterior chamber 10 or a
constriction that provide the desired pressure drop.
Osmotic Membrane (Anterior Chamber to Choroid)
[0229] FIG. 44 illustrates an osmotic membrane device 30s having
features and advantages in accordance with one embodiment. This
embodiment provides a channel for flow between the anterior chamber
20 and the highly vascular choroid 17. The osmotic membrane 30s is
used to replace a portion of the endothelial layer of the choroid
17. Since the choroid 17 is highly vascular with blood vessels, the
concentration of water on the choroid side is lower than in the
anterior chamber 20 of the eye 10. Therefore, the osmotic gradient
drives water from the anterior chamber 20 into the choroid 17.
[0230] Clinically, the choroid 17 (FIG. 44) can be at pressures
lower than those desired for the eye 10. Therefore, desirably, both
osmotic pressure and the physical pressure gradient are in favor of
flow into the choroid 17. Flow control is provided by proper sizing
of the area of the membrane--the larger the membrane area is the
larger the flow rate will be. This advantageously enables tailoring
to tune the flow to the desired physiological rates.
Ab Externo Insertion of Stent Via Small Puncture
[0231] FIG. 45 illustrates the implantation of a stent 30t using an
ab externo procedure having features and advantages in accordance
with one embodiment. In the ab externo procedure of FIG. 45, the
stent 30t is inserted into Schlemm's canal 21 with the aid of an
applicator or delivery apparatus 100c that creates a small puncture
into the eye 10 from outside.
[0232] Referring to FIG. 45, the stent 30t is housed in the
applicator 100c, and pushed out of the applicator 100c once the
applicator tip is in position within the trabecular meshwork 21.
Since the tissue surrounding the trabecular meshwork 21 is
optically opaque, an imaging technique, such as ultrasound
biomicroscopy (UBM) or a laser imaging technique, is utilized. The
imaging provides guidance for the insertion of the applicator tip
and the deployment of the stent 30t. This technique can be used
with a large variety of stent embodiments with slight modifications
since the trabecular meshwork 21 is punctured from the scleral side
rather than the anterior chamber side in the ab externo
insertion.
[0233] FIG. 46 a glaucoma stent device 30u having features and
advantages in accordance with a modified embodiment. This
grommet-style stent 30u for ab externo insertion is a modification
of the embodiment of FIG. 36. In the embodiment of FIG. 46, the
upper part or head 38u is tapered while the lower part or base 172
is flat, as opposed to the embodiment of FIG. 36. The stent 30u is
inserted from the outside of the eye 10 through a puncture in the
sclera. Many of the other embodiments of stents taught or suggested
herein can be modified for similar implantation.
[0234] This ultra microscopic device 30u (FIG. 46) can be used with
(1) a targeting Lasik-type laser, or with (2) contact on eyes or
with (3) combined ultrasound microscope or (4) other device
inserter handpiece.
Targeted Drug Delivery to the Trabecular Meshwork
[0235] FIG. 47 illustrates a targeted drug delivery implant 30v
having features and advantages in accordance with one embodiment.
This drawing is a depiction of a targeted drug delivery concept.
The slow release implant 30v is implanted within the trabecular
meshwork 21.
[0236] A drug that is designed to target the trabecular meshwork 21
to increase its porosity, or improve the active transport across
the endothelial layer of Schlemm's canal 22 can be stored in this
small implant 30v (FIG. 47). Advantageously, slow release of the
drug promotes the desired physiology at minimal dosage levels since
the drug is released into the very structure that it is designed to
modify.
Dose Response
[0237] The programmed (also know as "Targeted") stent placement
refers to the intentional placement of a stent or stents at a
particular location or locations in Schlemm's canal for the purpose
of providing a benefit in the form of more optimal outflow. For
example, a method can be provided which includes assessing the
aqueous flow characteristics of an eye. Such characteristics can
include, for example, but without limitation, collector channel
distribution, collector channel flow characteristics, outflow
resistance, outflow capacity, shape/size/tortuosity of Schlemm's
canal, and other factors). The method can also include determining
an optimal stent placement and implanting stents in one or
plurality of positions and procedures. For example, the
determination of the desired stent placement can include
consideration of a database of cadaver anatomy regarding the number
and location of collector channels, the patient's micro-anatomy
data, the number of stents to be used, the type of stents to be
used, the location of any previously implanted stents whether the
desired stent is drug-loaded, gene-loaded or surface treated,
and/or any associated drug therapy.
[0238] FIG. 48 includes a flow diagram illustrating a decision tree
for determining desired stent placement. In the illustrated
embodiment, after it is determined that a patient is suffering from
excess of intraocular pressure (IOP), a bypass flow model is
determined to aid in the decision of whether or not to use single
or multiple stents. Optionally, the configuration of collector
channels in the patient's eye can be met to aid in the creation of
a bypass flow model. Further, other information can be used, such
as, for example, but without limitation, outflow resistance,
aqueous production, and venous pressure.
[0239] The bypass flow model, which can be based on the above-noted
information, is determined so as to provide a desired strategy for
lowering the excessive intraocular pressure. If it is decided that
a single stent should be used, an optimized stent location is first
determined based on the bypass flow model. The implantation of the
single stent results in reduced IOP. After this implantation, it is
again determined if there is a need for further reduction in IOP.
