Not applicable.
Not applicable.
The present disclosure relates to storing and presenting an intraocular lens (IOL) to a patient, and particularly to a kit having a shuttle, a vial and an injector, and more particularly to a shuttle that is moveable between an engaged IOL retaining storage configuration and an engaged IOL retaining loading configuration, wherein the vial interacts with the shuttle to dispose the shuttle in the storage configuration in which the IOL is retained in a nominal state and the injector interacts with the shuttle to dispose the shuttle in the loading configuration, in which at least a portion of the IOL retained in the shuttle is preferentially biased or deformed.
Intraocular lenses (also referred to herein as IOLs or simply as lenses) are artificial lenses used to replace natural crystalline lenses of eyes when the natural lenses are diseased or otherwise impaired. Under some circumstances a natural lens may remain in an eye together with an implanted IOL. IOLs may be placed in either the posterior chamber or the anterior chamber of an eye.
IOLs come in a variety of structures and materials. Various instruments and methods for implanting such IOLs in an eye are known. Typically, an incision is made in a cornea and an IOL is inserted into the eye through the incision. In one technique, a surgeon uses surgical forceps to grasp the IOL and insert it through the incision into the eye. While this technique is still practiced today, more and more surgeons are using IOL injectors which can offer advantages such as affording a surgeon more control when inserting an IOL into an eye and permitting insertion of IOLs through smaller incisions. Smaller incision sizes (e.g., less than about 3 mm) are preferred over larger incisions (e.g., about 3.2 to 5+ mm) since smaller incisions have been associated with to reduced post-surgical healing time and reduced complications such as induced astigmatism.
In order for an IOL to fit through a smaller incision, the IOL is typically folded and/or compressed prior to entering an eye where it will assume its original unfolded/uncompressed shape. Since IOLs are very small and delicate articles of manufacture, great care must be taken in their handling, both as they are loaded into an injector and as they are injected into the eye.
It is important that an IOL be expelled from the tip of the IOL injector and into the eye in an undamaged condition and in a predictable orientation. Should an IOL be damaged or expelled from the injector in an incorrect orientation, a surgeon must remove or further manipulate the ME in the eye, possibly resulting in trauma to the surrounding tissues of the eye. To achieve proper delivery of an IOL, consistent loading of the IOL, into the injector with a minimum opportunity for damaging the IOL is desirable.
Various IOL injectors and other devices have been proposed which attempt to address issues related to loading and presenting the IOL to the patient, yet there remains a need for a shuttle, vial and injector assembly which eliminates the need for operator handling of the IOL and thereby reduces the likelihood of damage to the IOL prior to presentation to a patient.
The present disclosure provides a shuttle for retaining an IOL having an optic, the shuttle having a first shuttle plate and a separate second shuttle plate operably coupled and then configurable between a coupled storage configuration and a coupled loading configuration, the first and the second shuttle plates in each of the coupled storage configuration and the coupled loading configurations defining an IOL chamber extending along a longitudinal axis, the IOL chamber axially bounded by a proximal port and a distal port, wherein each of the proximal port and the distal port in each of the coupled storage configuration and the coupled loading configurations has a major dimension transverse to the longitudinal axis, the major dimension being smaller than a diameter of the optic.
The present disclosure further provides a shuttle for retaining an IOL having an optic, the shuttle including a first shuttle plate and a separate second shuttle plate configured to operably engage the first shuttle plate, such that the operably engaged first and second shuttle plates are configured to be disposed between an engaged storage configuration and an engaged loading configuration; wherein the operably engaged first and second shuttle plates define a shuttle having (i) a shuttle lumen extending along a longitudinal axis, the shuttle lumen having an IOL chamber sized to retain an optic of an IOL, (ii) a storage set of confronting surfaces, (iii) a loading set of confronting surfaces and (iv) a flexure interface intermediate the storage set of confronting surfaces and the loading set of confronting surfaces, wherein the operably engaged first and second shuttle plates contact the storage set of confronting surfaces in each of the engaged storage configuration and the engaged loading configuration, and the loading set of confronting surfaces flex from being spaced apart in the engaged storage configuration of the operably engaged first and second shuttle plates to abutting in the engaged loading configuration of the operably engaged first and second shuttle plates.
