Patent Application
20120289886
1. Field of the Invention
The disclosure pertains to systems and methods for stabilizing corneal tissue, and more particularly, systems and methods for conveying a cross-linking agent to regions of the cornea where the cross-linking agent is activated by an initiating element.
2. Description of Related Art
A variety of eye disorders, such as myopia, keratoconus, and hyperopia, involve abnormal shaping of the cornea. Laser-assisted in-situ keratomileusis (LASIK) is one of a number of corrective procedures that reshape the cornea so that light traveling through the cornea is properly focused onto the retina located in the back of the eye. During LASIK eye surgery, an instrument called a microkeratome is used to cut a thin flap in the cornea. The cornea is then peeled back and the underlying cornea tissue ablated to the desired shape with an excimer laser. After the desired reshaping of the cornea is achieved, the cornea flap is put back in place and the surgery is complete.
In another corrective procedure that reshapes the cornea, thermokeratoplasty provides a noninvasive procedure that applies electrical energy in the microwave or radio frequency (RF) band to the cornea. In particular, the electrical energy raises the corneal temperature until the collagen fibers in the cornea shrink at about 60° C. The onset of shrinkage is rapid, and stresses resulting from this shrinkage reshape the corneal surface. Thus, application of energy according to particular patterns, including, but not limited to, circular or annular patterns, may cause aspects of the cornea to flatten and improve vision in the eye.
After a treatment produces a desired change to the shape of a cornea, the cornea can be strengthened by initiating cross-linking in the corneal collagen fibrils. The cross-linking prevents the corneal fibrils in the treated regions from moving and causing undesired changes to the shape of the cornea. In some instances, cross-linking is initiated by applying a cross-linking agent to the eye, followed by application of an initiating element to activate the cross-linking agent. For example, the cross-linking agent may be Riboflavin and the initiating element may be photoactivating light, such as ultraviolet (UV) light. The Riboflavin, acts as a photosensitizer to convert O2 into singlet oxygen which causes cross-linking within the corneal tissue when initiated by UV light.
Systems and approaches for stabilizing a three-dimensional structure of corneal tissue through controlled activation of cross-linking in corneal tissue are disclosed herein. Aspects of the present disclosure provide approaches for controlling the distribution of cross-linking agent within corneal tissue in three dimensions. For example, the cross-linking agent and/or the initiating element may be applied in a series of timed and controlled steps to allow distinct applications of cross-linking agent to incrementally diffuse through the corneal tissue. One or more of the applications of cross-linking agent can be applied with a concentration distinct from other applications. In addition, the activation of the cross-linking agent, once distributed, can be carried out by an initiating element applied in a pattern and with a characteristic focal depth to thereby regulate the activation of cross-linking in the corneal tissue in three dimensions. Moreover, the delivery and activation of the cross-linking agent at depths in the cornea depend on the concentration(s) of the cross-linking agent when applied and the power(s) of the initiating element.
In addition to controlling the distribution of cross-linking agent within the corneal tissue by allowing the cross-linking agent to diffuse within the cornea, additional agents can be applied to the eye to influence the diffusion of the cross-linking agent along the depth of the corneal tissue. In some embodiments, a second (neutral) compound may be applied after one or more of the concentrations of the cross-linking agent has been applied. The second compound applies a pressure to the cross-linking agent and promotes diffusion of the cross-linking agent to depths of the cornea. For example, the neutral compound may be applied at a time when diffusion of the cross-linking agent has slowed and needs to be encouraged by the neutral compound. Concentrations of cross-linking agent at varying depths of the cornea may also be controlled by applying a reverse osmotic substance, e.g., a fluid, gel, etc., to the surface of the cornea to draw cross-linking agent from the corneal tissue, particularly from regions near the surface of the cornea. In some embodiments, iontophoresis is employed to urge cross-linking agent past the epithelium and through the corneal tissue via electromotive forces applied to charged cross-linking agent.
Furthermore, aspects of the present disclosure provide systems and approaches for influencing the permeability of corneal tissue to a cross-linking agent by applying heat energy or ultrasound energy to the corneal tissue. Aspects of the present disclosure may include a delivery system that accurately and precisely delivers the initiating element to corneal fibrils according to a selected pattern. In embodiments where the initiating element is UV light, the delivery system may deliver the UV light in the form of a laser.
These and other aspects of the present disclosure will become more apparent from the following detailed description of embodiments of the present disclosure when viewed in conjunction with the accompanying drawings.
FIB. 4B illustrates another high resolution image of the cornea of
The cross-linking agent 130 can be conveyed to the cornea 2 by, for example, an eye dropper, a drug application device, such as a bandage, or can be included in a cream applied to the eye 1. The delivery system 100 includes a light source 110 and optical elements 112 for directing light to the cornea 2. The delivery system 100 also includes a controller 120 that is coupled to the conveyor 132 and the optical elements 112. The conveyor 132 may be an apparatus adapted to apply the cross-linking agent 130 according to particular patterns on the cornea 2 advantageous for causing cross-linking to take place within the corneal tissues. The conveyor 132 may apply the cross-linking agent 130 to a corneal surface 2A (e.g., an epithelium), or to other locations on the eye 1. Particularly, the conveyor 132 may apply the cross-linking agent 130 to an abrasion or cut of the corneal surface 2A to facilitate the transport or penetration of the cross-linking agent through the cornea 2 to a mid-depth region 2B. As described further herein, the conveyor 132 can be adapted to convey the cross-linking agent 130 to regions of the eye 1 including depths below the corneal surface 2A, by utilizing iontophoresis, reverse-osmotic fluids, neutral compounds, and/or by increasing the permeability of the cornea 2 using heat energy and/or ultrasound to modify the corneal structure and increase its permeability. Additionally or alternatively, the delivery system 100 can include one or more additional components (not shown) to convey the cross-linking agent 130.
For the sake of clarity, the non-limiting embodiments disclosed herein describe the operation of aspects of the present disclosure in conveying the cross-linking agent 130 to regions of the cornea 2. However, the system 100, and the embodiments disclosed herein for conveying the cross-lining agent 130 to regions of the eye 1, refer to systems and methods for directing the cross-linking agent 130 to regions of at least one eye component, and it is understood that the at least one eye component may include a cornea, a limbus, a sclera, and/or a retina.