If additional IOP reduction is desired, then a further bypass flow
model is created. For example, the second bypass flow model can be
determined in the same or similar manner as the first bypass flow
model described above. In light of the second bypass flow model, an
additional stent can be implanted at an optimized location to
further reduce IOP.
[0240] If it is determined, in light of the first bypass flow
model, that multiple stents should be used, the location of the
multiple stents is first optimized. Then, the multiple stents are
implanted. Afterwards, it is again determined if additional
intraocular pressure reduction is needed, and the trimming can
continue as noted above.
[0241] Where additional stents are implanted in light of the second
bypass flow model, the additional stents can be different from the
first stents implanted. For example, where single or multiple
stents are implanted in accordance with the first bypass flow
model, the additional stents can be of a different type. For
example, in one embodiment, the first stent is a G1 (First
generation) trabecular stent that has been disclosed in copending
applications and the second stent(s) is the same G1 trabecular
stent. In another embodiment, the second stent(s) is different from
the first stent; for example, the second stent is a G2 stent (that
is, "injectable axisymmetric stent"; a second generation stent). In
still another embodiment, the second stent(s) is smaller than (in
some case, larger than) the first stent. The dose response may also
relate to the stent configuration or characteristics such as
drug-loading or surface treatment enabling enhancing aqueous
transport or therapeutic effects on the tissue as needed.
Drug-loaded or drug-eluting stent may comprise different types of
drugs including, but not limited to, those cited in copending
patent application Ser. No. 10/046,137 filed Nov. 8, 2001, entitled
DRUG RELEASING TRABECULAR IMPLANT FOR GLAUCOMA TREATMENT, the
entire contents of which is hereby incorporated by reference.
[0242] With reference to FIG. 49A, a stent extending between an
anterior chamber 20 of an eye, through the trabecular meshwork 21,
and into Schlemm's canal 22 of an eye can be configured to be
axisymmetric with respect to the flow of aqueous therethrough. For
example, as shown in FIG. 49A, the stent 229A comprises an inlet
end 230 configured to be disposed in the anterior chamber 20. The
second end 231 of the stent 229A is configured to be disposed in
Schlemm's canal 22.
[0243] At least one lumen 239 extends through the stent 229A
between the inlet and outlet ends 230, 232. The lumen 239 defines
an opening 232 at the inlet end 230 as well as an outlet 233 at the
outlet end 231.
[0244] In the illustrated embodiment, an exterior surface 238 of
the stent 229A is cone-shaped. Thus, a circumference of the
exterior surface 238 adjacent to the inlet end 230 is smaller than
the circumference of the outer surface 238 at the outlet end
231.
[0245] With the stent 229A extending through the trabecular
meshwork 21, the tissue of the trabecular meshwork 221 provides
additional anchoring force for retaining the stent 229A with its
inlet end 230 in the anterior chamber and its outlet end 231 in
Schlemm's canal. For example, the trabecular meshwork 21 would
naturally tend to close an aperture occupied by the stent 229A. As
such, the trabecular meshwork 221 would tend to squeeze the stent
229A. Because the exterior surface 238 is conical, the squeezing
force applied by the trabecular meshwork 221 would tend to draw the
stent 229A towards Schlemm's canal 22. In the illustrated
embodiment, the stent 229A is sized such that a portion 234 of the
stent 229 adjacent to the inlet end 230 remains in the anterior
chamber 20 while a portion 235 of the stent 229 adjacent to the
outlet end 231 remains in Schlemm's canal 22.
[0246] In the illustrated embodiment, the outer surface 238 of the
stent 229A is straight. Alternatively, the outer surface 238 can
have other contours such as, for example, but without limitation
curved or stepped. In one embodiment, the outer surface 238 can be
curved in a concave manner so as to produce a trumpet-like shape.
Alternatively, the outer surface 238 can be convex.
[0247] The stent 229A preferably includes one or plurality of posts
or legs 236 configured to maintain a space between the outlet
opening 233 and a wall of Schlemm's canal 22. As such, the legs 236
prevent a wall of Schlemm's canal from completely closing off the
outlet opening 233 of the stent 229A. In the illustrated
embodiment, the legs 236 are coupled to the distal-most surface of
the stent 229A and are substantially parallel to an implant axis
extending through the stent 229A and between the anterior chamber
20 and Schlemm's canal 22.
[0248] This arrangement of the legs 236 and the outlet 233 imparts
an axisymmetric flow characteristic to the stent 229A. For example,
aqueous can flow from the outlet 233 in any direction. Thus, the
stent 229A can be implanted into Schlemm's canal at any angular
position relative to its implant axis. Thus, it is not necessary to
determine the angular orientation of the stent 229A prior to
implantation, nor is it necessary to preserve a particular
orientation during an implantation procedure.
[0249] FIG. 49B illustrates a modification of the stent 229A,
identified generally by the reference numeral 229B. In this
embodiment, the stent 229B includes a flange 237 extending radially
from the portion 234. Preferably, the flange 237 is configured to
retain the first portion 234 within the anterior chamber 20. It is
to be recognized that although generally, aqueous will flow from
the anterior chamber 20 towards Schlemm's canal 22, the stent 229A,
229B or any of the above-described stents as well as other stents
described below, can provide for omni-directional flow of
aqueous.
[0250] FIG. 49C illustrates another modification of the stent 229A,
identified generally by the reference numeral 229C. In this
embodiment, the outer surface 238C is not conical. Rather, the
outer surface 238C is cylindrical. The stent 229C includes a flange
240 that can be the same size and shape as the flange 237. The legs
236C extend from the flange 240.