Also disclosed is a method of disposing an IOL having an optic within a shuttle, the method including the steps of capturing an IOL while located on a fixture within an IOL chamber defined by an engaged first shuttle plate and second shuttle plate, the engaged first shuttle plate and a second shuttle plate defining a shuttle; and withdrawing the fixture from the IOL through a port in the IOL chamber to retain the IOL within the IOL chamber defined by the engaged first shuttle plate and second shuffle plate.
Generally, the present disclosure provides for a kit having a shuttle 100, a vial 200, and an injector 300, wherein the shuttle retains and stores an IOL 10, the vial retains the shuttle and the injector injects the IOL along a longitudinal axis into an eye of a patient.
As used herein, an IOL 10 is an artificial lens used to replace the natural crystalline lens of the eye when the natural lens has cataracts or is otherwise diseased. IOLs 10 are also sometimes implanted into an eye to correct refractive errors of the eye in which case the natural lens may remain in the eye together with the implanted IOL. The IOL 10 may be placed in either the posterior chamber or anterior chamber of the eye. IOLs 10 come in a variety of structures and materials. Some common IOL 10 styles include the so-called open-looped haptics which include the three-piece type having an optic and two haptics 12, 14 attached to and extending from an optic 16; the one-piece type wherein the optic and haptics are integrally formed (e.g., by machining the optic and haptics together from a single block of material); and also the closed looped haptic IOLs. A further style of IOL is called the plate haptic type wherein the haptics are configured as a flat plate extending from opposite sides of the optic. The IOL 10 may be made from a variety of materials or combination of materials such as, but not limited to PMMA, silicone, hydrogels and silicone hydrogels.
It is also understood that the IOL 10 structure shown and described herein is for discussion purposes only, and that the present invention is not to be limited by the particular structure of the IOL. The present system may be easily adapted to IOLs 10 of any structure and type (e.g., IOLs with plate, open or closed loop haptics, anterior chamber IOLs, posterior chamber IOLs, accommodating IOLs (including single and double lens types), etc.). The IOL 10 has a nominal state in the absence of external forces (other than gravity). That is, the nominal state is the formation the IOL assumes upon the removal of deforming forces.
Referring to
As seen in
The orienting surfaces 210 are configured as elongate ribs for friction fitting with a surface of the shuttle 100, and typically an outer surface of the shuttle. The orienting surfaces 210 function to orient and constraint the shuttle 100 is a predetermined relationship within the vial 200. Further, the orienting surfaces 210 can be sized to provide a friction fit engagement with the shuttle 100 to assist in retaining the shuttle relative to the vial 200.
The locating surfaces 220 are configured to be disposed within a portion of the shuttle 100 upon the shuttle being operably engaged with the vial 200. The locating surfaces 220 bound or limit movement of the IOL 10 within the shuttle 100. As seen in
The wedging surfaces 230 of the vial 200 are configured to urge or force the shuttle 100 to a storage configuration, such as the engaged or coupled storage configuration, upon operable engagement of the shuttle and the vial.
The lid 202 seals the vial 200 by any of a variety of mechanisms known in the art to retain the solution within the vial.
The surfaces of the vial 200 in conjunction with the lid are configured to engage and retain the shuttle 100 relative to the vial so as to preclude unintended displacement of the shuttle and restrict the shuttle in the vial from compressing or deforming the IOL 10 during intended storage and transportation.
Thus, the vial 200 is constructed to engage, and dispose the shuttle 100 to a storage configuration and retain the shuttle in the storage configuration, wherein an IOL optic 16 is maintained in a nominal, unstressed, state.
The shuttle 100 includes a first shuttle plate 120 and a second shuttle plate 160, wherein the first and the second shuttle plates are configured to operably engage and define (i) a shuttle lumen 102 having an IOL chamber 104 sized to receive the IOL 10, (ii) a storage set of confronting surfaces 122, 162, (iii) a loading set of confronting surfaces 124, 164 and (iv) a flexure interface 126, 166 intermediate the storage set of confronting surfaces and the loading set of confronting surfaces, such that portions of the operably engaged first and second shuttle plates flex about the flexure interface between (a) a storage configuration, such as an engaged or coupled storage configuration, wherein the storage set of confronting surfaces abut and the loading set of confronting surfaces are spaced apart and (b) a loading configuration, such as an engaged or coupled loading configuration, wherein both the storage set of confronting surfaces and the loading set of confronting surfaces abut. The terms storage configuration and loading configuration are intended to encompass engaged or coupled storage configuration and engaged or coupled loading configuration, respectively.