As described below in connection with
Although eye therapy treatments may initially achieve desired reshaping of the cornea 2, the desired effects of reshaping the cornea 2 may be mitigated or reversed at least partially if the collagen fibrils within the cornea 2 continue to change after the desired reshaping has been achieved. Indeed, complications may result from further changes to the cornea 2 after treatment. For example, a complication known as post-LASIK ectasia may occur due to the permanent thinning and weakening of the cornea 2 caused by LASIK surgery. In post-LASIK ectasia, the cornea 2 experiences progressive steepening (bulging).
Aspects of the present disclosure provide approaches for initiating molecular cross-linking of corneal collagen to stabilize corneal tissue and improve its biomechanical strength. For example, embodiments may provide devices and approaches for preserving the desired corneal structure and shape that result from an eye therapy treatment, such as LASIK surgery or thermokeratoplasty. In addition, aspects of the present disclosure may provide devices and approaches for initiating cross-linking at depths of the cornea 2 below the epithelium 2A by first conveying the cross-linking agent 130 to regions of the cornea 2 below the epithelium 2A. Advantageously, aspects of the present disclosure allow for conveying the cross-linking agent 130 to regions below the epithelium 2A of the cornea 2 without requiring removal of the epithelium 2A. As described herein, the devices and approaches disclosed herein may be used to preserve desired shape or structural changes following an eye therapy treatment by stabilizing the corneal tissue of the cornea 2. The devices and approaches disclosed herein may also be used to enhance the strength or biomechanical structural integrity of the corneal tissue apart from any eye therapy treatment.
Some approaches initiate molecular cross-linking in a treatment zone of the cornea 2 where structural changes have been induced by, for example, LASIK surgery or thermokeratoplasty. However, it has been discovered that initiating cross-linking directly in this treatment zone may result in undesired haze formation. Accordingly, aspects of the present disclosure also provide alternative techniques for initiating cross-linking to minimize haze formation. In particular, the structural changes in the cornea 2 are stabilized by initiating cross-linking in selected areas of corneal collagen outside of the treatment zone. This cross-linking strengthens corneal tissue neighboring the treatment zone to support and stabilize the actual structural changes within the treatment zone.
With reference to
The delivery system 100 also includes a controller 120 for controlling the operation of the optical elements 112 or the conveyor 132, or both. By controlling aspects of the operation of the optical elements 112 and the conveyor 132, the controller 120 can control the regions of the cornea 2 that receive the cross-linking agent 130 and that are exposed to the light source 110. By controlling the regions of the cornea 2 that receive the cross-linking agent 130 and the light source 110, the controller 120 can control the particular regions of the cornea 2 that are strengthened and stabilized through cross-linking of the corneal collagen fibrils. Furthermore, by controlling the depth region that the cross-linking agent 130 is conveyed to, the controller 120 can control the depth of cross-linking activity within the corneal tissue. In an implementation, the cross-linking agent 130 can be applied generally to the eye 1, without regard to a particular region of the cornea 2 requiring strengthening, but the light source 110 can be directed to a particular region of the cornea 2 requiring strengthening, and thereby control the region(s) of the cornea 2 wherein cross-linking is initiated by controlling the regions of the cornea 2 that are exposed to the light source 110. In another implementation, the light source 110 can be directed generally to the eye 1, and the cross-linking agent 130 can be conveyed to particular region(s) of the cornea 2, and thereby control the region of the cornea 2 wherein cross-linking is initiated. In yet another implementation, both the cross-linking agent 130 and the initiating element 110 can be conveyed and/or directed to particular regions of the cornea 2, and thereby jointly control the region(s) of the cornea 2 wherein cross-linking is initiated.
The optical elements 112 can be used to focus the light emitted by the light source 110 to a particular focal plane within the cornea 2, such as a focal plane that includes the mid-depth region 2B. In addition, according to particular embodiments, the optical elements 112 may include one or more beam splitters for dividing a beam of light emitted by the light source 110, and may include one or more heat sinks for absorbing light emitted by the light source 110. The optical elements 112 may further include filters for partially blocking wavelengths of light emitted by the light source 110 and for advantageously selecting particular wavelengths of light to be directed to the cornea 2 for activating the cross-linking agent 130. The controller 120 can also be adapted to control the light source 110 by, for example, toggling a power switch of the light source 110.
In an implementation, the controller 120 may include hardware and/or software elements, and may be a computer. The controller 120 may include a processor, a memory storage, a microcontroller, digital logic elements, software running on a computer processor, or any combination thereof. In an alternative implementation of the delivery system 100, the controller 120 may be replaced by two or more separate controllers or processors. For example, one controller may be used to control the operation of the conveyor 132, and thereby control the precise rate of delivery, location of conveyance, depth of penetration, and/or concentration of the cross-linking agent 130 to the cornea 2. Another controller may be used to control the operation of the optical elements 112, and thereby control with precision the delivery of the light source 110 (i.e. the initiating element) to the cornea 2 by controlling any combination of: wavelength, bandwidth, intensity, power, location, depth of penetration, and duration of treatment. In addition, the function of the controller 120 can be partially or wholly replaced by a manual operation. For example, the conveyor 132 can be manually operated to deliver the cross-linking agent 130 to the cornea 2 without the assistance of the controller 120. In addition, the controller 120 can operate the conveyor 132 and the optical elements 112 according to inputs dynamically supplied by an operator of the delivery system 100 in real time, or can operate according to a pre-programmed sequence or routine.
Referring to
As the example embodiment 200B of
According to one approach, the Riboflavin may be applied topically to the corneal surface, and transepithelial delivery allows the Riboflavin to be applied to the corneal stroma. In general, the application of the cross-linking agent sufficiently introduces Riboflavin to mid-depth regions of the corneal tissue where stronger and more stable structure is desired.
According to aspects of the present disclosure, a treatment is employed to produce a desired change to the shape of the cornea 2. For example, thermokeratoplasty applies energy to the cornea 2 to reshape the cornea 2.
As further illustrated in
With the concentric arrangement of conductors 311A and 311B, a substantially annular gap 311C of a selected distance is defined between the conductors 311A and 311B. The annular gap 311C extends from the proximal end 310A to the distal end 310B. A dielectric material 311D may be used in portions of the annular gap 311C to separate the conductors 311A and 311B. The distance of the annular gap 311C between conductors 311A and 311B determines at least partially the penetration depth of microwave energy into the cornea 2 according to established microwave field theory. Thus, the energy conducting element 311 receives, at the proximal end 310A, the electrical energy generated by the electrical energy source 320, and directs microwave energy to the distal end 311B, where the cornea 2 is positioned.