[0251] Constructed as such, the natural tendency of the tissue of
the trabecular meshwork 21 to close the hole in which the stent
229C is disposed, aids in anchoring the stent 229C in place.
Additionally, the legs 236C aid in preventing the walls of
Schlemm's canal from completely closing the outlet 233C of the
lumen 239C.
Device for Mechanically Distending Collector Duct
[0252] FIG. 50A is an enlarged cross-sectional view of a portion of
the eye 10 showing, anatomically, the trabecular meshwork 21,
Schlemm's canal 22, and a collector duct 23 in a natural state.
FIG. 50B shows a stent 229C extending into and thereby distending
the collector duct 23.
[0253] The collector duct 23 has an inner diameter identified
generally by the reference numeral D.sub.1, when in a relaxed or
natural state. Because the collector duct 23 is not typically
perfectly round, the diameter D.sub.1 can correspond to an
"equivalent" diameter. As used herein, the equivalent diameter can
be determined by dividing the circumference of the inner surface of
the collector duct 23 by .pi..
[0254] The stent 229D is sized to extend from the anterior chamber
20 and into the collector duct 23. Thus, in the illustrated
embodiment, the stent 229D includes an upstream end portion 230D
and a downstream end portion 243.
[0255] The upstream portion 230D is configured to open into the
anterior chamber 20. The stent 229D is sized so as to extend from
the anterior chamber 20 and into the collector duct 23. In the
illustrated embodiment, the stent 229D is sized so as to extend
from the anterior chamber 20, through the trabecular meshwork 21,
through a portion of Schlemm's canal 22, and into the collector
duct 23. However, it is conceived that the stent 229D could bypass
Schlemm's canal 22 and extend directly into a portion of the
collector duct 23 downstream from Schlemm's canal 22.
[0256] The downstream end portion 243 can have an outer diameter
D.sub.2 that is larger that the diameter D.sub.1. Preferably, the
end potion 243 is sized and configured for easy insertion into a
collect duct 23 without injuring the tissue or tissue surface of
the collector duct 23. Thus, when the end portion 243 is disposed
in the collector duct 23, the collector duct 23 is distended, i.e.,
enlarged. As such, the resistance against the outflow of aqueous
provided by the collector duct 23 in its natural state can be
reduced, thereby reducing IOP.
[0257] Preferably, the end portion 243 has a diameter D.sub.2
substantially larger than the equivalent diameter D.sub.1 of the
duct 23 so as to deform the collector duct beyond its elastic
threshold into plastic deformation region. As such, the collector
duct 23 can aid in anchoring the stent 229D in place.
Applicator for Multiple Stent Implantation
[0258] FIG. 51A is a perspective view of a stent delivery
applicator 201 configured for multiple stent deployment. The
delivery applicator 201 comprises an injection sheath 246 defining
a stent lumen 249, a distal stent-holding section 259, and a handle
205.
[0259] The handle 205 includes an outer surface preferably
configured to be grasped by a human hand. Additionally, the handle
can comprise a stent delivery button 203. By way of example, the
stent delivery button 203 is configured to cause a stent discharge
mechanism to discharge, from the applicator sheath 246, one stent
at a time. The applicator 201 can be configured to store and
discharge a plurality of any combination of the stents 229, 30,
30a, 30b, 30c, 30d, 30e, 30f, 30g, 30h, 30i, 30j, 30k, 30m, 30n,
30p, 30q, 30r, 30s, 30t, 30u, 30v, 229A, 229B, 229C, and 229D
described above, the additional stents described below, or any
other ocular stent or implant. In the illustrated embodiment, the
applicator 201 is loaded with a plurality of the stents 229C
[0260] The applicator 201 can include other features as well, for
example, but without limitation, an optional connector 209 for
connecting to an external ultrasound power source, a fluid infusing
port 204 for fluid infusion or viscocanalostomy, and a steering
mechanism control device 202 configured to control the steering of
a steerable section 251 of the applicator 201.
[0261] The steerable section 251 can be configured to deflect the
distal stent-holding section 259 about at least one axis.
Optionally, the steerable section 251 can configured to deflect the
distal stent-holding section 259 about at least two axes, one axis
being substantially perpendicular to the other. Thus, the portion
of the sheath 246 which defines part of the steerable section 251
is flexible. Generally, similar steering mechanisms for deflecting
a portion of an medical device, such as endoscopes, are well-known
in the art.
[0262] With reference to FIG. 51B, in the illustrated embodiment,
the steering actuator 202 is connected to a plurality of pulling
wires 256A, 256B. The wires 256A, 256B have distal portions 253A,
253B, respectively, disposed distally from the handle 205. The end
252A of the distal wire portion 253A of the first pulling wire 256A
is attached to one side of an inner surface of the sheath 246. The
second pulling wire 256B has its end 252B of the distal wire
portion 253B attached to the opposite side of the inner surface of
the sheath 246. The wire ends 252A and 252B are disposed within the
steerable distal section 251.
[0263] With reference to FIG. 51C, a relatively rigid guide 254 is
disposed in the lumen at an appropriate location proximal to the
wire ends 252A, 252B. The guide is configured to guide the pull
wires 256A, 256B such that the sheath 246 is deflected when the
pull wires 256A, 256B are pulled. In the illustrated embodiment,
the guide 254 is in the form of a plate member.
