Patent Application
20240399126
When the ear is functioning normally, sound waves travel through the air to the outer ear, which collects the sound and directs it through the ear canal to the middle ear. The sound waves strike the eardrum, or tympanic membrane, and cause it to vibrate. This vibration is transmitted to the cochlea by the middle ear bones, called ossicles. The three ossicles that comprise the ossicular chain are termed the malleus, incus and stapes, but are also commonly referred to as the “hammer”, “anvil” and “stirrup”, respectively. Motion of these bones, transmits sound pressure waves arriving at the eardrum to the cochlea's oval window membrane, which in turn, gives rise to a travelling displacement wave within the cochlea.
The inner ear consists of the bony labyrinth, a system of passages making up the following two main functional parts: 1) the cochlea, which is dedicated to hearing, and 2) the vestibular system, which is dedicated to balance. The cochlea is lined with thousands of tiny sensory receptors, commonly referred to as hair cells, that are arranged in rows along the basilar membrane. As the basilar membrane vibrates in response to incoming pressure waves, the hair cells transduce this mechanical motion into electrical impulses that result in neurotransmitter release and excitation of the auditory neurons. Afferent signaling from the auditory neurons is then processed and transmitted by a series of neural connections all the way to the cortex, where sound is perceived.
Hearing loss is the most common sensory impairment in humans, affecting over 5% of individuals in industrialized nations. It is also an important health problem in the elderly, and 40% of the population aged 65 years or older have a hearing loss great enough to impair communication.
Hearing loss can be a result of a variety of auditory disorders. Conductive Hearing Loss (CHL) involves the loss of normal mechanical pathways for sound to reach the hair cells in the cochlea, for example by anatomical malformations/anomalies, ear infections, allergies, tumors, bone remodeling, and/or damage to the ossicles. Sensorineural Hearing Loss (SNHL) is due to impaired ability of the cochlea to effectively transduce pressure waves into neural signaling. SNHL is typically associated with exposure to loud noise, aging, head trauma, exposure to ototoxic drugs, infection, autoimmune disease, Meniere's disease, genetic mutations, tumors of the auditory nerve and the like.
Although new therapies to treat hearing loss are emerging, there is a need for safe, direct, efficient and effective drug delivery devices. Methods capable of providing long-term drug delivery for sustained therapeutic effect in treating hearing loss and other maladies of the ear represent unmet medical needs. These needs are particularly pronounced for ailments affecting the inner ear including areas in and around the cochlea, semicircular canals, vestibule for example.
In an implementation, described is an implantable device for delivering a therapeutic agent to treat an ear of a patient. The device includes a body having a distal end region and a proximal end region. The body defines, at least in part, a reservoir configured to contain the therapeutic agent. The device includes a shaft attached to the distal end region of the body and has a lumen extending through the shaft. The lumen has at least one inlet at a proximal end region of the shaft in fluid communication with the reservoir and at least one outlet at a distal end region of the shaft. The shaft has a length between the proximal end region and the distal end region. Upon implantation of the body in a region of the ear, the length of the shaft is sufficient to extend from the body to at least the round window membrane of the ear. The device is configured to deliver the therapeutic agent to the ear from the reservoir via passive diffusion.
The body may be sized to be implanted in a tympanic cavity or in a mastoid cavity of a middle ear of the patient or in an ear canal of the patient. The reservoir may have a volume of about 5 uL to about 1 mL. The device may further include an access port into the reservoir. A re-sealable penetrable barrier may be positioned within the access port that is configured to be penetrated for refilling of the reservoir with therapeutic agent. The device may further include a porous drug release element positioned relative to at least one of the inlet and the outlet from the lumen of the shaft. The body may be rigid or compliant. The therapeutic agent may include corticosteroids, aminoglycosides, antimicrobials, antifungals, antivirals, non-steroidal anti-inflammatories, decongestants, anticholinesterases, mydriatics, sypathomimetics, antineoplastics, immunological drugs, hormonal agents, beta adrenergic blockers, growth factors, anhysrase inhibitors, prostaglandins, antiprostaglandins, prostaglandin precursors, antioxidants, NMDA receptor antagonists, nootropics, anti-apoptotic agents, neurotrophins, neuroprotective agents, cannabinoids, monoclonal antibodies, gene therapies, cell therapies, and inhibitors of APAF-1.
The shaft may be configured to extend through the round window membrane. The device may further include an annular anchor having an outer surface and an inner surface. The outer surface may be configured to seal against a perimeter of a round window membrane and the inner surface may encircle a first segment of the distal end region of the shaft extending through the annular anchor. The shaft may further include a second segment located immediately proximal to the first segment. The second segment may have a distensible wall.
The device may further include a porous drug release element positioned within the lumen of the shaft proximal to the second segment. The porous drug release element may be configured to control the passive diffusion through the first segment of the shaft. Upon implantation of the device, the first segment of the shaft may be in contact with a liquid environment of a cochlea of the ear and the shaft proximal to the first segment may be in contact with air of a middle ear of the patient. Upon implantation of the device, the porous drug release element may dampen a pressure wave from the cochlea and shunt the pressure wave to the distensible wall of the second segment. Upon implantation of the device, the distensible wall of the second segment may interface with air of the middle ear. The annular anchor may be formed of a conformable material or of a semi-rigid material.
The device may further include an annular anchor having an outer ring surface configured to seal against a perimeter of a round window membrane and an inner ring surface. The anchor may include a channel extending through the annular anchor from a proximal surface of the annular anchor to a distal surface of the annular anchor. The channel may have an inner diameter configured to receive an outer diameter of at least the distal end region of the shaft. The anchor may include a distensible membrane coupled to a distal side of the annular anchor. The anchor may include a rigid plate coupled to a proximal side of the annular anchor opposite the distensible membrane. A chamber may be located within the annular anchor and defined collectively by the inner ring surface, an inner surface of the rigid plate, and an inner surface of the distensible membrane. The length of the shaft may provide the passive diffusion. Upon implantation of the device, the chamber may be filled with air and the distal surface of the distensible membrane may be surrounded by perilymph. The distensible membrane may provide acoustic impedance similar to an acoustic impedance of the round window membrane.
The device may further include an annular anchor having an outer ring surface configured to seal against a perimeter of a round window membrane and an inner ring surface. A first distensible membrane may be coupled to a proximal side of the annular anchor. A second distensible membrane may be coupled to a distal side of the annular anchor opposite the first distensible membrane. The first distensible membrane may be non-permeable to the therapeutic agent and the second distensible membrane may be permeable to the therapeutic agent or both the first and second distensible membranes may be permeable to the therapeutic agent. The annular anchor may include a chamber located within the annular anchor defined collectively by the inner ring surface, an inner surface of the first distensible membrane, and an inner surface of the second distensible membrane. The at least one outlet at the distal end region of the shaft may be positioned in fluid communication with the chamber. The therapeutic agent may passively diffuse through at least one of the first distensible membrane and the second distensible membrane.