In general, the outer diameter of the inner conductor 311B may be selected to achieve an appropriate change in corneal shape, i.e., keratometry, induced by the exposure to microwave energy. Meanwhile, the inner diameter of the outer conductor 311A may be selected to achieve a desired gap between the conductors 311A and 311B. For example, the outer diameter of the inner conductor 311B ranges from about 2 mm to about 10 mm while the inner diameter of the outer conductor 311A ranges from about 2.1 mm to about 12 mm. In some systems, the annular gap 311C may be sufficiently small, e.g., in a range of about 0.1 mm to about 2.0 mm, to minimize exposure of the endothelial layer of the cornea (posterior surface) to elevated temperatures during the application of energy by the applicator 310.
A controller 340 may be employed to selectively apply the energy any number of times according to any predetermined or calculated sequence. In addition, the heat may be applied for any length of time. Furthermore, the magnitude of heat being applied may also be varied. Adjusting such parameters for the application of heat determines the extent of changes that are brought about within the cornea 2. Of course, the system 300 can limit the changes in the cornea 2 to an appropriate amount of shrinkage of collagen fibrils in a selected region and according to a selected pattern. When employing microwave energy to generate heat in the cornea 2, for example with the applicator 310, the microwave energy may be applied with low power (of the order of 40W) and in long pulse lengths (of the order of one second). However, other systems may apply the microwave energy in short pulses. In particular, it may be advantageous to apply the microwave energy with durations that are shorter than the thermal diffusion time in the cornea 2. For example, the microwave energy may be applied in pulses having higher power in the range of 500 W to 3 kW and pulse duration in the range of about 10 milliseconds to about one second.
Referring again to
In general, an interposing layer, such as the dielectric layer 310D, may be employed between the conductors 311A and 311B and the cornea 2 as long as the interposing layer does not substantially interfere with the strength and penetration of the microwave radiation field in the cornea 2 and does not prevent sufficient penetration of the microwave field and generation of a desired heating pattern in the cornea 2. The dielectric material may be elastic, such as polyurethane and silastic, or nonelastic, such as Teflon® and polyimides. The dielectric material may have a fixed dielectric constant or varying dielectric constant by mixing materials or doping the sheet, the variable dielectric being spatially distributed so that it may affect the microwave hearing pattern in a customized way. The thermal conductivity of the material may have fixed thermal properties (thermal conductivity or specific heat), or may also vary spatially, through mixing of materials or doping, and thus provide a means to alter the heating pattern in a prescribed manner. Another approach for spatially changing the heating pattern is to make the dielectric sheet material of variable thickness. The thicker region will heat less than the thinner region and provides a further means of spatial distribution of microwave heating.
During operation, the distal end 310B of the applicator 310 as shown in
The system 300 of
As further illustrated in
Treatment of the cornea 2 produces structural changes to the stroma 2C. As described previously with reference to
Thus, aspects of the present disclosure provide techniques that promote the effective delivery of the cross-linking agent 130 across the epithelium 2A to the corneal tissue below, without requiring removal of the overlying epithelium 2A.
Studies have been directed at the effects of conveying a cross-linking agent to a cornea after thermokeratoplasty. The studies have discovered distinct enhancement in the uptake, i.e., movement, of the cross-linking agent (Riboflavin) into the regions that are treated with energy. In particular, fluorescence indicating the presence of the cross-linking agent in the cornea is brighter in the regions that receive energy. In other words, the pattern of brighter fluorescence matches the pattern of energy application. The pattern of energy application generally depends on the shape of the thermokeratoplasty applicator and the contact between the applicator and the cornea. For example, using the applicator 310, the regions of the cornea exhibiting an enhanced capacity to receive the cross-linking agent correspond closely to the annular pattern defined by the outer conductor 311A and inner conductor 311B. In addition, the fluorescence is bigger and brighter when the intended correction via thermokeratoplasty is greater, i.e., greater amounts of energy are applied. Correspondingly, the greater uptake of the cross-linking agent in these treated regions should result in greater cross-linking when the cross-linking agent is appropriately activated. According to the studies, the delivery of the cross-linking agent is enhanced where cross-linking activation is particularly desired, i.e., where the energy is applied to treat the eye according to thermokeratoplasty.
As discussed previously with reference to
In some embodiments, the dosage of the cross-linking agent and other aspects of its application are modified to account for the increased capacity of treated regions to accommodate greater amounts of cross-linking agent after the application of energy. For example, referring to the example embodiment 500A shown in
In other embodiments, another treatment, such as LASIK, may be employed. In LASIK surgery, an instrument called a microkeratome is used to cut a thin flap in the cornea. The flap is peeled back and the underlying corneal tissue is ablated to the desired shape with an excimer laser. After the desired reshaping of the cornea is achieved, the cornea flap is put back in place to complete the surgery. In such treatments, energy may not be applied to the cornea in the same manner as thermokeratoplasty. However, the application of energy may be employed as an additional step to enhance the movement of the cross-linking agent 130 into regions that are treated. For example, referring to the example embodiment 500B shown in
In general, energy may be applied to selected regions of the cornea 2 according to any pattern, for example, with an applicator similar to the applicator 310 described previously. Although the pattern defined by the applicator 310 may be annular, the pattern may have any non-annular and/or asymmetric shape. The pattern determines the regions of the cornea 2 that will have enhanced permeability to receive the cross-linking agent 130 and that will experience greater cross-linking relative to the other regions of the cornea 2. Thus, the application of energy provides a technique for achieving patterned activation of cross-linking in the cornea 2. Examples of the non-annular shapes by which energy may be applied to the cornea are described in U.S. patent Ser. No. 12/113,672, filed on May 1, 2008, the contents of which are entirely incorporated herein by reference.
In one example, a lower concentration of the cross-linking agent is broadly applied to the cornea, e.g., in the form of a drip, after a pattern of energy is applied. The lower concentration of the cross-linking agent is effective in activating cross-linking in the regions treated with energy, because these regions receive more cross-linking agent. Meanwhile, the effect on the other regions of the cornea may be insignificant due to the low concentration and the lower amount of cross-linking agent received by these other regions.
Referring to the embodiment 600A shown in
Referring to the embodiment 600B shown in
While the embodiments 600A and 600B each provide for increasing the permeability of the corneal tissues, in some embodiments, the cross linking agent 130 may be dissolved in a different carrier to promote delivery across the corneal surface 2A. For example, the cross-linking agent 130 may be combined in varying concentrations with another agent, such as EDTA, benzalkonium chloride, or an alcohol, to promote further delivery across the corneal surface 2A.