[0264] The guide 254 can include holes 255A, 255B through which the
pulling wires 253A, 253B extend. The guide 254 and the points at
which the wire ends 252A, 25B are spaced. As such, when the pull
wires 253A, 253B are pulled by actuation of the steering actuator
202, the distal end of the sheath 246 is deflected. For example, as
shown in FIG. 51D, when the wire 256A is pulled, the sheath
deflects from Position I to Position II.
[0265] As noted above, the delivery apparatus 201 can be configured
to discharge a plurality of stents, one at a time, for
implantation. In the illustrated embodiment, as shown in FIG. 51B,
the delivery apparatus 201 includes a plunger 244 connected with
the stent delivery button 203. The plunger 244 can comprise one or
a plurality of plunger bodies that are joined at the distal plunger
end 244B. The distal plunger end 244B has a generally round
configuration and smooth surface adapted for evenly pushing a
stent, such as the stent 229C, out of the sheath during a
deployment phase of an implantation procedure.
[0266] As noted above, the sheath 246 defines a lumen 249 having a
plunger 244. A space between the plunger 244 and the distal end 242
is reserved for storing a plurality of stents. The sheath 246
includes at least one holding member 245 for each stent 229C stored
therein. The holding members 245 are configured to retain the
stents 229C in place during storage and use, and to allow the
stents 229C to pass when the stent 229C is pushed by the plunger
244.
[0267] In the illustrated embodiment, the sheath 146 includes a row
of a plurality of holding members 245 upstream and downstream from
each stent 229C stored in the sheath 246. Thus, each stent 229C is
prevented from unintentionally moving in the upstream and
downstream directions.
[0268] FIG. 51B illustrates two stents 229C being stored in the
sheath 246. However, it is conceived that the sheath 246 and
holding members 245 can be configured to hold one, three, or more
stents 229C within the stent-holding distal end 259.
[0269] The holding member 245 can be a wire configured to exerted a
force to hold the stents 229C in place during storage and use,
until the plunger 244 is moved to discharge a stent 229C from the
end 242. For example, the wire can be made from a spring metal, an
elastically deformable plastic, or other material, sized and shaped
to retain the stents 229C during storage, and to allow the stents
229C to pass under a force that can be generated by or applied to
the plunger 244, toward the end 242. In the illustrated embodiment,
the wires forming the holding members 245 extend generally parallel
to and convexly into the lumen 249, and thus define stops for
preventing unintentional movement of the stents 229C.
[0270] Alternatively, the holding members 245 can be in the form of
a mechanically or electronically actuatable gate. Such a gate can
be configured to move from a closed position in which the stents
229C are retained in the storage positions, and an open position in
which the stents 229C can be moved in the downstream direction. A
mechanical gate can be formed from members that can be moved or
deflected radially from the inner surface of the lumen 249, under
the control of a pull wire (not shown). An electronic gate can also
include radially moveable or deflectable members controlled by an
electronic actuator, such as, for example, but without limitation,
solenoids, stepper motors, servo motors, and piezoelectric
modules.
[0271] Alternatively, piezoelectric modules can be used to form the
holding members. For example, small piezoelectric modules can be
mounted on the inner surface of the sheath 246 to form stops when
in a locked position. The piezoelectric modules can be connected to
a power supply with conduits. Thus, when actuated, the
piezoelectric modules can contract so as to move to an open
position in which the stents 229C can pass.
[0272] As noted above, the applicator 201 preferably is configured
to eject one stent at a time from the end 242. Thus, the applicator
201 can be configured to move the plunger 244 a predetermined
distance each time the button 203 is depressed. For example, the
button can be mechanically connected to the plunger 244 so as to
move the plunger 244 downstream through the sheath 246 over the
predetermined distance. The predetermined distance can be, for
example, equal to about the length of the stent 229C.
[0273] Alternatively, the plunger can be driven by an electronic
actuator (not shown) configured to eject one stent 229C at a time
from the sheath 246. For example, the electronic actuator can be
configured to drive the plunger 244 over the predetermined distance
each time the button 203 is depressed. The electronic actuator can
be, for example but without limitation, solenoids, stepper motors,
servo motors, and piezoelectric modules. Driver electronics (not
shown) can be configured to drive the actuator so as to urge the
plunger 244 over the predetermined distance.
[0274] Preferably, the end 242 of the sheath 246 is sharpened to
define a cutting (microtrephining) tip for creating a hole within
the trabecular meshwork 21 for stent placement. Thus, the
applicator 201 can be used for cutting the trabecular meshwork 21
and for implanting stents.
[0275] A further advantage is provided where the applicator
includes an illumination feature for illuminating at least a
portion of the implantation site. For example, the illumination
feature can be configured to generally illuminate the site at which
a stent is to be implanted. Optionally, the illumination feature
can be configured to generate a reticule for aligning the
applicator with the desired implantation site. In one embodiment, a
light source is provided to the tip section 242 of the stent
applicator 201 wherein either laser light is provided for
cutting/spotting or fiber optic light is provided for
illumination.