As used in connection with the description of the engaged shuttle plates 120, 160 flexing or moving between and assuming the different arrangements or relative positions, the term configuration is intended to encompass the different arrangements or relative positions of the shuttle plates, when the shuttle plates are flexed relative to each other while engaged, as set forth below. Further, the term abut means next or adjacent to, having a common boundary or in contact.
As seen in
Referring to
As seen in
In one embodiment of the shuttle plates 120, 160, the storage set of confronting surfaces 122, 162 are parallel and the loading set of confronting surfaces 124, 164 are nonparallel in the first or storage configuration in of the shuttle 100. In this embodiment of the shuttle plates 120, 160, the storage set of confronting surfaces 122, 162 remain parallel and the loading set of confronting surfaces 124, 164 are flexed to a parallel orientation in the second or loading configuration of the shuttle 100.
The flexure interface 126, 166 is the interlace for the flexing or hinging of the shuttle plates 120, 160 and specifically pivoting the loading set of confronting surfaces 124, 164 relative to the storage set of confronting surfaces 122, 162. The flexure interface 126, 166 can be points of contact, a line of contact or contacting two-dimensional areas. Referring to
The flexure interface 126, 166 can provide for flexing of portions of the shuttle plates 120, 160 (and particularly the loading set of confronting surfaces 124, 164) about an axis, wherein the axis is generally parallel to the longitudinal axis. It is further understood the flexing of the shuttle plates 120, 160 can include a rocking movement or relationship, wherein the movement is of an arcuate or concave surface against another surface which can be arcuate, planar, concave or convex. Thus, rather than a line or axis of flexure, the flexing relationship can include movement along an area of the flexure interface 126, 166.
Thus, along a direction transverse to the longitudinal axis, the flexure interface 126, 166 or surface, is intermediate the storage set of confronting surfaces 122, 162 and the loading set of confronting surfaces 124, 164. Accordingly, the IOL chamber 104 is intermediate the storage set of confronting surfaces 122, 162 and the loading set of confronting surfaces 124, 164 along a direction transverse to the longitudinal axis.
Each shuttle plate 120, 160 also includes a retaining tab 128, 168 moveable between a nominal, relaxed position and a flexed position. The retaining tabs 128, 168 are configured to engage and lock in the injector 300, and in one configuration preclude nondestructive separation of the shuttle 100 from the injector. Conversely, the engagement of the shuttle 100 and vial 200 is constructed to permit selectively disengagement of the shuttle from the vial. While each shuttle plate 120, 160 is shown having two retaining tabs 128, 168, it is contemplated each shuttle plate can include one or three or more retaining tabs. It has been found satisfactory for each shuttle plate 120, 160 to include two longitudinally spaced retaining tabs 128, 168.
The first and the second shuttle plates 120, 160 also define an access port 150, as shown in
The shuttle plates 120, 160 further include an interconnect structure for interconnecting the shuttle plates while allowing relative movement, such as flexing of the loading set of confronting surfaces 124, 164 of the shuttle plates between the storage configuration and the loading configuration. Referring to
The remaining mating post and receiving hole, such as 136 and 171 are configured to function as a guide for the relative engagement of the shuffle plates 120, 160. That is, the remaining mating post and receiving hole provide that the engaged shuttle plates 120, 160 can only flex about the flexure interface 126, 166 parallel to the longitudinal axis. The engagement of the remaining post and receiving hole (i) prevent the engaged shuttle plates from spinning about the engagement or the first mating post and the first receiving hole and (ii) permit flexing of the portions of the shuttle plates 120160 about the flexure interface 126, 166.
Referring to the
The first and the second shuttle plates 120, 160 are separate independent elements. That is, the shuttle plates 120, 160 are not joined or connected prior to their engagement to form the shuttle 100. There is no integral connection of the shuttle plates 120, 160 before the individual shuttle plates are interconnected to form the shuttle 100. The shuttle plates 120, 160 being independent means the shuttle plates are separate elements which are interconnected, such as by being coupled or engaged, only as part of the assembling or formation of the shuttle 100. It is contemplated the first and the second shuttle plates 120, 160 are individually formed and form the IOL chamber 104 only upon coupling or engagement of the separate shuttle plates. Thus, the term separate means discrete, independent components that are not integrally connected or joined.