In an interrelated implementation, disclosed is an implantable device for delivering a therapeutic agent to treat an ear of a patient. The device includes a body having a distal end region and a proximal end region. The body is configured to be implanted in a cavity of a middle ear of the patient. The body defines, at least in part, a reservoir configured to contain the therapeutic agent. The device further includes a shaft attached to the distal end region of the body. A lumen extends through the shaft and the lumen has at least one inlet at a proximal end region of the shaft in fluid communication with the reservoir and at least one outlet at a distal end region of the shaft. When the body is implanted in the cavity, the shaft extends through a wall of the cavity and the at least one outlet is positioned into a cochlear space. A helical thread-form is on an outer surface of the shaft that is configured to cut through and linearly advance into the wall upon rotation. The device is configured to deliver the therapeutic agent from the reservoir via passive diffusion through the at least one outlet of the shaft into the perilymph of the cochlear space.
The shaft may be configured to substantially anchor and seal the device within the wall. The helical thread-form on the shaft may be a self-tapping thread-form. The shaft may be tapered distally. The shaft may have a longitudinal axis that is coaxial with a longitudinal axis of the device. The internal lumen may have a longitudinal axis that is off-set from the longitudinal axis of the shaft. The device may further include a porous drug release element positioned relative to at least one of the inlet and the outlet from the lumen of the shaft. The device may further include an access port into the reservoir and a resealable penetrable barrier positioned within the access port that is configured to be penetrated for refilling of the reservoir with therapeutic agent. The body may be rigid or compliant. The therapeutic agent includes antimicrobials, antifungals, antivirals, non-steroidal anti-inflammatories, decongestants, anticholinesterases, mydriatics, sypathomimetics, antineoplastics, immunological drugs, hormonal agents, beta adrenergic blockers, growth factors, anhydrase inhibitors, prostaglandins, antiprostaglandins, prostaglandin precursors, antioxidants, NMDA receptor antagonists, nootropics, anti-apoptotic agents, neurotrophins, neuroprotective agents, cannabinoids, monoclonal antibodies, gene therapies, and inhibitors of APAF-1. The reservoir may have a volume of about 5 uL to about 1 mL. The cavity may include the mastoid cavity or the tympanic cavity. The cavity may be the tympanic cavity and the wall may be a medial wall of the tympanic cavity.
Other features and advantages will be apparent from the following description of various implementations, which illustrate, by way of example, the principles of the disclosed devices and methods.
These and other aspects will now be described in detail with reference to the following drawings. Generally speaking, the figures are not to scale in absolute terms or comparatively but are intended to be illustrative. Also, relative placement of features and elements may be modified for the purpose of illustrative clarity.
Conductive Hearing Loss (CHL) involves the loss of normal mechanical pathways for sound to reach the hair cells in the cochlea, for example by anatomical malformations/anomalies, ear infections, allergies, tumors, bone remodeling, and/or damage to the ossicles. Sensorineural Hearing Loss (SNHL) is due to impaired ability of the cochlea to effectively transduce pressure waves into neural signaling. SNHL is typically associated with exposure to loud noise, aging, head trauma, exposure to ototoxic drugs, infection, autoimmune disease, Meniere's disease, genetic mutations, tumors of the auditory nerve, and the like.
Treatment of SNHL, depending on the cause, can include drug treatments for hair cell and cochlear nerve afferents regeneration, reversal of cochlear oxidative stress damage, and apoptosis inhibition. There are several drugs in the final stages of clinical development for the treatment of hearing loss including STS (Fennec Pharmaceuticals) to protect against cisplatin-induced hearing loss; AM-101 (Auris Medical) for the treatment of tinnitus; AM-111 (Auris Medical) for otoprotection in acute inner ear hearing loss; OTO-104 (Otonomy) for the treatment of Meniere's Disease; SPI-1005 (Sound Pharmaceuticals) for the treatment of mild to moderate acute noise-induced hearing loss and for the treatment of Meniere's Disease.
However, the inner ear presents a unique and delicate anatomy that is difficult to treat effectively. For example, the presence of the blood-cochlear barrier (BCB) limits access of many of these compounds to the inner ear. Thus systemic administration, oral, intravenous, and intramuscular routes often require high doses and/or result in systemic side effects. Local drug delivery methods are also known. For example, inner ear therapy (e.g. drugs formulated as biocompatible gels) can be delivered to the middle ear via intra-tympanic injections across the tympanic membrane (TM), which are subsequently absorbed into the cochlea through the round and oval window membranes.
Local drug delivery to the inner ear using osmotic pumps or infusion pump is also known. For example, implantable and programmable intracochlear micropumps known in the art can provide targeted, controllable, and extended drug delivery. However, the pumps require precise micromechanical pumping technology in order to maintain a constant fluid volume and can increase the risk of damage to the inner ear due to malfunctions or delivery of too much fluid. Additionally, some pumps like osmotic pumps include reservoirs that are incapable of being refilled, which requires the entire pump to be replaced. Similarly, electronic pumps are dependent upon power and require batteries and/or recharging of the power.
Regardless of the delivery method (i.e. local delivery via injections or pumping), the therapeutic effect achieved by the drug is limited by the clearance and distribution (pharmacokinetics) of the drug within the fluids of the inner ear.
Described herein are drug delivery devices and systems capable of providing long-term (i.e. extended) drug levels for sustained, site-specific, controlled or other modified therapeutic agent(s) released for treating hearing loss and other maladies of the ear. The drug delivery devices and systems can be passive systems in that drug delivery is achieved without active pumping and/or without fluid flow. The drug delivery devices and systems described herein incorporate passive diffusion and capillary action to provide drug delivery. It should be appreciated that the devices and systems described herein can be positioned in many locations of the ear and need not be implanted specifically as shown in the figures or as described herein. The devices and systems described herein can be used to deliver therapeutic agent(s) for an extended period of time from a body that defines, at least in part, a reservoir to one or more of the following tissues: round window membrane, cochlea, hair cells of the cochlea, and other tissues of the middle and inner ear. Although specific reference is made below to the delivery of treatments to the ear, it also should be appreciated that medical conditions besides these conditions can be treated with the devices and systems described herein. For example, the devices and systems can deliver treatments for inflammation, infection, and cancerous growths. Any number of drug combinations can be delivered using any of the devices and systems described herein.
The materials, compounds, compositions, articles, and methods described herein may be understood more readily by reference to the following detailed description of specific aspects of the disclosed subject matter and the examples included therein. Before the present materials, compounds, compositions, articles, devices, and methods are disclosed and described, it is to be understood that the aspects described below are not limited to specific methods or specific reagents, as such may vary. It is also to be understood that the terminology used herein is for the purpose of describing particular aspects only and is not intended to be limiting.