[0276] For example, but without limitation, the illumination
feature can comprise a small diameter light pipe or optic fiber
element configured to emit a fine point or beam of light and
configured to be introduced ab-internally. Additionally, the face
or lens of the pipe or element can be configured to be placed
against the trabecular meshwork. In one embodiment, the light pipe
or optic fiber is the construct material of the sheath 246 of the
stent delivery applicator 241A for multiple stent deployment as
shown in FIG. 51B. In another embodiment, the light pipe or optic
fiber is snugly inserted within the lumen 249 of the applicator
sheath 246 or over the outer periphery of the applicator sheath
246. Optionally, the illumination device can be configured such
that the point or beam emitting from the light tube would be highly
visible from the outside of the eye and serve to guide the
implantation of a stent.
[0277] As an alternative to including an illumination feature with
the applicator 201, simple non-invasive trans-scleral illumination,
if of the proper intensity and wavelength, perhaps in a darkened
environment, could silhouette the Schlemm's canal, trabecular
meshwork, or more probably, the scleral spur with sufficient
resolution to enable ab-externo placement of a device into
Schlemm's canal. In this case, blood could be backed up in a
retrograde manner into Schlemm's canal by the surgeon to provide
additional optical density. Imaging means for ab internally imaging
the anatomic structures for TBS stent implantation using ultrasound
imaging, laser imaging, OCT imaging or multi-wavelength scanning
can also be provided.
[0278] A further advantage is provided where the applicator 201
also includes an imaging feature. For example, where the applicator
201 includes an imaging feature for transmitting a video
representation of an implantation site of a stent to a user of the
applicator, an implantation procedure can be further simplified.
The imaging feature can utilize any type of known imaging
techniques, including, for example, but without limitation,
optical, and ultrasonic. In one embodiment, an endoscope is mounted
at the tip section 242 of the stent applicator 201 for
visualization during stent deployment and/or implantation.
[0279] FIG. 51D shows one embodiment of the applicator 201 of FIG.
51A having an ultrasonic imaging system. The illustrated embodiment
of the imaging system is included on an applicator with a steerable
section. However, it is to be noted that the imaging system can be
used on an applicator that does not have a steerable section.
[0280] In one embodiment, the ultrasonic imaging system comprises
two ultrasonic probes or transducers 206, 207. The transducers 206,
207 can be formed from an ultrasound ring or ultrasound tape.
Preferably, the transducers 206, 207 are located adjacent to the
distal end 242 of the delivery apparatus 201. As such, the
transducers 206, 207 can move with the distal end 242 during an
implantation procedure.
[0281] The ultrasonic transducers 206, 207 are connected by
flexible wires (not shown) through the interior void 243 of the
apparatus or through within the sheath 246 to the connector 209
located at the handle 205 so that the ultrasonic signals are
directed outwardly and received inwardly relative to the
transducers 206, 207. For example, one of the transducers 206, 207
can be configured to emit ultrasonic energy, and the other can be
configured to absorb the reflected portion of the emitted
ultrasonic energy and to produce a signal indicative of the
absorbed energy.
[0282] In order to enhance the viewing and positioning of the
distal end 242 of the apparatus, an ultrasonic marker 208, which is
visible to ultrasonic energy, can be mounted at about the distal
end 242 of the applicator 201. For example, but without limitation,
such a marker 208 can be in the form of one or a plurality of
encapsulated air bubbles. In one illustrative example, the bubble
in a marker 208 can be formed by introducing air by a syringe (not
shown) penetrating the wall of the sheath 246 and thereafter
sealing the hole created by the syringe with epoxy.
[0283] Optionally, a plurality of markers 208 can be disposed in
the front distal section 259. The markers 208 can be sized and
configured to aid in locating and identifying the orientation of
the distal end section 259. For example, the markers 208 can be
located and/or viewed with external ultrasonic imaging systems (not
shown), such as those commonly used in similar medical
procedures.
[0284] A further advantage is provided where the stent delivery
applicator 201 is both steerable and configured for multiple stent
implantation. As such, the applicator 201 can be inserted into the
anterior chamber 20, through an incision, such as a corneal
incision, and multiple stents can then be implanted at different
locations without removing the applicator 201 or creating other
incisions, described in greater detail below.
[0285] FIG. 52A shows another embodiment of the stent delivery
distal portion 241, identified generally by the reference numeral
241B, and another embodiment of a stent, identified generally by
the reference numeral 229E.
[0286] The stent 229E comprises a first (proximal) flange 240E and
a second (distal) flange 237E with a plurality of supporting legs
or posts 236. The second flange 237E of the stent 229E is
configured to be foldable. For example, the first flange 237E can
be configured to be elastically foldable toward an upstream
direction. As such, the first flange 237E can be folded toward an
upstream direction, as illustrated in FIG. 52A when stored in the
sheath 246. Thus, after the first flange 237E has been pushed
through the end 242, the first flange 237E can resiliently unfold.
As such, the first flange 237E can provide enhanced anchoring for
the stent 229E when implanted into the trabecular meshwork 21.
[0287] A further advantage can be provided where the applicator 201
includes a cutting device that can extend through the lumens 239E
of the stents 229E. For example, as shown in FIG. 52A, a cutting
device 250 can include a cutting tip 247 and can be configured to
extend through the stents 229E during an implantation procedure. As
such, the cutting device can being an incision at the center of the
site at which the stent 229E is to be inserted through the
trabecular meshwork 21. In the illustrated embodiment, the cutting
device is in the form of a trocar. In further embodiments, the
trocar has a cutting edge sufficiently sharp to cut through the
wall of Schlemm's canal, but not so sharp as to significantly
damage the scleral wall of Schlemm's canal.