Upon operable engagement or coupling of the shuttle plates 120, 160, the resulting shuttle 100 defines the shuttle lumen. 102 having the IOL chamber 104 for retaining the IOL 10, wherein the IOL chamber is bounded along the longitudinal axis by the proximal port 108 and the distal port 106. The haptic ramps 132, 172 are thus located in the IOL chamber 104. By retaining the IOL 10, the IOL chamber 104 forms a container that captures the IOL, wherein the IOL cannot pass from the chamber in any direction without deformation from a nominal state, and in select embodiments without deformation of the optic 16 of the IOL. In select embodiments, the IOL chamber 104 is entirely defined by the first and the second shuttle plates 120, 160.
The distal port 106 and the proximal port 108 are sized pass a portion of the injector 300. In one embodiment, the distal port 106 and the proximal port 108 define a continuous periphery, wherein the periphery of each port lies in a corresponding plane. However, as seen in the Figures, the periphery of each the distal port 106 and the proximal port 108 can extend along a dimension of the longitudinal axis. That is, the periphery of each of the distal port 106 and the proximal port 108 does not lie in a single plane, but rather extends a distance along the longitudinal axis. In the loading configuration, at least the bottom of the shuttle lumen defines a substantially continuous surface. That is, the bottom is free of gaps or spacings between the shuttle plates that would detrimentally interfere with the movement of the IOL 10 along and from the shuttle lumen. As the IOL 10 is preferentially curved along the bottom of the shuttle lumen, a top portion of the lumen at the proximal end need not be continuous. It is advantageous in deforming the IOL 10 to a presentation configuration that the distal end of the top of the shuttle lumen 102 be a sufficiently continuous surface to preclude detrimental engagement with the IOL as the IOL passes the distal port.
The distal port 106 and the proximal port 108 have a major dimension transverse to the longitudinal axis. As seen in the
As set forth above, the interconnection of shuffle plates 120, 160 permits the relative flexing, or pivoting, of the loading set of confronting surfaces 124, 164 of the shuttle plates, while the shuttle plates remain in an interconnected, coupled or engaged, configuration. Specifically, with the engaged first and second shuttle plates 120, 160, the loading set of confronting surfaces 124, 164 can be flexed about the flexure interface between (i) a storage configuration, wherein the storage set of confronting surfaces 122, 162 abut and the loading set of confronting surfaces 124, 164 are spaced apart and (ii) a loading configuration, wherein the storage set of confronting surfaces remain abutting while the loading confronting surfaces are pivoted about the flexure interface to abut.
The IOL chamber 104, existing and defined and operable in both the storage configuration of the shuttle 100 and the loading configuration of the shuttle, changes a dimension far retaining the IOL 10 as the shuttle is configured between the storage configuration and the loading configuration. Specifically, the IOL chamber 104 defines (i) a storage dimension transverse to the longitudinal axis for the optic 16 of the IOL 10 in the storage configuration and (ii) a loading dimension transverse to the longitudinal axis for the optic of the IOL in the loading configuration, wherein the loading dimension is smaller than the storage dimension. In one embodiment, the storage dimension is sufficient to retain at least the optic 16 of the IOL 10 in a nominal state. The loading dimension and surfaces defining the IOL chamber 104 are selected such that upon the shuttle 100 being disposed in the loading configuration, the optic 16 of the IOL 10 is preferentially deformed or curved to a substantially predetermined shape.
The representative injector 300 is shown in
In one embodiment, the injector body 310 further cooperates with an injector tip 320 which defines an extension of the lumen so as to define a pathway of the IOL 10 from the shuttle 100 to the eye of the patient. The injector tip 320 defines a terminal end of a size for insertion or presentation to the eye, with the IOL 10 correspondingly deformed within the injector tip. However, it is understood, the injector body 310 can include an integral injector tip or nozzle defining a portion of the lumen for directing the IOL 10 from the shuttle to the eye of the patient.
Referring to
The shuttle bay 330 also includes caroming surfaces 334 that flex or pivot the loading set of confronting surfaces 124, 164 of the engaged shuttle plates 120, 160 from the storage configuration to the loading configuration. As seen in
The injector 100 is shown as employing a user imparted actuation force for moving the IOL 10 from the shuttle 100 and into the eye.