Unless defined otherwise, all technical and scientific terms used herein have the same meaning as is commonly understood by one of ordinary skill in the art. All patents, patent applications, published applications and publications, websites and other published materials referred to throughout the entire disclosure herein, unless noted otherwise, are incorporated by reference in their entirety. In the event that there are pluralities of definitions for terms herein, those in this section prevail. Where reference is made to a URL or other such identifier or address, it is understood that such identifiers can change and particular information on the internet can come and go, but equivalent information is known and can be readily accessed, such as by searching the internet and/or appropriate databases. Reference thereto evidences the availability and public dissemination of such information.
As used herein, relative directional terms such as anterior, posterior, proximal, distal, lateral, medial, sagittal, coronal, transverse, etc. are used throughout this disclosure. Such terminology is for purposes of describing devices and features of the devices and is not intended to be limited. For example, as used herein “proximal” generally means closest to a user implanting a device and farthest from the target location of implantation, while “distal” means farthest from the user implanting a device in a patient and closest to the target location of implantation.
As used herein, a disease or disorder refers to a pathological condition in an organism resulting from, for example, infection or genetic defect, and characterized by identifiable symptoms.
As used herein, treatment means any manner in which the symptoms of a condition, disorder or disease are ameliorated or otherwise beneficially altered. Treatment also encompasses any pharmaceutical use of the devices described and provided herein.
As used herein, amelioration or alleviation of the symptoms of a particular disorder, such as by administration of a particular pharmaceutical composition, refers to any lessening, whether permanent or temporary, lasting or transient that can be attributed to or associated with administration of the composition.
As used herein, an effective amount of a compound for treating a particular disease is an amount that is sufficient to ameliorate, or in some manner reduce the symptoms associated with the disease. Such an amount can be administered as a single dosage or can be administered according to a regimen, whereby it is effective. The amount can cure the disease but, typically, is administered in order to ameliorate the symptoms of the disease. Repeated administration can be required to achieve the desired amelioration of symptoms. Pharmaceutically effective amount, therapeutically effective amount, biologically effective amount and therapeutic amount are used interchangeably herein to refer to an amount of a therapeutic that is sufficient to achieve a desired result, (i.e. therapeutic effect, whether quantitative or qualitative). In particular, a pharmaceutically effective amount, in vivo, is that amount that results in the reduction, delay, or elimination of undesirable effects (such as pathological, clinical, biochemical and the like) in the subject.
As used herein, a subject includes any animal for whom diagnosis, screening, monitoring or treatment is contemplated. Animals include mammals such as primates and domesticated animals. An exemplary primate is human. A patient refers to a subject such as a mammal, primate, human, or livestock subject afflicted with a disease condition or for which a disease condition is to be determined or risk of a disease condition is to be determined.
As used herein, a therapeutic agent referred to with a trade name encompasses one or more of the formulation of the therapeutic agent commercially available under the tradename, the active ingredient of the commercially available formulation, the generic name of the active ingredient, or the molecule comprising the active ingredient. As used herein, a therapeutic or therapeutic agents are agents that ameliorate the symptoms of a disease or disorder or ameliorate the disease or disorder. Therapeutic agent, therapeutic compound, therapeutic regimen, or chemotherapeutic include conventional drugs and drug therapies, including vaccines, which are known to those skilled in the art and described elsewhere herein. Therapeutic agents include, but are not limited to, moieties that are capable of controlled, sustained release into the body. As used herein, sustained release encompasses release of effective amounts of an active ingredient of a therapeutic agent for an extended period of time. The sustained release may encompass first order release of the active ingredient, zero order release of the active ingredient, or other kinetics of release such as intermediate to zero order and first order, or combinations thereof. The sustained release may encompass controlled release of the therapeutic agent via passive molecular diffusion driven by a concentration gradient across a drug release element. The sustained release can generally include liquids, suspensions, emulsions, resins, or gels, for example.
As used herein, a composition refers to any mixture. It can be a solution, a suspension, an emulsion, liquid, powder, a paste, aqueous, non-aqueous or any combination of such ingredients.
As used herein, fluid refers to any composition that can flow. Fluids thus encompass compositions that are in the form of semi-solids, pastes, solutions, aqueous mixtures, gels, lotions, creams and other such compositions.
As used herein, a kit is a packaged combination, optionally, including instructions for use of the combination and/or other reactions and components for such use.
The devices and systems described herein are referred to as drug delivery devices, drug delivery systems, treatment devices, therapeutic devices, port delivery systems, implants, and the like. It should be appreciated that these terms are used interchangeably herein and are not intended to be limiting to a particular implementation of one device over another device. For the sake of brevity, explicit descriptions of each of those combinations may be omitted although the various combinations are to be considered herein. Additionally, described herein are different methods for implantation and access of the devices. The various implants can be implanted, filled, refilled, etc. according to a variety of different methods and using a variety of different devices and systems. Provided are some representative descriptions of how the various devices may be implanted and accessed, however, for the sake of brevity, explicit descriptions of each method with respect to each implant or system may be summarized or omitted.
The drug delivery devices described herein can deliver drug from a relatively small, self-contained system over an extended period of time by passive mechanisms such as those that involve no fluid flow, such as passive diffusion, or other passive mechanisms such as capillary action, for drug delivery. The devices described need not incorporate an active pumping element or rely upon electrical or mechanical drug delivery. Meaning, the reservoir of the drug delivery devices can be smaller in size even for the long-term, chronic delivery of drug, which given the relatively limited space in the middle ear, ear canal, or mastoid recess, is a distinct advantage. The reservoir can, but need not, be refillable as will be described in more detail below. The devices provide sufficient anchoring within the ear for the life of the device and minimally impact the acoustic impedance at the site of implantation. The devices described herein can incorporate an intracochlear portion and an extracochlear portion.
Described herein are implantable devices for delivering a therapeutic agent to treat an ear of a patient. The device is configured to deliver the therapeutic agent to the ear from the reservoir via passive diffusion. The device can include a body having a distal end region and a proximal end region. The body can define, at least in part, a reservoir configured to contain the therapeutic agent. A shaft can be attached to the distal end region of the body. A lumen can extend through the shaft such that at least one inlet at a proximal end region of the shaft is in fluid communication with the reservoir and at least one outlet at a distal end region of the shaft. The shaft can have a length between the proximal end region and the distal end region such that upon implantation of the body in a region of the ear, the length of the shaft is sufficient to extend from the body to at least the round window membrane of the ear. The body can be sized to be implanted in a cavity of a middle ear of a patient. For example, in some implementations the reservoir of the drug delivery device can be positioned entirely within the tympanic cavity or a mastoid cavity of the middle ear and be coupled to a relatively short, shaft or intracochlear portion for delivery of drug directly into the cochlea. In some implementations, the shaft attached to the distal end region of the body can be a rigid, intracochlear portion having a helical thread-form on an outer surface configured to cut through and linearly advance into a wall of a cavity within which the body is implanted upon rotation.