[0288] With continued reference to FIG. 52A, the cutting device 250
is configured to be moveable axially through the lumen 249 of the
applicator end portion 241B of the sheath 146. Additionally, the
cutting device 250 can be moved axially relative to the stent or
stents through which it extends.
[0289] Another advantage can be provided where the cutting device
250 also includes at least one holding member for holding a stent.
For example, the cutting device 250 includes at least one holding
device 245, described above with reference to FIG. 51B, can be
configured to hold a stent at least during an implantation
procedure, and to release the stent at the appropriate time.
[0290] Preferably, the holding members 245B are arranged to align
the sides of the cutting tip 247 with the distally facing sides of
the flange 237E when the flange 237E is folded. For example, as
shown in FIG. 52A, when the flange 237E is folded, the distally
facing side of the flange 237E is aligned with the sides of the
cutting tip 247, as indicated by the dashed-lines identified by the
letter "A." This alignment can be facilitated by arranging the
holding members 245B such that the cutting device 250 extends
distally from the flange 237E sufficiently to cause the sides of
the cutting tip 247 to become aligned with the flange 237E . As
such, the sides of the cutting tip 247 and the distally facing side
of the flange 237E generate a more smooth surface for penetrating
the trabecular meshwork 21 during an implantation procedure.
[0291] During operation, the applicator end portion 241B can be
pushed into trabecular meshwork 21, with the flange 237E disposed
in Schlemm's canal 22, as shown in FIG. 52B. The sheath 246 can
then be retracted out of Schlemm's canal 22, leaving the cutting
device 250 and stent 229E in place (FIG. 52C).
[0292] With the sheath 246 retracted, the first flange 237E can
unfold, as indicated by the arrows U in FIG. 52C, thereby providing
enhanced anchoring of the stent 229E within Schlemm's canal 22
(FIG. 52D). Additionally, the second flange 240E is within the
anterior chamber 20.
[0293] As shown in FIG. 52D, the cutting device 250 can then be
retracted relative to the applicator end portion 241B and the stent
229E, leaving the stent 229E in place. Optionally, the cutting
device 250 and the sheath 246 can be retracted together.
[0294] As noted above, the holding members 245 are configured to
limit the movement of the stents 229E relative to the cutting
device 250. When the cutting device is retracted, the next stent
229E preferably is moved passed (in the downstream direction) the
holding member 245 that was previously between the stents 229E. As
such, the next stent 229E can be moved into position for
implantation. Thus, the holding members 245 preferably are
configured to allow the stent 229E to move toward the cutting tip
247 when the cutting device 250 is retracted. For example, the
holding members 245 can be controlled so as to retract when the
cutting device 250 is retracted.
[0295] With reference to FIG. 53, another embodiment of an
axisymmetric trabecular stenting device is illustrated therein and
identified generally by the reference numeral 229F. For ease of
description, but without limitation, the stent 229F is described
below with reference to cylindrical coordinates of x, r and angle a
as shown in FIG. 53.
[0296] The stent 229F comprises an inlet (proximal) section having
a first flange 240F, an outlet (distal) section having a second
flange 237F and a middle section 284 connecting the inlet section
and the outlet section. A lumen 239F of the device 229F is
configured to transport aqueous, liquid, or therapeutic agents
between the inlet section and the outlet section. As referred to
herein, "therapeutic agent" is intended to include pharmaceutical
agents, drugs, genes, cells, proteins, and/or growth factors.
[0297] The inlet section of the stent 229F has at least one inlet
opening 286 and the outlet section comprises at least one outlet
opening 287. A further advantage is provided where the outlet
section 237F includes at least one opening 287, 288 suitably
located for discharging substantially axisymmetrically the aqueous,
liquid or therapeutic agents, wherein the opening 287, 288 is in
fluid communication with the lumen 285 of the device 281. In the
illustrated embodiment, the openings 288 extend radially from the
lumen 285 and open at the outwardly facing surface around the
periphery of the outlet flange 237F.
[0298] In one embodiment of an implantation procedure, Pilocarpine
is administered preoperatively to constrict the pupil to provide
maximal protection of the lens in phakic individuals and to further
open the anterior chamber angle to provide a better view of the
surgical site. Topical and retrobulbar anesthetic are recommended.
A small self-sealing temporal corneal incision can be made and
Healon.RTM. viscoelastic (VE) can be injected to maintain the
anterior chamber.
[0299] A microscope can be tilted slightly toward the surgeon and
the patient's head can be rotated away from the surgeon to provide
a suitable view of the nasal trabecular meshwork using a
direct-view gonioscope that is placed on the eye. The applicator
201 with a preloaded stent, such as, for example, but without
limitation, an one or any combination of the stents a plurality of
any combination of the stents 229, 30, 30a, 30b, 30c, 30d, 30e,
30f, 30g, 30h, 30i, 30j, 30k, 30m, 30n, 30p, 30q, 30r, 30s, 30t,
30u, 30v, 229A, 229B, 229C, 229D, 229E, 229F, or any of the other
stents described below, is advanced through the corneal wound and
across the anterior chamber. The stent is pushed against the
trabecular meshwork and moved inferiorly to pierce the trabecular
meshwork and guide the stent into Schlemm's canal. After successful
implantation and release of the stent, the applicator is withdrawn
and the VE is flushed from the eye.