Referring to
After manufacture of the IOL 10, the IOL is releasably retained on a fixture. The fixture can be any of a variety of constructions that can retain and repeatedly locate an IOL 10 without damage to the IOL. In one embodiment, the fixture is a mount fixed at an end of an elongate shaft, wherein the mount and a portion of the elongate shaft can be passed through the access port 150 of the shuttle 100. The orientation of the mounted IOL can be aby of a variety of orientations, such as but not limited to orienting the IOL 10 such that an optical axis of the IOL is perpendicular to or parallel to the shuttle lumen 102.
As the IOL 10 is retained on the fixture, the first shuttle plate 120 and the second shuttle plate 160 are brought together and interconnected, such as engaged or coupled, about the retained IOL so as to form the IOL chamber 104 about the retained IOL, wherein the a portion of the fixture is disposed within the access port 150. As the shuttle plates 120, 160 are engaged as set forth above, thereby capturing the IOL 10 in the IOL chamber 104, the IOL is released from the fixture and the fixture is withdrawn through the access port 150, leaving the IOL, retained in the shuttle 100.
In one configuration, the IOL 10 is oriented within the IOL chamber 104 such that one haptic 12 is adjacent or towards the distal port 106 thereby defining a leading haptic and the remaining haptic 14 is adjacent or towards the proximal port 108 thereby defining a trailing haptic as oriented within the IOL chamber 104 of the shuttle 100.
When the shuttle 100 is unconstrained in either the vial 200 or the injector 300, the IOL chamber 104 captures the IOL 10 and precludes exiting of the IOL under intended operating parameters. In each of the engaged storage and the engaged loading configuration of the shuttle plates 120, 160, passage of the IOL 10 from the shuttle 100 is inhibited by the size of the distal and proximal ports 106, 108 and the access port 150 relative to the size of the IOL (or at least the size of the optic 16 of the IOL).
The shuttle 100 carrying the retained IOL 10 is then engaged with the vial 200. Upon engagement of the shuttle 100 with the vial 200, the orienting surfaces 210 of the vial contact select exposed surfaces of the shuttle to orient the shuttle in the vial.
The locating surfaces 220 of the vial 200 project into the IOL chamber 104 for locating the IOL 10 within the shuttle 100, as seen in
The wedging surfaces 230 of the vial 200 contact the shuttle plates 120, 160 to dispose the shuttle 100 in the storage configuration. That is, the wedging surfaces 230 contact surfaces 150 on both shuttle plates and impart or ensure the loading set of confronting surfaces 124, 164 are spaced apart, such that the IOL chamber 104 does not bend or fold the IOL 10. Thus, the storage set of confronting surfaces 122, 162 remain in an abutting position and the loading confronting surfaces 124, 164 to a spaced or separated position. As seen in
The distal port 106 and the proximal port 108 having a smaller dimension than the IOL 10 (or at least the optic 16 of the IOL) preclude passage of the IOL from the IOL chamber 104 through the ports. Similarly, the access port 150 has a dimension to preclude passage of the IOL 10 under intended operating parameters. Absent an external removal force, such as the plunger acting on the IOL 10, the IOL chamber 104 retains the IOL within the chamber in both the engaged storage configuration of the shuttle (the engaged first and second shuttle plates 120, 160) and the engaged loading configuration of the shuttle (the engaged first and second shuttle plates).
Thus, as the shuttle 100 is engaged with the vial 200, the storage set of confronting surfaces 122, 162 are abutting; the loading set of confronting surfaces 124, 164 are spaced apart. The orienting surfaces 210 of the vial 200 contact the outer surfaces of the shuttle 100 to position and retain the shuttle within the vial. The wedging surfaces 230 of the vial 200 contact the surfaces 150 of the shuttle 100 to maintain the loading set of confronting surfaces 124, 164 in the nominal spaced apart relation to dispose the shuttle in the storage configuration and the locating surfaces 220 of the vial 200 project into the IOL chamber 104 and limit movement or contact a periphery of the IOL, 10 and locate the IOL, within the IOL chamber.
The loaded shuttle 100 is retained in the vial 200, sterilized and packaged with a volume of sterile solution. As the IOL 10 is in an unstressed, nominal state, the only limitation on the duration of the storage is the duration of the sterile conditions/packaging.