Referring to embodiment 700A shown in
Referring to embodiment 700B shown in
Referring to the embodiment 800A shown in
To achieve greater concentrations of Riboflavin farther below the surface, in step 810, the reverse osmotic fluid 812, such as distilled water, is applied to the corneal surface 2A. The reverse osmotic fluid 812 at the surface acts to draw the cross-linking agent 130 out from regions of corneal tissue closer to the corneal surface 2A. The concentration of the cross-linking agent 130 in the regions closer to the corneal surface 2A is then reduced relative to the regions farther below. Thus, the use of the reverse osmotic fluid 812 can produce a “reverse gradient” of the amount of the cross-linking agent 130 along a path moving deeper into the cornea 2.
The resulting distribution of the cross-linking agent 130 is then activated by the application of an initiating element 222, e.g., UV light, in step 220 to initiate cross-linking in the corneal regions treated with the cross-linking agent 130. The cross-linking activity generally corresponds to the distribution of cross-linking agent 130, which is produced in part by the application of the reverse osmotic fluid 812 in step 810.
Referring to the embodiment 800B shown in
Referring to
The cross-linking agent 912 is then activated in step 220 with an initiating element 922. Activation of the cross-linking agent 912 is triggered by the application of microwaves or light. As such, the initiating element 922 is applied with a power P. The power P of the initiating element 922 determines the extent to which the distribution of cross-linking agent 912 is activated. For example, an initiating element applied with a greater power P may reach greater depths below the epithelium 2A and allow the cross-linking agent to be activated at these depths. The parameters C, P, and T may be selected as independent variables to achieve the appropriate amount of cross-linking at desired depths of the cornea.
As the example embodiment 900B of
While the embodiment 1000A shown in
Referring to
In step 902′, a period of time T1 is allowed to pass. As described previously, during the period of time T1, the Riboflavin diffuses from the corneal surface into the underlying corneal structure according to an exponential gradient. Thus, the concentration of Riboflavin in the corneal tissue is generally greater in regions closer to the surface. In some cases, it is desirable to have greater concentrations of Riboflavin in regions farther below the surface relative to the concentrations of Riboflavin in regions closer to the surface. For example, greater concentrations of Riboflavin at greater depths may be more effective in stabilizing the corneal structure, whereas excessive cross-linking at or near the surface may create unwanted effects.
To achieve greater relative concentrations of Riboflavin farther below the surface, in step 810′, a reverse osmotic substance 812, such as distilled water, is applied to the corneal surface for a period of time T2. The reverse osmotic substance 1718 at the surface acts to draw the Riboflavin out from regions of corneal tissue closer to the surface. The concentration of the Riboflavin in the regions closer to the surface is then reduced relative to the regions farther below. Thus, the use of the reverse osmotic substance 318 can produce a “reverse gradient” of the Riboflavin concentration traveling in to the corneal tissue.
It is understood that distilled water is merely one example of a reverse osmotic substance 812 and other hypotonic fluids/solutions with appropriate concentrations may be employed. Alternatively, the reverse osmotic substance 812 may be a gel, hydrogel, a semisolid substance, or other non-liquid substance that can draw the cross-linking agent 914′ out of the corneal tissue.
The resulting distribution of Riboflavin is then activated by the application of an initiating element 932, i.e., UV light, in step 930 to initiate cross-linking in the corneal regions treated with Riboflavin. The cross-linking activity generally corresponds to the distribution of Riboflavin produced in part by the application of the reverse osmotic substance 812.
While described as first concentration C1 and durations T1 and T2, the embodiment 1000B can be carried out in an iterative scheme with each iteration having distinct values of concentration, duration(s), power, etc. (similar to the discussion in connection with the embodiment 1000A of
Further, in an iterative implementation of the embodiment 1000A or 1000B, one or more of the steps (508, 604, 720, 820, 902, 810, etc.) can be adjusted according to feedback information indicative of the progress of cross-linking in strengthening the corneal tissue. In an example embodiment, feedback information can be supplied by a feedback system (e.g., the feedback system(s) 1510 described in
The absorption of Riboflavin follows Beer's law at higher concentrations (typically near the surface of the cornea) and less so at greater depths in the corneal tissue where the concentration of Riboflavin becomes smaller. Such results indicate that unsafe concentrations of Riboflavin are less likely to reach the endothelium than was previously understood from misleading spectrophotometric data. In particular, the noise limit of the spectrophotometer led to the incorrect conclusion that there was a saturation point for the Riboflavin. However, with a clearer understanding of how Riboflavin is received by the corneal tissue, there is a need for systems and methods that can modify/tailor the concentration gradient according to aspects of the present disclosure described above. For example, some embodiments of the present disclosure provide for a system configured to distribute Riboflavin agent within corneal tissue without accounting for a saturation point of the Riboflavin.
In sum, embodiments stabilize a three-dimensional structure of corneal tissue through controlled application and activation of cross-linking in the corneal tissue. For example, the cross-linking agent and/or the initiating element are applied in a series of timed and controlled steps to activate cross-linking incrementally. Moreover, the delivery and activation of the cross-linking agent at depths in the cornea 2 depend on the concentration(s) of the cross-linking agent and the power(s) of the initiating element.
Although cross-linking agents, such as Riboflavin, may be effectively applied to the stroma by removing the overlying epithelium before application, it has been shown that cross-linking agents can chemically transition across the epithelium into the stroma. Indeed, Riboflavin may also be delivered to the stroma by applying it topically on the epithelium. Moreover, in some cases, the epithelium may be treated to promote the transition of the cross-linking agent through the epithelium. Accordingly, in the embodiments described herein, no removal of the epithelium is required. Advantageously, this eliminates the post-operative pain, healing period, and other complications associated with the removal of the epithelium.
Although embodiments of the present disclosure may describe stabilizing corneal structure after treatments, such as LASIK surgery and thermokeratoplasty, it is understood that aspects of the present disclosure are applicable in any context where it is advantageous to form a stable three-dimensional structure of corneal tissue through cross-linking
In addition to regulating distribution and/or concentration of cross-linking agent during initiation of cross-linking so as to control the pattern of resulting cross-linking in the tissue, aspects of the present disclosure provide systems and methods for controlling the concentration of cross-linking agent within tissue following treatment. For example, aspects of the present disclosure provide better control of corneal cross-linking and prevent unintended cross-linking and/or other local phototoxicity by safely inhibiting, deactivating, or destroying, i.e., quenching, any residual Riboflavin that may remain in the corneal tissue after the desired cross-linking activity has been achieved. By quenching residual Riboflavin, aspects of the present disclosure improve patient safety and provide more accurate control of corneal cross-linking activity.