[0300] The G2 stent (for example, stent 229F of FIG. 53) can be
smaller and of a significantly different design than the G1 stents,
thus allowing it to be passed through a smaller corneal incision
and be implanted with a simple axial motion. Reduced size and
simplified surgical motions may enable implantation of the G2 stent
without the use of viscoelastic and therefore eliminate a
significant expendable material cost and the time necessary to
administer and remove it.
[0301] Additionally, viscoelastic use in patients undergoing eye
surgery can cause post-operative transient IOP spikes that can
further damage the remaining glaucoma-compromised retina. Reduced
surgical manipulations reduce the burden on the surgeon and reduce
the stimulation and irritation of intraocular tissues. Furthermore,
reduction in the corneal incision size raises the possibility that
the incision could be made by the G2 applicator, and could
potentially reduce the surgical implant procedure to an injectable
implant procedure. Injectable stent therapy represents a
potentially superior alternative to both end-stage surgical therapy
and to patients burdened by the cumulative side effects,
complications, and compliance issues associated with drug
therapy.
[0302] The G2 stent and applicator system are sized, dimensioned
and configured for placement through trabecular meshwork in an ab
interno or ab externo procedures. FIGS. 54A-C illustrate additional
examples of preferred G2 stent and applicator embodiments .
[0303] FIG. 54A shows yet another embodiment of a stent injector
assembly for multiple stent deployment, identified generally by the
reference numeral 260. The stent injector 260 comprises a housing
261 with a distal cap 262 and a distal stent-holding element 263
that is distal from the distal cap 261. Optionally, at least a
portion of the distal stent-holding element 263 can be configured
to be steerable with a steering mechanism that can be constructed
in accordance with the description of the steerable section 251
described above with reference to FIGS. 51A-D.
[0304] The stent-holding element 263 can comprise an elongate
member 264 with at least one stent slidably disposed thereon. The
elongate member 264 can be configured to extend through the lumen
of any of the stents 229A, 229B, 229C, 229D, 229E, 229F, or any of
the other stents described below.
[0305] In the illustrated embodiment, the elongate member 264
extends through the lumen of stents 229G (FIG. 54B). In one
embodiment, the distal stent 229G can be the same as the second or
proximal stent 229G. In another embodiment, the distal stent and
the proximal stent are different in size or configuration for
placement at different locations. For example, the proximal and
distal stents of FIG. 54B can be any combination of the stents
229A, 229B, 229C, 229D, 229E, 229F, and 229G. Additionally, the
applicator 260 can be configured to be loaded with only one, three,
or more stents.
[0306] In the illustrated embodiment, the distal flange 237G of the
stent 229G can be wedge-shaped. For example, the distal end of the
flange 237G can have a smaller diameter than that of the proximal
end of the flange 237G. As such, the stent 229G can pass more
easily through the trabecular meshwork 21. Additionally, the
distally facing surface of the flange 237G can be inclined so as to
be aligned with a distal surface of the elongate member 264. As
noted above with respect to the cutting member 250, the elongate
member 264 can be in the form of a trocar.
[0307] The stent-holding element further comprises a sleeve 265
configured to support the elongate member 264. The sleeve 265 (for
example, made of hypo tubing) can be pressed or bonded onto the
distal cap 262 to form a sleeve-cap subassembly. The elongate
member 264 can be configured to be axially moveable relative to the
sleeve 265, as indicated by the arrow 266 (FIG. 54C).
[0308] The housing 261 can also comprise a tip actuator 267 that
has a distal end 268 and a proximal end 269. The elongate member
264 can be press fit or bonded into the distal end portion of the
tip actuator 267 to form a tip/tip actuator subassembly. In one
exemplary but non-limiting embodiment, the elongate member 264 can
be a 0.08 mm diameter sharpened rod made from a hard material, such
as a metal.
[0309] The tip/tip actuator subassembly is fed through the
sleeve-cap subassembly and the cap 262 is screwed onto or bonded
with the housing 261. The proximal end 269 can include a threaded
portion 270 adapted for threaded engagement with a rotation knob
271 located at the proximal end portion of the housing 261. Thus,
the coupling mechanism comprises the tip/tip-actuator subassembly
screwed into the rotation knob 271 to form an actuator-knob
subassembly.
[0310] An interlock arrangement 272 is configured to retain the
knob 271 on the housing 261 and allow the knob 271 to rotate
relative to the housing 261. The interlock arrangement 272 can
include an annular rib disposed on the housing 261 and a groove
disposed on the knob 271. A clearance is provided between the
groove and the rib so as to allow the knob 271 to rotate freely
relative to the housing 261. The knob 271 can be pressed onto the
housing 261 and thus spins freely on housing 261 without coming off
because of an interlock arrangement 272.
[0311] With reference to FIGS. 54A and 54C, the housing 261 can
include a slot line 273 at a location perpendicular to a
longitudinal axis 275 of the housing. One side of the slot line 273
can be drilled through to the opposite side of the housing, thus
allowing an anti-rotation pin 274 to extend therethrough.
[0312] FIG. 54C shows a top cross-sectional view, identified as
section 3-3 of FIG. 54A, with the anti-rotation pin 274 aligned
with the slot 276. During assembly, of the injector 260, the tip
actuator 267 is rotated until the slot 276 is aligned with the
drilled hole adapted for the anti-rotation pin 274 to extend into
the drilled hole. The anti-rotation pin 274 is pressed through a
first side of housing, through the tip actuator, and through a
second opposite side of housing.