For presenting the IOL 10 to the patient, the lid 202 is removed from the vial 200, thereby exposing the shuttle 100 as it is retained in the vial. The shuttle 100 is disengaged from the vial 200.
The shuttle 100 is then engaged with the injector 300 by engaging the retaining tabs 128168 of the shuttle with the engaging surfaces 332 of the injector. The engaging surfaces 332 or camming surfaces 334 can function as alignment surfaces of the injector 300 and contact corresponding surfaces of the shuttle 100 to operably locate the shuttle 100 in the injector. The camming surfaces 334 are configured to dispose the shuttle 100 in the loading configuration, wherein the loading set of confronting surfaces 124, 164 are flexed or pivoted about the flexure interface and both the storage set of confronting surfaces 122, 162 and the loading set of confronting surfaces 124, 164 abut as seen in
In the loading configuration, the IOL chamber 104 defines a reduced dimension for the optic 16 of the IOL 10, thereby imparting a predetermined bend or curvature to the IOL, as seen in
To dispense the IOL 10 from the injector 300, the plunger 340 is actuated causing the plunger tip 344 to enter the shuttle lumen 102 and the IOL chamber 104. The predetermined bend in the optic 16 of the IOL 10 retards movement of the IOL along the shuttle lumen 102. Thus, as the plunger tip 344 first contacts the IOL 10 and specifically the trailing haptic 14, the trailing haptic begins to contact the corresponding haptic ramp and fold over the optic 16. Continued contact by the plunger tip 344 and resistance from the curvature of the optic 16 pushes the trailing haptic 14 up the haptic ramp and folds the trailing haptic over the optic such that the plunger tip then contacts the periphery of the optic. Upon continued contact of the plunger tip 344 and the IOL 10 as the plunger tip advances along the shuttle lumen 102, the leading haptic 12 moves up the corresponding haptic ramp to be disposed above the optic 16.
As the plunger 340 continues to move the IOL 10 along the longitudinal axis and the shuttle lumen 102, the optic 16 of the IOL 10 continues to deform or bend in the direction imparted by the transition of the shuttle 100 from the storage configuration to the loading configuration, and each of the leading and trailing haptics 12, 14 moves up along the respective haptic ramps 132, 172 to dispose a majority of each haptic in an overlying position with respect to the optic.
The plunger 340 continues to move the IOL 10 along the shuttle lumen 102 passing from the shuttle 100 and to the injector tip 320, whereby the IOL can be further deformed to an insertion configuration for presentation to the eye.
Thus, the present shuttle 100 provides for releasably engaging or retaining the IOL 10, wherein the shuttle includes a first component, such as the first shuttle plate 120 and an independent second component, such as the second shuttle plate 160 wherein the first component and the second component define a first set of confronting surfaces and a second set of confronting surfaces and are configured to operably engage so as to define a shuttle lumen 102 extending along the longitudinal axis, the shuttle lumen having the IOL chamber 104 bounded by the proximal port 108 and the distal port 106 on the longitudinal axis; and the operable engagement of the first component and the second component providing (i) a first configuration of the IOL chamber and (ii) a second configuration of the IOL chamber by selectively flexing or pivoting a portion of the engaged shuttle plates about a flexure interface to simultaneously contact the first set of confronting surfaces and the second set of confronting surfaces.
It is contemplated a center line of the optic 16 of the IOL 10 can be located along the longitudinal axis, upon the first shuttle plate 120 and the second shuttle plate 160 being in the first configuration. That is, a midpoint of the optic 16 of the IOL 10 retained within the IOL chamber 104 lies on the longitudinal axis of the lumen. However, it is understood that based on the specific structure of the IOL chamber 104, the midpoint of the optic 16 can be above or below a horizontal plane encompassing the longitudinal axis.
Having thus described the inventive concepts and a number of exemplary embodiments, it will be apparent to those skilled in the art that the invention may be implemented in various ways, and that modifications and improvements will readily occur to such persons. Thus, the embodiments are not intended to be limiting and presented by way of example only. The invention is limited only as required by the following claims and equivalents thereto.
The present application is a continuation of Ser. No. 16/913,255, filed Jun. 26, 2020, which is a division of Ser. No. 15/708,873 filed Sep. 19, 2017, now U.S. Pat. No. 10,772,346, the disclosure of each of which is hereby expressly incorporated by reference.
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