It has been observed that corneal cross-linking is an inefficient process, in which amounts of the cross-linking agent, e.g., Riboflavin, applied to the corneal tissue may not react with UV light during the cross-linking treatment. In addition, cross-linking treatments may attempt to achieve a desired depth and degree of cross-linking activity, for example, by limiting the amount of UV light directed at the cornea after Riboflavin has been applied or by limiting the potential for localized or regional patterning of cross-linking Limiting the activation of cross-linking activity during a treatment may result in applied Riboflavin remaining unreacted.
Accordingly, residual Riboflavin may remain in the corneal tissue after the treatment. Because Riboflavin's absorption spectrum includes a portion of the visible spectrum, environmental light can excite Riboflavin so as to serve as an initiating element even in the absence of an application of UV light. Residual Riboflavin may result in additional, unwanted cross-linking activity when the cornea is exposed to environmental light. Such problems have been addressed in photodynamic therapy by minimizing exposure to environmental light, e.g., keeping the patient in a dark room, until residual photodynamic agents either degrade or migrate from the treatment area. Riboflavin in the absence of light is generally regarded as safe (“GRAS”) and over time migrates out of the cornea and eye by diffusion, active transport, circulation, etc. However, aspects of the present disclosure provide systems and methods for quenching Riboflavin remaining in the eye following treatment and thereby prevent undesired cross-linking activity from occurring.
Referring to
In step 210, the cross-linking agent may be applied directly on the treated tissue and/or in areas around the treated tissue. In some embodiments, the cross-linking agent may be an ophthalmic solution that is broadly delivered by a dropper, syringe, other drug application device, or the like. Alternatively, the cross-linking agent may be selectively applied as an ophthalmic ointment with an appropriate ointment applicator. The cross-linking agent 214 is then activated in step 220 with an initiating element 224. In particular, photoactivation of the cross-linking agent 214 is triggered by the application of UV light from a corresponding energy or light source. The UV light initiates cross-linking activity by exciting the applied Riboflavin to generate reactive Riboflavin radicals and reactive oxygen radicals in the corneal tissue. Thus, the Riboflavin acts as a sensitizer to radical Riboflavin and to convert O2 into singlet oxygen which causes cross-linking within the corneal tissue. The resulting cross-linking of and between collagen fibrils provides resistance to changes in corneal structure, thereby increasing strength.
Referring to
Examples of photoactivation of Riboflavin to thereby cause the formation of cross-links in fibril tissue are described further below, including Type I and Type II photoactivation mechanisms. Generally, Riboflavin absorbs energy from incident light according to the absorption spectrum shown in
Aspects of the present disclosure provide more effective control of cross-linking activity to minimize, for example, photoactivation of residual Riboflavin by exposure to environmental light. In particular, embodiments allow Riboflavin to be photoactivated when desired, titrated to a desired endpoint, and quenched with a selected substance to prevent unwanted cross-linking activity from residual Riboflavin. Referring again to
Practically, Riboflavin-5-phosphate (also known as Flavin Mononucleotide (FMN)) is used for pharmaceutical preparations of Riboflavin. The photochemical and biological behavior of FMN is substantially identical to those of Riboflavin, but FMN is more soluble in water. The fluorescence of a solution of FMN may be quenched by the addition of purines or adenosine. Complexing FMN with a protein, as in most flavoproteins, abolishes the fluorescence. This type of fluorescence quenching is not necessarily associated with changes in absorption spectra, and arises because the complex formed is nonfluorescent. Heating the solution dissociates the complex, and the fluorescence therefore increases with temperature.
Fluorescence quenching of Riboflavin can also occur by a diffusional encounter between a Riboflavin molecule in the first singlet excited state and metal ions (e.g., mercuric, ferric, ferrous, etc.) or iodide ion. For this collisional quenching, an increase in temperature results in a decreased fluorescence, since encounters are more frequent at the higher temperatures.
Ascorbic acid quenches both excited triplet Riboflavin and singlet oxygen (type I and type II mechanisms). The addition of ascorbic acid can protect Riboflavin oxidation in foods exposed to light. Ascorbic acid appears to inhibit photo-degradation of Riboflavin in a dose-dependent manner. When combined with greater than 40 mM ascorbic acid, more than 90% of
Riboflavin remains unreacted after 4 hours of light exposure. This suggests that ascorbic acid does not chemically degrade riboflavin, but blocks the light reaction. Ascorbic acid is also a potent anti-oxidant, effectively scavenging singlet oxygen which may be produced. Ascorbic acid preparations have been used topically to improve wound healing after laser refractive surgery in concentrations of approximately 10% ascorbic acid in distilled water.
Phenol and terpine are phenolic compounds found in food products, including beer. Phenolic compounds present in beer were shown by fluorescence spectroscopy and laser flash photolysis to deactivate both singlet- and triplet-excited states of Riboflavin with bimolecular rate constants close to the diffusion control. Fairly high concentrations of these compounds (greater than 0.3 M) are required for quenching, however, at concentrations of 0.36 M, greater than 90% of triplet-state is inhibited. A variety of phenolic compounds are extracted from plants and used as pharmaceuticals. This class of compounds provides a number of options for Riboflavin quenching. Other aromatic organic compounds which quench Riboflavin fluorescence include diphenols, purines, and pyrimidines.
Riboflavin fluorescence is also effectively quenched by metal ions, such as, for example, HgII, FeII, FeIII, CoIII, and AuIII. The quenching occurs with Riboflavin catalyzed photoreduction of the metal ions. The metal ions are provided in the form of metal salts. For example, 0.018 M AgNO3 produced 69% quenching, CuSO4 and FeSO4 and their associated ions produced greater than 99% reduction in fluorescence at concentrations of 0.01 M. The mechanisms of Riboflavin catalyzed photoreduction degrades Riboflavin to compounds with no photoactivity and which do not have absorption in the visible spectrum. Iron sulfate, FeSO4, is a common food additive provided to supplement dietary iron.
Flavoproteins are a class of proteins containing Riboflavin or its cousins FMN or flavin adenine dinucleotide (FAD). Their function is to bind and transport Riboflavin in an inert state until it reaches its functional target. There is a large class of these compounds which perform the transport role in eukaryotic cells.