Generally, the devices 100 described herein can include a body 101 having a distal end region and a proximal end region. The body 101 can define, at least in part, a reservoir 115 for containing a source of therapeutic agent 133 for sustained delivery to the ear via passive diffusion or capillary action such as via a lumen of a shaft and/or a drug release element 110. The shaft 123 can be an elongate element configured to extend from the body 101 to another region of the ear. Shaft 123 can be attached to the distal end region of the body 101 and have a lumen extending through the shaft 123. The lumen can have at least one inlet 113 at a proximal end region of the shaft 123 in fluid communication with the reservoir 115 and at least one outlet 117 at the distal end region of the shaft 123. Upon implantation of the body 101 in a region of the ear, the length of the shaft 123 is sufficient to extend from the body 101 to at least a portion of the ear for treatment. The length of the shaft 123 can provide the passive diffusion. In some implementations, the shaft 123 can be an elongate and relatively flexible cannula 120, and may be referred to herein interchangeably as a shaft or a cannula depending on configuration of the device and implantation location. In other implementations, the shaft 123 can be a relatively short element configured to extend through a wall of a cavity, such as the medial wall of the tympanic cavity 30 or a wall of the mastoid cavity. For example, the shaft 123 can be a relatively rigid, cannulated screw shaft having threads on an outer surface and a lumen extending through an interior of the shaft 123.
The device can include a porous drug release element 110 positioned relative to at least one of inlet 113 to the lumen of the shaft 123 and the outlet 117 from the lumen of the shaft 123. The drug release element 110 can be positioned near a distal end of the device 100 such that it can be positioned within the target treatment area. For example, the drug release element 110 can be positioned within the cochlea 20 or cochlear space 132 such that the one or more therapeutics 133 contained within the reservoir 115 can be delivered over time directly into the fluid of the cochlea 20 or the cochlear space 132. The drug release element 110 can be positioned at the end of a distal cannula that extends. Alternatively or additionally, the drug release element 110 can be positioned upstream from the cannula within an exit port of the reservoir. Each of these components can vary in material, structure and dimension (e.g. size, shape), as will be described in more detail below depending on the implantation location.
A substantial volume of the reservoir 115 of the device 100 can be positioned external to the ear or internal to the ear. In the various implementations, the device 100 can include a shaft having a lumen such as a proximal cannula 120 extending from the reservoir 115. The proximal cannula 120 can communicate with an intracochlear portion of the device 100. The proximal cannula 120 can communicate between an intracochlear portion of the device 100 and an extra-cochlear portion of the device.
In some implementations, the intracochlear portion 105 can be positioned within, on, or near the round window 25. The reservoir 115 can include an access port 125 accessible through the ear canal 40, as shown in
The drug release element 110 can be positioned such that it is in fluid communication with the cochlea 20. For example, the drug release element 110 can be positioned near a distal end region of the intracochlear portion 105 (see
In some implementations, the device 100 replaces the round window membrane 27 entirely and in other implementations, the device is positioned within a hole created in the round window membrane 27 given the anatomical variations in dimension of the membrane and shape of the round window niche. For example, a drill (e.g. 2 mm) may be used to create a pilot hole in the location of the round window and the drug delivery device 100 may be positioned within the hole. Positioning the drug delivery device 100 in this manner may result in a more reproducible fit relative to the anatomy compared to replacing the entire membrane. The drug delivery device 100 may also be implanted without creating a pilot hole and incorporate self-tapping threads or other anchoring implantation features, which will be described in more detail below.
When placing a cannula through the round window membrane 27 for chronic local drug delivery, there can be a risk of tearing or perforation. Dislocation or wound healing subsequent to cannula placement through the membrane may potentially result in fibrosis or membrane overgrowth of the round window membrane 27. Thus, in some implementations, the round window membrane 27 is removed entirely and replaced with a permanent device. The intracochlear portion 105 can be positioned within the cochlea 20 such that hearing is not impacted by the drug delivery device 100. The intracochlear portion 105 can replace the round window membrane 27. The device can provide anchoring within the location as well as sealing between the device and the surrounding tissues. The device can provide therapy through a drug release element. Importantly, at least a portion of the device can be distensible to allow pressure waves to be transmitted from the oval window as would the natural round window membrane 27. The device can further include an annular anchor having an outer surface and an inner surface. The outer surface can be configured to seal against a region of the eye, such as a perimeter of a round window membrane. For example, the intracochlear portion 105 can include an annular anchor such as a support ring 107 spanned by the drug release element 110. The support ring 107 can be sized and shaped such that the outer surface of the annular structure can seal against and engage with the round window 25. The support ring 107 can be semi-rigid or rigid and the drug release element 110 can be compliant to maintain the functionality of the round window membrane 27. Thus, the drug release element 110 functions as the round window membrane following implantation of the device 100 within the round window 25. The support ring 107 can be sufficiently less compliant than the drug release element 110 such that it can provide support to the compliant drug release element 110 and anchor it within the round window 25. The compliant drug release element 110 can be permeable to the therapeutic agent to be delivered to the cochlea 20.
The various functions of the device (i.e., anchoring/sealing/drug release/distensibility) can be performed by a single component of the device. Alternatively, different components of the device can provide one or more of the functions. For example, in the example provided above, the support ring 107 can provide anchoring and sealing whereas the drug release element 110 can provide both drug release and distensibility for maintaining acoustic impedance. In another implementation, the device 100 can include a drug release element 110 that is a rigid, porous outer ring configured to control drug diffusion from the reservoir while a flexible, interior ring can be incorporated that is configured to be responsive to perilymph movement/pressure wave. Regardless of the configuration, the devices described herein can replace the round window membrane while retaining the natural function of the round window membrane by matching its impedance properties.
The intracochlear portion 105 can have a shape and size configured to provide a snug fit (i.e. conforming fit) within the round window 25 or medial wall 138 of the tympanic cavity 30 thereby minimizing fluid leakage from the inner ear 20 while the drug release element 110 allows for normal sound-induced vibrations to be transmitted. In some implementations, the intracochlear portion 105 can have a generally hour-glass shape. For example and as shown in
In the implementation shown in
In another implementation, the intracochlear portion 105 can include a cannula 120 extending from a drug reservoir 115 and an annular anchor. The annular anchor can have an outer surface and an inner surface. The outer surface can be configured to seal against a perimeter of a round window membrane and the inner surface can encircle a segment of the shaft that extends through the anchor. The annular anchor can be formed of a conformable material or a semi-rigid material. For example, the cannula 120 can have a first segment 122 surrounded by a conforming, semi-rigid support ring 107 for fixation in the cochlea (see
In yet another implementation, the intracochlear portion 105 can include a rigid or semi-rigid ring 107. The ring 107 is an annular anchor having an outer ring surface configured to seal against a perimeter of a round window membrane or other region of the eye and an inner ring surface. The ring 107 can be spanned by a distensible membrane 187 on a distal side (i.e. the perilymph side of the device) and includes a channel 188 extending through a portion of the ring 107 for passage of the drug delivery cannula 120 into the cochlea (see
The distensible components described herein (e.g. the distensible membrane 187, the second segment 124 of the cannula 120) can be formed of silicone, polyurethane, and other elastomeric polymers having a shore hardness capable of being deformed upon application of a sound pressure wave within the ear. The rigid components described herein (e.g., the fenestrated plate 189) can be formed of PEEK, titanium, and other relatively non-distensible materials that maintain their shape upon application of a sound pressure wave within the ear. The ring 107 described above can be rigid (i.e. formed of PEEK, titanium, etc.) or can be semi-rigid. Materials suitable for a semi-rigid ring 107 include, but are not limited to silicone, PTFE and other materials having a shore hardness capable of conforming to a degree relative to the anatomy in the ear to provide sufficient anchoring and sealing upon implantation.