[0313] In operation, one or more stents are placed over the member
264 and against the blunt front end of the sleeve 265. After the
injector approaches the target site, the elongate member 264 and
the first stent are pressed into tissue where implantation is to
take place. In an ab interno procedure, the first tissue is the
trabecular meshwork facing the anterior chamber. In an ab externo
procedure, the first tissue is the trabecular meshwork facing
Schlemm's canal. Once the first stent is in a proper location, the
knob 271 is rotated to withdraw the elongate member 264, leaving
the first stent in place. Stents can be snugly held onto the tip
264 with a mechanical feature on the elongate member, such as the
holding members 245 described above with reference to FIGS. 51A-D.
Optionally, the sleeve 265 can include a mechanical feature for
holding stents in place. Further viscoelastic material or other
means can be provided for holding the stents so that stent
deployment does not occur until desired.
[0314] After the first stent is implanted, the injector is slightly
withdrawn away from the trabecular meshwork. The tip of the
injector is moved and pointed to a second target site without
withdrawing the injector from the incision on the sclera. This
re-positioning of the injector can be accomplished with a steerable
section of the injector 260 noted above.
[0315] The term "targeted placement" of trabecular stents refers to
the intentional placement of a stent at a particular location in
Schlemm's canal for the purpose of providing a maximum benefit in
the form of maximum outflow facility. With reference to FIG. 50A,
aqueous enters Schlemm's canal 22 through the trabecular meshwork
21 and travels along the canal to exit through the collector
channels 23. Schlemm's canal is a narrow channel with approximate
dimensions of 250 .mu.m.times.20 .mu.m with a 40 mm length
(Volume.about.0.2 .mu.l) and it provides measurable resistance to
the flow of aqueous. Therefore, placing a stent into Schlemm's
canal 22 through the trabecular meshwork 21 yields the best
improvement in outflow facility when it is placed near a large
collector channel 23 or a group of smaller ones that combine to
have a larger hydraulic diameter. It is one aspect of the present
invention to locate/detect the most appropriate collector
channel(s) to implant a trabecular shunting stent adjacent said
collector channel(s) 23.
[0316] The term "Multi-stent therapy" refers to the intentional
placement of a stent in each of several locations in Schlemm's
canal 22. Since Schlemm's canal 22 has measurable resistance to
flow at physiological flow rates, a plurality of stents is
strategically placed close to concentrations of collector ducts 23
or a large collector and distributed around Schlemm's canal 22 to
maximize the impact of multiple stents.
[0317] An injector or device applicator to hold a plurality of
serial devices has advantages of placing the device one at a time
without reloading the device or without completely withdrawing the
applicator out of a portion of the body. The advantages may include
saving operating time, reducing redundant incision or injury, or
exact positioning for device placement.
[0318] By way of example, but without limitation, an injector or
device applicator for multiple device deployment may be used for
implanting punctum plugs in an eye, for implanting drug-eluting
devices into sclera tissue of an eye, implanting drug-eluting
devices into tissue of a posterior segment, or implanting
cardiovascular stents. Some aspects of at least one of the
inventions disclosed herein relate to a method of multiple device
deployment comprising: (a) loading a plurality of devices within a
device-retaining space of a device applicator; (b) delivering the
applicator to a first target implant site; (c) deploying a first
device at the first target implant site; (d) detaching the
applicator from the first target implant site; (e) directing the
applicator to a second target implant site; (f) deploying a second
device at the second target implant site; and (g) withdrawing the
applicator.
[0319] The device of the exemplary embodiment preferably comprises
a biocompatible material such that inflammation arising due to
irritation between the outer surface of the device and the
surrounding tissue is minimized. Biocompatible materials which may
be used for the device 81 preferably include, but are not limited
to, titanium, titanium alloys, polypropylene, nylon, PMMA
(polymethyl methacrylate), medical grade silicone, e.g.,
Silastic.TM., available from Dow Coming Corporation of Midland,
Mich.; and polyurethane, e.g., Pellethane.TM., also available from
Dow Corning Corporation.
[0320] In other embodiments, the device of the embodiments may
comprise other types of biocompatible material, such as, by way of
example, polyvinyl alcohol, polyvinyl pyrolidone, collagen,
heparinized collagen, polytetrafluoroethylene, expanded
polytetrafluoroethylene, fluorinated polymer, fluorinated
elastomer, flexible fused silica, polyolefin, polyester,
polysilicon, and/or a mixture of the aforementioned biocompatible
materials, and the like. In still other embodiments, composite
biocompatible material may be used, wherein a surface material may
be used in addition to one or more of the aforementioned materials.
For example, such a surface material may include
polytetrafluoroethylene (PTFE) (such as Teflon.TM.), polyimide,
hydrogel, heparin, therapeutic drugs (such as beta-adrenergic
antagonists and other anti-glaucoma drugs, or antibiotics), and the
like.
[0321] Although preferred embodiments of the inventions have been
described in detail, including a method for treating glaucoma
comprising placing a plurality of trabecular stents for
transporting aqueous from an anterior chamber to Schlemm's canal,
certain variations and modifications will be apparent to those
skilled in the art, including embodiments that do not provide all
of the features and benefits described herein. Accordingly, the
scope of the present invention is not to be limited by the
illustrations or the foregoing descriptions thereof, but rather
solely by reference to the appended claims.
* * * * *