Accordingly, aspects of the present disclosure may apply appropriate preparations of any of the quenching substances described herein to provide better control of corneal cross-linking and prevent unintended cross-linking and/or other local phototoxicity produced from any residual Riboflavin. Examples are described herein, but it is understood that aspects of the present disclosure can generally be applied to inhibit R*, O2*, and/or any excited intermediates, as shown by the various “X” symbols on
Studies have shown that in the presence of light, Riboflavin can exhibit photosensitizing properties reacting with a wide range of electron donating substances (e.g., amines or amino acids) through a combination of Type I and Type II photochemical mechanisms. In the Type I mechanism, which is favored at low oxygen concentrations, excited Riboflavin reacts with compounds from the surrounding substrate to generate free radicals or radical ions by hydrogen atom or electron transfer. In the Type II mechanism, excited Riboflavin reacts with oxygen to form singlet molecular oxygen. Because Type II photosensitization requires molecular oxygen, as the oxygen in a system decreases, Type II photosensitization is shifted to Type I. The radicals/radical ions and the singlet molecular oxygen from Type I and/or Type mechanisms results in cross-linking activity of fibril structures in the corneal tissue.
A model of the photochemical kinetics of corneal cross-linking with Riboflavin in ex vivo porcine cornea was developed by the inventors. During experiments to test the model, measurements of oxygen validated the model. De-epithelialized porcine corneas were soaked with 0.1% riboflavin in distilled water for 20 minutes and exposed to 365 nm UV light (UVA) for 30 minutes at an irradiance of 3 mW/cm2 for a total dose of 5.4 J/cm2. Oxygen concentrations in the cornea at a known depth in the corneal tissue were monitored during UVA illumination with a dissolved oxygen fiber optic microsensor. Data from the oxygen and temperature experiments were used to validate the model. Oxygen concentration in the cornea depends on the UVA irradiance and temperature and quickly decreases at the beginning of the procedure. The oxygen dynamics in the cornea during the activation of Riboflavin indicate that the Type-I mechanism is the predominant mechanism for cross-linking during the treatment. The Type-II mechanism is significant in providing cross-linking for a short period when the Riboflavin is initially illuminated.
Additionally, more than halfway through the illumination period in the study, the oxygen concentration in the cornea slowly increases where the Type-II mechanism may play a further role in cross-linking During this phase, one expects a growing input from the singlet oxygen-mediated cross-linking together with the enhancement of secondary radical reactions that are modulated by oxygen. In general, however, the study suggests that the primary photochemical kinetics mechanism is the direct interaction between excited Riboflavin triplets and reactive groups of corneal proteins which leads to the cross-linking of the fibril proteins mainly through radical reactions. Thus, the inventors have established a new framework for the photochemical kinetics of corneal cross-linking with Riboflavin, and are further investigating the kinetics of free radical polymerization.
Aspects of the present disclosure control the distribution of the cross-linking agent according to the kinetics associated with its application. In particular, varying concentrations of the cross-linking agent may be achieved at various regions and depths of the corneal tissue to achieve a desired pattern of cross-linking activity. For example, the cross-linking agent may be applied by employing techniques and/or chemistries that enhance or slow the delivery of the cross-linking agent to various regions and depths of the corneal tissue. Some embodiments of the present disclosure accordingly provide ophthalmic drug application devices suitable for conveying the cross-linking agents, reverse osmotic substances, quenching agents, etc., to the corneal tissue in ordered steps to thereby regulate the distribution of the cross-linking agent within the corneal tissue.
As discussed in connection with
The kinetics associated with the cross-linking agent depends on temperature. In particular, diffusion by the cross-linking agent increases with temperature. For example, the diffusion coefficient of riboflavin in corneal tissue increases by approximately a factor of 2 when the temperature of riboflavin increases from 20° F. to 34° F. Therefore, aspects of the present invention control the distribution of a cross-linking agent in corneal tissue, at least partially, by controlling (increasing or decreasing) the temperature of the cross-linking agent in the corneal tissue.
According to aspects of the present disclosure, the temperature of the cross-linking agent applied in specific areas of the cornea may be increased and/or decreased to control distribution of the cross-linking agent according to a particular pattern. As such, the distribution of the cross-linking agent throughout the corneal structure is determined at least partially by this pattern. For example, keratoconus may be treated by patterned application of a cross-linking agent, i.e., controlled delivery of the cross-linking agent throughout the corneal tissue relative to the keratoconic cone. In this treatment, the temperature of different areas of the cornea may be increased or decreased to achieve a desired distribution of the cross-linking agent relative to the keratoconic cone. The keratoconic cone may be heated or cooled directly, while the areas outside the keratoconic cone are maintained at a different temperature. Alternatively, the areas outside the keratoconic cone may be heated or cooled directly, while the keratoconic cone is maintained at a different temperature. Alternatively, the keratoconic cone may be heated or cooled directly, while the areas outside the keratoconic cone may be actively, but oppositely, cooled or heated. Such patterned heating may be achieved, for example, provided by controlled targeting of a laser.
In combination with controlling the distribution of the cross-linking agent through the use of temperature, the activation of the cross-linking agent may be controlled by patterned application of UV light, i.e., delivering specific doses of UV light to specific areas of the cornea. The patterned application of UV light determines in part the amount of cross-linking activity in the specific areas of the cornea. Systems and methods relating to controlling the application of UV light is described, for example, in U.S. patent application Ser. No. 13/051,699. For example, in the treatment of keratoconus, the keratoconic cone may be selectively illuminated with doses of UVA while the keratoconic cone is also heated. Other combinations of patterned delivery and patterned temperature control are contemplated.
For example, the controller 120 can operate the system 1500 according to any of the methods provided by the embodiments described above in connection with
In an exemplary operation of the system 1500, the permeability regulation system(s) 1520 apply energy to the corneal tissue 2 to increase the permeability of the corneal tissue to the cross-linking agent 130. The permeability regulation system(s) 1520 can include one or more of an ultrasound generator 1522, a laser system 1524, or a microwave thermokeratoplasty system 1526. The thermokeratoplasty system 1526 can be similar to the system 300 of
The system 1500 further includes the feedback system(s) 1510. The feedback system(s) 1510 are configured to dynamically monitor cross-linking activity in the corneal tissue 2, the distribution of the cross-linking agent 130 within the corneal tissue 2. The feedback system(s) 1510 monitors observable factors influencing (or indicative of) the distribution of cross-linking agent or the progress of cross-linking activity within the corneal tissue 2. Generally, the feedback system(s) 1510 can include sensors to measure characteristics of the corneal tissue 2, and outputs to convey signals indicative of the measured characteristics to the controller 120. The controller 120 can be configured to adjust a cross-linking therapy and/or distribution of the cross-linking agent 130 within the eye via the optical elements 112, the drug application device 132, the permeability regulation system(s) 1520, and/or the temperature regulation systems(s) 1530.