The intracochlear portion 105 can have a drug release element 110 configured to deliver therapeutic agent through the round window membrane 27 (see
The drug release element 110 can be any of a variety of structures as described herein. In some implementations, the drug release element 110 can be a porous foam or other porous material configured to be saturated with an aqueous solution of therapeutic agent delivered from the reservoir by the cannula 120 and then release the therapeutic onto the membrane 27. The drug release element 110 need not be formed of or incorporate a porous material per se, but rather itself can be a structure configured to control diffusion such as through a length of the path or size of an opening. For example, a length of a cannula leading from the reservoir can be sufficient to control diffusion from the reservoir to the treatment site such as for the implementation shown in
In an implementation, the device can include a reservoir 115 attached to an intracochlear portion 105 (i.e. proximal retention structure) as shown in
The flexible reservoir 115 can be placed in the tympanic cavity 30. The intracochlear portion 105 can have a lumen 121 that extends through the entire length of the intracochlear portion 105 from the proximal reservoir 115 to the distal delivery tip to deliver a therapeutic agent to a target treatment area (see
Upon implantation of the body 101 in a region of the ear, the length of the shaft 123 can be sufficient to extend from the body 101 to at least a region of the ear for treatment (e.g. the round window membrane). The shaft 123 can form at least a portion of the intracochlear portion 105 as described elsewhere herein. As such, at least a portion of the shaft 123 having a lumen 121 may be referred to herein as an intracochlear portion 105. The drug delivery devices described herein can include an implanted portion that is referred to as an intracochlear portion 105. It should be appreciated that the implanted portion of the device need not be positioned in direct communication with the cochlear space or intracochlearly. For example, in some implementations, the implanted portion 105 may be placed within the Eustachian canal 45 (see
The contents of the reservoir 115 can be delivered according to slow diffusion rather than expelled as a fluid stream or pumped from the reservoir 115. In some implementations, the drug release element 110 can be a covering or lining having a particular porosity to the substance to be delivered and can be used to provide a particular rate of release of the substance. The drug release element 110 can be a release control mechanism, including but not limited to a wicking material, permeable silicone, packed bed, small porous structure or a porous frit, multiple porous coatings, nanocoatings, rate-limiting membranes, matrix material, a sintered porous frit, a permeable membrane, a semi-permeable membrane, a capillary tube or a tortuous channel, nano-structures, nano-channels, sintered nanoparticles and the like.
As described herein, the device can include an elongate shaft 123 having a lumen 121. The elongate shaft 123 can be an elongate, flexible cannula 120 extending between the body 101 defining, at least in part, the reservoir 115 and the intracochlear portion 105. The path taken by the cannula 120 extending between the reservoir 115 and intracochlear portion 105 can vary and may depend on where the reservoir 115 is positioned. In some implementations, the cannula 120 extends from the reservoir 115 positioned within the ear canal 40 through the tympanic membrane 5 (see
In still other implementations, which will be described in more detail below, the device need not include a cannula connecting the reservoir 115 and the intracochlear portion 105. Rather, the body 101 defining the reservoir 115 and the intracochlear portion 105 can be directly attached such that the shaft 123 attached to the distal end region of the body 101 and the lumen 121 extending through the shaft 123 provides the fluid communication between the interior of the reservoir 115 and the inner ear. The length of the shaft 123 (i.e. a length between an inlet 113 into the lumen 121 to at least one outlet 117 from the lumen 121 at a distal end region of the shaft 123) is sufficient to extend from the body 101 into the target treatment location. The reservoir 115 can be positioned within the tympanic cavity 30 and the intracochlear portion 105 positioned through or within the medial wall 138. The lumen 121 extending through the intracochlear portion 105 can be in fluid communication with the reservoir 115 at a proximal end and communicate at a distal end with the cochlear space 132 of the inner ear (see
Generally, the devices described herein, once implanted, are configured to minimally disrupt the natural functions of the surrounding anatomy such that therapeutic effect can be provided with minimal to no impact on acoustic impedance. For example, if a device is implanted to extend through or replace the round window membrane, at least a portion of the device is configured to function as the round window membrane would otherwise function (e.g. transmittance of a pressure wave). Similarly, if a device is implanted to extend through the bony wall of the cochlea, at least a portion of the device is configured to function as the portion of the bony wall would otherwise function.
In some implementations, the reservoir 115 and/or the intracochlear portion 105 can have one or more retention features 139. For example, where the reservoir 115 is positioned within the ear canal 40, the reservoir 115 can include retention features 139 that engage with the wall of the ear canal 40. Where the reservoir 115 is positioned within the middle ear, the reservoir 115 can include one or more retention features 139 that engage with a medial wall 138 of the tympanic space 30. In other implementations, the one or more retention features 139 include flexible support members, sutures or suture holes, anchors or anchor holes, prongs, flanges, or an expandable feature like a stent or other deformable element configured to radially expand or change shape. Various other retention features 139 are described with reference to
In some implementations, the volume of the reservoir 115 can be at least about 1 μL, 2 μL, 3 μL, 4 μL, 5 μL, 10 μL, 15 μL, 20 μL, 25 μL, 30 μL, 35 μL, 40 μL, 45 μL, 50 μL, 55 μL, 60 μL, 65 μL, 70 μL, 75 μL, 80 μL, 85 μL, 90 μL, 95 μL, 96 μL, 97 μL, 98 μL, 99 μL, 100 μL, 125 μL, 150 μL, 175 μL, 200 μL, 225 μL, 250 μL, 275 μL, 300 μL, 325 μL, 350 μL, 375 μL, 300 μL, 425 μL, 450 μL, 475 μL, up to about 500 μL. In some implementations, the volume of the reservoir 115 is between about 5 uL to about 1 mL. As described above, the reservoir volume can vary depending on where the reservoir 115 resides. For example, a reservoir 115 positioned within the tympanic cavity 30 of the middle ear may have a smaller overall volume compared to a reservoir 115 positioned within the ear canal 40 or outside the ear (e.g. subcutaneously or within a mastoid pocket). Middle ear cavity reservoirs can have a volume sized up to about 25 μL. The maximum cross-sectional dimension of a reservoir implanted in the middle ear cavity can be up to about 5 mm. Reservoirs sized to be implanted within the mastoid cavity can be slightly larger than middle ear cavity reservoirs. Such reservoirs can have a volume up to about 1 mL. The maximum cross-sectional dimension of a reservoir sized for implantation within the mastoid cavity can be up to about 10 mm. It should be appreciated that any of a variety of volumes are considered herein, particularly where the reservoir 115 is positioned externally or under the skin. It should be appreciated that use of the term “reservoir” refers to the container holding a source volume of therapeutic agent, the source volume being sufficient for the extended delivery of the therapeutic. The “reservoir” as used herein, generally does not refer to the volume of drug that may reside within a cannula or the intracochlear portion 105 at any given time during sustained release of the therapeutic.
Because distensible (i.e. “stretchy”) materials can react to changes in pressure, some portions of the device within the inner and middle ear are formed of non-distensible material that do not react to pressure changes whereas other portions of the device within the inner and middle ear may preferably be formed of distensible materials that do react to pressure changes (e.g. the distensible membrane 187). However, implanting a device into the inner ear may benefit from being collapsible and expandable. For example,
Examples of collapsible, non-distensible, substantially non-compliant materials are provided herein, including but not limited to polyethylene terephthalate (PET), nylon, and acrylics. Other materials are also considered herein, including but not limited to silicone rubber, titanium, biocompatible plastics, urethane, and acrylics. The material of the reservoir can also include urethane, nylon, Pebax®, polyurethanes, cross-linked polyethylene, fluorinated ethylene propylene (FEP), polytetrafluoroethylene (PTFE), and similar materials and blends of materials. The materials may also include multiple layers of the above materials and other materials known in the art for manufacturing expandable elements.
As mentioned herein, the reservoir 115 of the device 100 can be refilled and includes one or more penetrable refill or access ports 125. The access port 125 can be configured to be penetrated from outside the inner ear for substantially non-invasive filling, flushing, and/or refilling of the reservoir 115. Generally, the access port 125 can include a penetrable barrier configured to be penetrated. In some implementations, the access port 125 can be formed by an opening within a region of the reservoir 115 and covered by or filled with a penetrable material configured to be penetrated and resealed such that material does not leak out of the device 100 following penetration. In other implementations, the access port 125 represents an external portion of the proximal cannula 120 configured to connect with a filling needle to fill a remote reservoir 115 positioned within the ear as described above. In some implementations, the access port 125 can incorporate a needleless valve. The reservoir 115 can be positioned subcutaneously or within a mastoid pocket and the access port 125 can be accessed by penetrating the skin.
The intracochlear portion 105 can include one or more pressure relief valves 111 that can open during pressurization, for example, when refilling of the reservoir. In some implementations, the relief valve can vent excess fluid from the implant 105 and direct the fluid towards the Eustachian canal 45 and digestive system (see
The devices described herein can remain in position to deliver one or more therapeutic agents to the ear for a period of time. In some implementations, drug can be delivered from the device 100 for at least about 30 days, preferably at least about 45 days, about 60 days, about 75 days, about 90 days, up to about 6 months or more. It should be appreciated the device 100 can, but need not, be removed from the ear after initial implantation. Thus, the device 100 can be refilled with fresh drug periodically during its lifetime without being removed from the patient.
An insertion instrument may be used to deliver the device 100 toward the round window 25. The approach can vary and include typical approaches that provides access to the inner ear or cochlea, including transcranial, transcanal, endaural, retroauricular (postaural), and other approaches. In some implementations, the devices described herein can be implanted using an elongate delivery tool 1000 (see
It should be appreciated that the treatment devices described herein can be used in a variety of locations and implanted in a variety of ways. The implantation method and use of the treatment devices described herein can vary depending on the type of treatment device being implanted and the intended location and drug for treatment. The treatment devices described herein can be primed, implanted, filled, refilled, and/or explanted using one or more devices.
In an implementation, access to the middle ear can be achieved without cutting the tympanic membrane. Using a transcanal approach, a tympanomeatal flap in the ear canal can be created allowing the tympanic membrane to be pulled back. Alternatively, a postaural approach can be used by creating an incision directly behind the ear, creating a channel between the ear canal wall and the mastoid process or temporal bone. The cochlea can be accessed by surgically removing the round window membrane or by creating a cochleostomy near the round window to create a new access point. The intracochlear portion 105 can be loaded within a delivery tool to drive the intracochlear portion into position. The delivery tool can be disengaged from the intracochlear portion leaving the intracochlear portion 105 in position. The middle ear access point can be closed. The proximal cannula 120, if present, can be routed as needed depending on where the reservoir 115 is to be located (i.e. along ear canal wall to postaural area). A subcutaneous port can be placed under the skin and the remaining incisions closed.
In some implementations, the device 100 can be positioned such that the drug release element 110 can be in fluid communication within the inner ear through a surgically created opening in the round window 25 or through a cochleostomy through the sidewall of the inner ear or through a cochleostomy through a medial wall separating the tympanic cavity, for example. The device 100 can be inserted through the round window 25 from the outer ear canal 35 and a tympanomeatal flap, using techniques typical of implant surgery. A suprameatal approach, an atticotomy approach, a trans-canal approach, a mastoidectomy and posterior tympanotomy approach, or a myringothomy approach for insertion of the device 100 is considered herein. In some implementations, the remote access proximal cannula 120 can pass through or around the tympanic membrane 5 and down the ear canal 40. In other implementations, the proximal cannula 120 can be fully subcutaneous and terminate near the ear, for example, behind the ear. In other implementations, the proximal cannula 120 can extend down the Eustachian tube 45 and into the nasopharynx.
Since a substantial portion of the device 100 may reside within the tympanic cavity 30 post-implantation it can be beneficial to anchor the device in place for long term use. The intracochlear portion 105 can have a shape configured to aid in the retention of the device 100 within the medial wall 138 of the tympanic cavity 30.
In addition, the intracochlear portion 105 can incorporate one or more retention features 139. Various retention features 139 configurations are contemplated herein. The retention features 139 can include threads such as self-tapping thread forms, flexible support members, sutures or suture holes, anchors or anchor holes, prongs, flanges, deflectable element, or an expandable feature like a stent or other deformable element configured to radially expand or change shape. The retention features 139 can be configured to engage with a region of a patient to fix the device 100 in place. In implementations, the retention features 139 can affix to a wall of the ear canal 40 or tympanic cavity 30, as described in more detail herein. Alternatively, the retention features 139 can be configured to anchor, engage or otherwise attach the device to the medial wall 138 separating the tympanic cavity 30 through an opening in the round window membrane 27. This opening can be created via cochleostomy 140, for example.
The retention feature 139 can incorporate a self-tapping screw. The self-tapping screw can have a wide range of tip and thread patterns, but generally has a thread covering an entire length of the shaft from tip to head. The tip can be a corkscrew tip to engage the distal end of the screw into the bone. The self-tapping screw can allow for driving the screw into the bone without a pilot hole drilled into the bone, which can lead to leakage of perilymph. Further, the self-tapping screw can have a thread pattern designed to direct excavated bone material outward and away from the distal end of the screw.