In some examples, the feedback system(s) 1510 include an interferometry system, a multi-camera Scheimpflug system, an Ocular Coherence Tomography (OCT) system, a Supersonic Shear Imaging (SSI) system, or another monitoring system for characterizing biomechanical properties of the eye 1. For example, an interferometry system can characterize the corneal topography by comparing interference patterns of light reflected from the corneal surface with light reflected from a reference surface. Observing the corneal topography over time allows for characterization of the dynamic deformation of the corneal tissue 2 in response to subtle perturbations, such as changes in intraocular pressure, external stimuli, etc. The rate and/or amount of deformation provide an indication of biomechanical strength or stiffness (e.g., a measure of the resistance to deformation) of the corneal tissue. Thus, feedback systems 1510 operative to provide indications of the biomechanical strength of the corneal tissue 2 can indicate the progress of cross-linking activity in the eye, and thus indicate the need for additional cross-linking activity. The feedback system 1510 can optionally include systems for detecting additional biomechanical properties of the eye 1, such as corneal thickness. Further the feedback system 1510 may include a video system for monitoring the position of the cornea 2 and aligning the optical elements 112 according to the position information.
The feedback system 1510 can alternatively or additionally include an OCT system or Scheimplflug system configured to dynamically characterize the deformation response of corneal tissue 2 to subtle perturbations and thereby determine the biomechanical strength of the corneal tissue. Systems and methods relating to monitoring the distribution of cross-linking agent and aspects of cross-linking activity are described, for example, in U.S. patent application Ser. No. 13/051,699; U.S. Provisional Patent Application No. 61/492,553, filed Jun. 2, 2011; U.S. Provisional Patent Application No. 61/542,269, filed Oct. 2, 2011; U.S. Provisional Patent Application No. 61/550,576, filed Oct. 24, 2011; and U.S. Provisional Patent Application No. 61/597,137, filed Feb. 9, 2012, the contents of these applications being incorporated entirely herein by reference.
In other examples, the feedback system 1510 can include a temperature sensor to indicate the temperature of the corneal tissue 2. The temperature information from the temperature sensor can then be used to determine an amount and/or pattern of heat energy to apply to the corneal tissue 2 via, for example, the laser system 1524, an infrared light delivery system, or microwave thermokeratoplasty system 1526 of the permeability regulation system(s) 1520. As described in connection with
In some embodiments, a laser system, such as, for example, an excimer laser, can be employed to thin selected regions of the corneal tissue so as to influence the diffusion rate of cross-linking agent into the corneal tissue. For example, a laser can selectively thin the outer epithelium of the eye in regions where increased cross-linking agent uptake is desired. In some examples, the regions that are selectively thinned or otherwise altered via the laser system are determined according to feedback information indicative of the biomechanical shape and/or structure of the corneal tissue.
Additionally or alternatively, diffusion influencing compounds 1540 can be applied to the cornea 2 via the drug application device 132 to urge the cross-linking agent 130 to further depths within the cornea 2 (e.g., a neutral compound as described in connection with
In some embodiments, feedback information from the feedback system(s) 1510 can then be used to develop a treatment plan or dynamically adjust a treatment plan that is suited to the monitored characteristics of the corneal tissue 2. The treatment plan can be characterized by one or more applications of the cross-linking agent 130 to achieve desired distributions within the cornea 2 and one or more energy doses of the initiating element delivered via the optical elements 112 according to desired patterns to controllably activate cross-linking in the corneal tissue 2. Exemplary systems and methods for controlling the activation of the cross-linking agent 130 by precisely delivering the initiating element both spatially and temporally, and optionally according to information received from a feedback system are provided in U.S. patent Ser. No. 13/051,699, filed Mar. 18, 2011, and which claims priority to U.S. Provisional Application No. 61/315,840, filed Mar. 19, 2010; U.S. Provisional Application No. 61/319,111, filed Mar. 30, 2010; U.S. Provisional Application No. 61/326,527, filed Apr. 21, 2010; U.S. Provisional Application No. 61/328,138, filed Apr. 26, 2010; U.S. Provisional Application No. 61/377,024, filed Aug. 25, 2010; U.S. Provisional Application No. 61/388,963, filed Oct. 1, 2010; U.S. Provisional Application No. 61/409,103, filed Nov. 1, 2010; and U.S. Provisional Application No. 61/423,375, filed Dec. 15, 2010, the contents of these applications being incorporated entirely herein by reference. These and other techniques may be combined with the permeability regulation system(s) 1520 and/or diffusion influencing compounds 1540 to control the diffusion of the cross-linking agent 130 into selected corneal regions according to a desired distribution and thereby generate cross-linking activity at selected regions of the corneal tissue.
The embodiments above may be described with respect to treatment of the cornea and the application of a cross-linking agent. In general, however, embodiments according to the present disclosure take advantage of the increase in the permeability of eye tissue caused by the application of energy. It is further understood that aspects of the present disclosure may be employed with other eye features, such as the limbus, sclera, and retina. Thus, for example, the increased permeability may be advantageous in treating retinal membrane problems. In addition, the application of energy may be employed to produce changes in permeability in the structure of the limbus and the sclera. For example, energy may be applied to form a 6 mm to 8 mm arc at the limbus overlying Schlemm's canal. The corresponding structural changes may result in lowering intraocular pressure, for example, in the treatment of glaucoma. Increased scleral permeability without the induction of fibroblastic elements may be an effective way to lower intraocular pressure. With the increased fluid movement after energy application, significant lowering of intraocular pressure may occur. Advantageously, the amount of energy may be applied with precision.