The retention feature 139 can include at least 1, 2, 3, 4, 5 or more deformable prongs 144 arranged symmetrically around the shaft 123. The prongs 144 can deform from a low-profile insertion configuration (i.e. constrained or undeployed) in which the prongs 144 are aligned with the central longitudinal axis of the device and an expanded deployed configuration in which the prongs 144 extend outward from the central longitudinal axis of the device. The shaft 123 can include one or more pockets 174 on its outer surface sized and shaped to receive each deformable prong(s) 144 when the retention feature 139 is in the undeployed (i.e. constrained) configuration (
A sheath or other tubular type structure can be used to retain the intracochlear portion 105 in the straight, insertion configuration. Upon removal of the sheath from the intracochlear portion 105, the intracochlear portion 105 (i.e. the prongs 144 of
The device 100 can align with and be substantially symmetrical around a central axis A. Alternatively, the device 100 can be asymmetrical with respect to the central axis A. For example, the reservoir 115 can have a first portion that is substantially greater than a second portion where the first portion is positioned eccentric to an insertion axis of the device. Any of a variety of shapes of the reservoir 115 are considered herein depending upon the implantation location, angle, and arrangement relative to the surrounding anatomy. The reservoir 115 can be configured to be refilled as described elsewhere herein.
Still with respect to
As mentioned above, the device can be assembled at the time of implantation. The mounting plate 142 can be first held by an insertion tool 153 (see
Generally, the implementations of the treatment devices described herein contain drug solutions, drug suspensions and/or drug matrices. The treatment devices described herein can also contain therapeutic agents formulated as one or more solid drug core or pellets formulated to deliver the one or more therapeutic agents at therapeutically effective amounts for an extended period of time. The period of time over which the treatment device delivers therapeutically effective amounts can vary. Drug diffusion rates in the inner ear are determined by various factors, such as molecular size, configuration, concentration, liposolubility and electrical charge of the drug, for example. A few examples of drugs that may be used in the middle and inner ear include methotrexate, gentamicin, aminoglycosides and steroids. This list of drugs is not intended to be comprehensive. Other known drugs and developmental drugs may also provide beneficial treatment to the ear. In some implementations, the treatment device can be implanted to provide a therapy over the effective life of the device such that refilling the device is not necessary.
The treatment devices described herein can be used to treat and/or prevent a variety of other conditions, including but not limited to hearing loss, including hidden hearing loss, noise-induced hearing loss, age-related hearing loss, drug-induced hearing loss, such as chemotherapy-induced hearing loss or aminoglycoside-induced hearing loss, sudden sensorineural hearing loss, and the like. Any of a variety of ear disorders can be treated using the devices described herein. The treatment devices described herein can be used to treat other ear disorders such as tinnitus. The treatment devices described herein can be used to treat balance disorders including vertigo, Meniere's disease, vestibular neuronitis, labyrinthitis, and the like.
Examples of therapeutic agents that may be delivered by the treatment devices described herein and/or are described in the applications incorporated by reference herein are provided below.
Therapeutics that can be delivered from the devices described herein include but are not limited to antioxidants, anti-inflammatories, corticosteroids, steroids, aminoglycosides, antimicrobials, NMDA receptor antagonists, nootropics, anti-apoptotic agents, neurotrophins, neuroprotective agents, neural protective proteins such as ciliary neurotrophic factor (CNTF), brain-derived neurotrophic factor (BDNF), pigment epithelium-derived factor (PEDF), nerve growth factor (NGF), and the like, cannabinoids, monoclonal antibodies, other proteins, gene therapy, iRNA, cell therapies, and protein therapies like anti-VEGF.
As an example, the therapeutic agent can include, but is not necessarily limited to, antimicrobials such as antibiotics such as tetracycline, chlortetracycline, bacitracin, neomycin, polymyxin, gramicidin, cephalexin, oxytetracycline, chloramphenicol kanamycin, rifampicin, ciprofloxacin, tobramycin, gentamycin, erythromycin and penicillin; antifungals such as amphotericin B and miconazole; anti-bacterials such as sulfonamides, sulfadiazine, sulfacetamide, sulfamethizole and sulfisoxazole, nitrofurazone and sodium propionate; antivirals such as idoxuridine, trifluorotymidine, acyclovir, ganciclovir and interferon; antiallergenics such as sodium cromoglycate, antazoline, methapyriline, chlorpheniramine, pyrilamine, cetirizine and prophenpyridamine; anti-inflammatories such as hydrocortisone, hydrocortisone acetate, dexamethasone, dexamethasone 21-phosphate, fluocinolone, medrysone, prednisolone, prednisolone 21-phosphate, prednisolone acetate, fluoromethalone, betamethasone, and triamcinolone; non-steroidal anti-inflammatories such as salicylate, indomethacin, ibuprofen, diclofenac, flurbiprofen and piroxicam; decongestants such as phenylephrine, naphazoline and tetrahydrozoline; miotics and anticholinesterases such as pilocarpine, salicylate, acetylcholine chloride, physostigmine, eserine, carbachol, diisopropyl fluorophosphate, phospholine iodide and demecarium bromide; mydriatics such as atropine sulfate, cyclopentolate, homatropine, scopolamine, tropicamide, eucatropine and hydroxyamphetamine; sypathomimetics such as epinephrine; antineoplastics such as carmustine, cisplatin and fluorouracil; immunological drugs such as vaccines and immune stimulants; hormonal agents such as estrogens, estradiol, progestational, progesterone, insulin, calcitonin, parathyroid hormone and peptide and vasopressin hypothalamus releasing factor; beta adrenergic blockers such as timolol maleate, levobunolol HCl and betaxolol HCl; growth factors such as epidermal growth factor, fibroblast growth factor, platelet derived growth factor, transforming growth factor beta, somatotropin and fibronectin; carbonic anhydrase inhibitors such as dichlorophenamide, acetazolamide and methazolamide and other drugs such as prostaglandins, antiprostaglandins and prostaglandin precursors; antioxidants, N-methyl-D-aspartate (NMDA) receptor antagonists, nootropics, anti-apoptotic agents, neurotrophins, neuroprotective agents, cannabinoids, monoclonal antibodies, other proteins, cell therapies, and gene therapy. Other therapeutic agents known to those skilled in the art which are capable of controlled, sustained release into the ear in the manner described herein are also suitable for use in accordance with implementations or features of the devices described herein.
The therapeutic agent can include, but is not limited to, sodium thiosulfate to protect against cisplatin-induced hearing loss; NMDA receptor antagonists for the treatment of tinnitus (AM-101; Auris Medical); AM-111 containing the synthetic peptide D-JNKI-1 (D-stereoisomer of c-Jun N-terminal Kinase Inhibitor 1; Auris Medical) for otoprotection in acute inner ear hearing loss; dexamethasone for the treatment of Meniere's Disease; D-methionine (Southern Illinois University) to protect against Noise-induced hearing loss; LY411575 (a selective gamma secretase inhibitor that blocks Notch activation); NT-3 neurotrophic factor; and APAF-1 inhibitors such as those described in U.S. Pat. No. 9,040,701, which is incorporated by reference here in its entirety.
Various pharmaceutically acceptable carriers for the therapeutic agents described herein can include such as, for example, solids such as starch, gelatin, sugars, natural gums such as acacia, sodium alginate and carboxymethyl cellulose; polymers such as silicone rubber; liquids such as sterile water, saline, dextrose, dextrose in water or saline; condensation products of castor oil and ethylene oxide, liquid glyceryl triester of a lower molecular weight fatty acid; lower alkanols; oils such as corn oil, peanut oil, sesame oil, castor oil, and the like, with emulsifiers such as mono- or di-glyceride of a fatty acid, or a phosphatide such as lecithin, polysorbate 80, and the like; glycols and polyalkylene glycols including P407 and other combinations of polyethylene glycol and polypropylene glycol; aqueous media in the presence of a suspending agent, for example, sodium carboxymethylcellulose, sodium hyaluronate, sodium alginate, poly(vinyl pyrrolidone) and similar compounds, either alone, or with suitable dispensing agents such as lecithin, cyclodextrins, polyoxyethylene stearate and the like. The carrier may also contain adjuvants such as preserving, stabilizing, wetting, colorizing, odorizing, emulsifying agents or other related materials.
While this specification contains many specifics, these should not be construed as limitations on the scope of what is claimed or of what may be claimed, but rather as descriptions of features specific to particular implementations or features. Certain features that are described in this specification in the context of separate embodiments can also be implemented in combination in a single implementation or feature. Conversely, various features that are described in the context of a single implementation or feature can also be implemented in multiple implementations or features separately or in any suitable sub-combination. Moreover, although features may be described above as acting in certain combinations and even initially claimed as such, one or more features from a claimed combination can, in some cases, be excised from the combination, and the claimed combination may be directed to a sub-combination or a variation of a sub-combination. Similarly, while operations are depicted in the drawings in a particular order, this should not be understood as requiring that such operations be performed in the particular order shown or in sequential order, or that all illustrated operations be performed, to achieve desirable results. Only a few examples and implementations are disclosed. Variations, modifications and enhancements to the described examples and implementations and other implementations may be made based on what is disclosed. The claimed subject matter has been described in conjunction with the detailed description thereof, the foregoing description is intended to illustrate and not limit the scope of the claimed subject matter of the appended claims.
In various implementations, description is made with reference to the figures. However, certain implementations may be practiced without one or more of these specific details, or in combination with other known methods and configurations. In the description, numerous specific details are set forth, such as specific configurations, dimensions, and processes, in order to provide a thorough understanding of the implementations. In other instances, well-known processes and manufacturing techniques have not been described in particular detail in order to not unnecessarily obscure the description. Reference throughout this specification to “one embodiment,” “an embodiment,” “one implementation, “an implementation,” or the like, means that a particular feature, structure, configuration, or characteristic described is included in at least one embodiment or implementation. Thus, the appearance of the phrase “one embodiment,” “an embodiment,” “one implementation, “an implementation,” or the like, in various places throughout this specification are not necessarily referring to the same embodiment or implementation. Furthermore, the particular features, structures, configurations, or characteristics may be combined in any suitable manner in one or more implementations.
The use of relative terms throughout the description may denote a relative position or direction. For example, “distal” may indicate a first direction away from a reference point. Similarly, “proximal” may indicate a location in a second direction opposite to the first direction. However, such terms are provided to establish relative frames of reference, and are not intended to limit the use or orientation of the devices and/or delivery systems to a specific configuration described in the various implementations.
Unless otherwise indicated, all numbers expressing dimensions, quantities, properties, and so forth used in the specification and claims are to be understood as being modified in instances by the term “about.” Accordingly, unless indicated to the contrary, the numerical parameters set forth in the specification and attached claims are approximations that may vary depending upon the desired properties sought to be obtained. At the very least, and not as an attempt to limit the application of the doctrine of equivalents to the scope of the claims, each numerical parameter should at least be construed in light of the number of reported significant digits and by applying ordinary rounding techniques.
The terms “a,” “an,” “the” and similar referents used in the context of describing the devices and methods (especially in the context of the following claims) are to be construed to cover both the singular and the plural, unless otherwise indicated herein or clearly contradicted by context. All methods described herein can be performed in any suitable order unless otherwise indicated herein or otherwise clearly contradicted by context. The use of any and all examples, or exemplary language (e.g., “such as”) provided herein is intended merely to better illuminate the invention and does not pose a limitation on the scope of any claim. No language in the specification should be construed as indicating any non-claimed element essential to the practice of the invention.
Groupings of alternative elements, embodiments, or implementations disclosed herein are not to be construed as limitations. Each group member may be referred to and claimed individually or in any combination with other members of the group or other elements found herein. It is anticipated that one or more members of a group may be included in, or deleted from, a group for reasons of convenience and/or patentability. When any such inclusion or deletion occurs, the specification is deemed to contain the group as modified thus fulfilling the written description of all Markush groups used in the appended claims.
In the descriptions above and in the claims, phrases such as “at least one of” or “one or more of” may occur followed by a conjunctive list of elements or features. The term “and/or” may also occur in a list of two or more elements or features. Unless otherwise implicitly or explicitly contradicted by the context in which it is used, such a phrase is intended to mean any of the listed elements or features individually or any of the recited elements or features in combination with any of the other recited elements or features. For example, the phrases “at least one of A and B;” “one or more of A and B;” and “A and/or B” are each intended to mean “A alone, B alone, or A and B together.” A similar interpretation is also intended for lists including three or more items. For example, the phrases “at least one of A, B, and C;” “one or more of A, B, and C;” and “A, B, and/or C” are each intended to mean “A alone, B alone, C alone, A and B together, A and C together, B and C together, or A and B and C together.”
Use of the term “based on,” above and in the claims is intended to mean, “based at least in part on,” such that an unrecited feature or element is also permissible.
This application is a continuation of U.S. patent application Ser. No. 17/668,090, filed on Feb. 9, 2022, which is a continuation of U.S. patent application Ser. No. 16/388,159, filed on Apr. 18, 2019 (now U.S. Pat. No. 11,273,295), which claims the benefit of priority to U.S. provisional patent application Ser. No. 62/660,163, filed Apr. 19, 2018, the disclosures of which are hereby incorporated by reference in their entirety.
| Number | Date | Country | |
|---|---|---|---|
| 62660163 | Apr 2018 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 17668090 | Feb 2022 | US |
| Child | 18800665 | US | |
| Parent | 16388159 | Apr 2019 | US |
| Child | 17668090 | US |