Aspects of the present disclosure provide for lowering intraocular pressure by generating structural changes in at least one eye component of an eye. The at least one eye component may be a cornea, a limbus, a sclera, and/or a retina. According to aspects providing treatment methods for glaucoma, the cross-linking agent is not necessarily conveyed to the cornea. Aspects provide for treating glaucoma or other eye conditions by decreasing intraocular pressure with or without cross-linking also taking place. Conventional glaucoma treatments provide for decreasing intraocular pressure by regulating the flow of aqueous humor through use of, for example, prescription medications or surgical interventions. Conventional treatments to decrease intraocular pressure may decrease capillary size, or surgically redirect a flow of aqueous humor. However, aspects of the present disclosure provide for decreasing intraocular pressure to treat glaucoma by generating a structural change of an eye component by application of energy to the eye component. For example, heat energy can be applied to the eye component using the applicator 310 shown in
The use of Riboflavin as the cross-linking agent and UV light as the initiating element in the embodiments above is described for illustrative purposes only. In general, other types of cross-linking agents may be alternatively or additionally employed according to aspects of the present disclosure. Thus, for example Rose Bengal (4,5,6,7-tetrachloro-2′,4′,5′,7′-tetraiodofluorescein) may be employed as the cross-linking agent 130, or as the cross-linking agent delivered in varying concentrations 912, 1022. Rose Bengal has been approved for application to the eye as a stain to identify damage to conjunctival and corneal cells. However, Rose Bengal can also initiate cross-linking activity within corneal collagen to stabilize the corneal tissue and improve its biomechanical strength. Like Riboflavin, photoactivating light may be applied to initiate cross-linking activity by causing the Rose Bengal to convert O2 in the corneal tissue into singlet oxygen. The photoactivating light may include, for example, UV light or green light. The photoactivating light may include photons having energy levels sufficient to individually convert O2 into singlet oxygen, or may include photons having energy levels sufficient to convert O2 into singlet oxygen in combination with other photons, or any combination thereof.
Although embodiments of the present disclosure may describe stabilizing corneal structure after treatments, such as LASIK surgery and thermokeratoplasty, it is understood that aspects of the present disclosure are applicable in any context where it is advantageous to form a stable three-dimensional structure of corneal tissue through cross-linking Furthermore, while aspects of the present disclosure are described in connection with the re-shaping and/or strengthening of corneal tissue via cross-linking the corneal collagen fibrils, it is specifically noted that the present disclosure is not limited to cross-linking corneal tissue, or even cross-linking of tissue. Aspects of the present disclosure apply generally to the controlled cross-linking of fibrous matter and optionally according to feedback information. The fibrous matter can be collagen fibrils such as found in tissue or can be another organic or inorganic material that is arranged, microscopically, as a plurality of fibrils with the ability to be reshaped by generating cross-links between the fibrils. Similarly, the present disclosure is not limited to a particular type of cross-linking agent or initiating element, and it is understood that suitable cross-linking agents and initiating elements can be selected according to the particular fibrous material being reshaped and/or strengthened by cross-linking
The present disclosure includes systems having controllers for providing various functionality to process information and determine results based on inputs. Generally, the controllers (such as the controllers 120, 340 described throughout the present disclosure) may be implemented as a combination of hardware and software elements. The hardware aspects may include combinations of operatively coupled hardware components including microprocessors, logical circuitry, communication/networking ports, digital filters, memory, or logical circuitry. The controller may be adapted to perform operations specified by a computer-executable code, which may be stored on a computer readable medium.
As described above, the controllers may be a programmable processing device, such as an external conventional computer or an on-board field programmable gate array (FPGA) or digital signal processor (DSP), that executes software, or stored instructions. In general, physical processors and/or machines employed by embodiments of the present disclosure for any processing or evaluation may include one or more networked or non-networked general purpose computer systems, microprocessors, field programmable gate arrays (FPGAs), digital signal processors (DSPs), micro-controllers, and the like, programmed according to the teachings of the exemplary embodiments of the present disclosure, as is appreciated by those skilled in the computer and software arts. The physical processors and/or machines may be externally networked with image capture device(s), or may be integrated to reside within an image capture device. Appropriate software can be readily prepared by programmers of ordinary skill based on the teachings of the exemplary embodiments, as is appreciated by those skilled in the software art. In addition, the devices and subsystems of the exemplary embodiments can be implemented by the preparation of application-specific integrated circuits or by interconnecting an appropriate network of conventional component circuits, as is appreciated by those skilled in the electrical art(s). Thus, the exemplary embodiments are not limited to any specific combination of hardware circuitry and/or software.
Stored on any one or on a combination of computer readable media, the exemplary embodiments of the present disclosure may include software for controlling the devices and subsystems of the exemplary embodiments, for driving the devices and subsystems of the exemplary embodiments, for enabling the devices and subsystems of the exemplary embodiments to interact with a human user, and the like. Such software can include, but is not limited to, device drivers, firmware, operating systems, development tools, applications software, and the like. Such computer readable media further can include the computer program product of an embodiment of the present disclosure for performing all or a portion (if processing is distributed) of the processing performed in implementations. Computer code devices of the exemplary embodiments of the present disclosure can include any suitable interpretable or executable code mechanism, including but not limited to scripts, interpretable programs, dynamic link libraries (DLLs), Java classes and applets, complete executable programs, and the like. Moreover, parts of the processing of the exemplary embodiments of the present disclosure can be distributed for better performance, reliability, cost, and the like.
Common forms of computer-readable media may include, for example, a floppy disk, a flexible disk, hard disk, magnetic tape, any other suitable magnetic medium, a CD-ROM, CDRW, DVD, any other suitable optical medium, punch cards, paper tape, optical mark sheets, any other suitable physical medium with patterns of holes or other optically recognizable indicia, a RAM, a PROM, an EPROM, a FLASH-EPROM, any other suitable memory chip or cartridge, a carrier wave or any other suitable medium from which a computer can read.
While the present disclosure has been described in connection with a number of exemplary embodiments, and implementations, the present disclosure is not so limited, but rather covers various modifications, and equivalent arrangements.
This application is a continuation-in-part of U.S. application Ser. No. 13/086,019, filed Apr. 13, 2011, which claims priority to U.S. Provisional Application No. 61/323,388, filed Apr. 13, 2010; U.S. Provisional Application No. 61/326,527, filed Apr. 21, 2010; U.S. Provisional Application No. 61/345,873, filed May 18, 2010; and U.S. Provisional Application No. 61/378,281, filed Aug. 30, 2010, the contents of each of these applications being incorporated entirely herein by reference. This application also claims the benefit of, and priority to, U.S. Provisional Patent Application No. 61/487,404, filed May 18, 2011; U.S. Provisional Patent Application No. 61/555,925, filed Nov. 4, 2011; and U.S. Provisional Patent Application No. 61/586,788, filed Jan. 15, 2012, the contents of these applications being incorporated entirely herein by reference.
| Number | Date | Country | |
|---|---|---|---|
| 61323388 | Apr 2010 | US | |
| 61326527 | Apr 2010 | US | |
| 61345873 | May 2010 | US | |
| 61378281 | Aug 2010 | US | |
| 61487404 | May 2011 | US | |
| 61555925 | Nov 2011 | US | |
| 61586788 | Jan 2012 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 13086019 | Apr 2011 | US |
| Child | 13475175 | US |
