Patent Application
20060235313
Eye examining instruments and methods.
Our previous U.S. Pat. No. 5,070,875, entitled “Applanation Tonometer Using Light Reflection To Determine Applanation Area Size”, and U.S. Pat. No. 6,179,779, entitled “Replaceable Prism System For Applanation Tonometer” and our pending application Ser. No. 09/756,316, entitled “Method of Operating Tonometer”, and Ser. No. 09/811,709, entitled “Replaceable Prism For Applanation Tonometer” suggest tonometers, tonometer operating methods, and tonometer prisms for measuring intra ocular pressure (IOP) of an eye. Our type of applanation tonometer has an actuator that presses a prism with a variable and determinable force against a cornea of an eye being examined while a source directs light to reflect from an applanation surface of the prism to a detector producing a detected light signal received by a microprocessor.
Our experiments and experiences with working prototypes improving upon the disclosures of our issued patents and pending applications have led to several related discoveries. We have found that by changing and adding to the eye examining procedures that are possible with instruments such as ours we can obtain considerably more diagnostic information than has previously been clinically available. These discoveries involve not only eye examining methods but also structuring and programming a tonometer to perform such methods to obtain new measurements and new information of value to a clinician concerning the heath and functioning of an eye being examined. Such improvements are the subject of this application.
The tonometers that are commonly used clinically have operated only during a diastolic phase and have measured only a diastolic intra ocular pressure (IOP). In contrast to this, we have discovered that our instrument can produce a useable signal during a systolic pulse occurring in an eye being examined. Upon exploring this, we found that a systolic phase signal from our instrument can be used to determine an ocular pulse pressure or a systolic IOP. This constitutes valuable additional information not obtainable with previous clinical tonometers. It provides a measure not only of diastolic IOP, but also of systolic IOP, and enables an average, weighted average, or mean IOP determination that more accurately represents the true or complete IOP experienced by the eye being examined.
Other experiments with IOP signals attainable from our instrument have led to eye examining methods differing from our previous suggestions. We have found, for example, that IOP can be determined from a slope of a signal obtained as prism pressing force is changed during a time interval. This has eliminated any need to applanate an eye to a predetermined applanation area.
We have also found that a prism pressing force variation range for IOP examining purposes can begin with a preliminary value and change from that value through a predetermined signal change range, rather than proceeding from a reference applanation area to a measurement applanation area. This method eliminates variations in corneal thickness and curvature of different eyes, since these variations are automatically compensated for by the preliminary value from which the predetermined signal excursion range proceeds.
Experience with systolic pulse signals produced by our instrument has led to discovery of other measurements available from examining an eye. We found that we can determine ocular blood flow derived from the departure of the detected light signal from the diastolic IOP during the systolic pulses. Moreover, we have found that we can determine a tonography measure from the way the detected light signal changes from a systolic pulse back to the diastolic phase. We can also determine tonography by measuring a preceding IOP; then pressing the prism against the eye with a predetermined force sufficient to raise the IOP for a predetermined interval; followed closely by determining a subsequent IOP. From this we can derive the tonography measure from the differences between the preceding and the subsequent IOP determinations. An ocular blood flow measurement, and a tonographic measurement of the effectiveness of an eye's trabecular meshwork add significant and previously inaccessible diagnostic information of value to a clinician.
The ability of our instrument to determine ocular pulse pressure (OPP) and ocular blood flow (OBF) can also be exploited to give evidence of blood flow in the carotid and other arteries supplying organs above the neck. If tests with our tonometer indicate sub-normal blood flow in one or both of the eyes, this can indicate possible constriction of blood flow in arteries leading not only to the eyes, but also to the brain and other organs of importance. Since examination of a pair of eyes with our instrument is quick and convenient in determining OPP and OBF, our instrument can serve as an advantageous preliminary test to determine whether, for example, a carotid artery ultrasound examination should be undertaken. Conversely, examinations with our instrument indicating a normal OPP or OBF for each eye can be considered evidence that an ultrasound evaluation of arterial blood flow may not be necessary.
Finally, to ensure that the additional information produced by our eye examining method and instrument is readily available to clinicians, we have made our instrument fast acting, compact, convenient, and objective in its operation. Besides producing much new information, our instrument automatically rejects false readings, and automatically requires concentric contact with a cornea at a proper orientation to attain an accurate reading. The microprocessor in our instrument can preferably store, send, and receive information to perform all the required tasks and operations and to co-operate with computers and other information processing equipment.
Our eye examining method requires an instrument that can produce a signal representing intra ocular pressure (IOP) of an eye being examined. Such instruments are normally called tonometers, but our instrument and the ways it can be used produces information going beyond what can be expected of previous tonometers. Several variations of tonometers suitable for our purposes are described in our previous patents and applications. A presently preferred embodiment of such a tonometer 10 is schematically represented in
The essential components of tonometer 10 include microprocessor 50, prism 30, some form of actuator 15, a light or radiation source 20, and a transducer or detector 25 receiving light or radiation reflected from applanation surface 31 and sending a corresponding electric signal to microprocessor 50. The precise working relationships among these essential components can be varied considerably, however, and the schematic illustrations of
Prism 30 is preferably replaceable and disposable so that it can be removed from prism holder 32 after each examination and replaced with a fresh prism. This ensures that infectious agents, including the possibility of prions, are not transmitted from one pair of eyes to another.
Prism holder 32 is preferably mounted on arm 12, which is arranged to rotate or turn slightly around pivot 13. Since only a few millimeters of movement back and forth of prism 30 is required, as indicated by the double headed arrow, the rotational turning of arm 12 is slight.
A counter balance 14 arranged on arm 11 is arranged with a suitable moment arm relative to pivot 13 to return prism holder arm 12 to a base position. Proper arrangement and balancing of arms 11 and 12 around pivot 13 can eliminate the need for any return spring, and can enable instrument 10 to operate in different orientations.
Actuator 15 can be any of a variety of motors and other preferably electromagnetic prime movers. The preferred actuator schematically illustrated in
Internal wiring within instrument 10 preferably connects a power supply (not shown) with microprocessor 50, which powers actuator 15, light source 20, and light detector 25. Microprocessor 50 preferably drives display 51 to display information directly to an instrument operator, and microprocessor 50 preferably has connections enabling it to receive and output information to and from other devices such as computer keyboards and number pads 52.
The light emitted by source 20 is preferably in a visible red region of the electromagnetic spectrum, but other colors of visible light are also possible, as is radiation energy at infra red or microwave frequencies. For simplicity, all of these possible different radiation frequencies are characterized as “light” within this application. As is well known, use of electromagnetic radiation at different frequencies can require angular adjustments so that light within prism 30 that is internally incident on applanation surface 31 is internally reflected to detector 25 except for a portion of the light that transmits into eye 40 through an applanation region of contact with prism surface 31. Of course, any radiation entering eye 40 must not cause injury.
Prism 30 is preferably molded of resin material to have a low enough manufacturing cost to be affordably disposable. Much more information on preferred characteristics of prism 30 is available in our U.S. Pat. No. 6,179,779 and our pending application Ser. No. 09/811,709. As we have previously suggested, microprocessor 50 is preferably programmed to require that prism 30 be replaced after being used for examining a pair of eyes. This is intended to prevent the tonometer prism from transporting infectious agents from the eyes of one person to the eyes of another.
Experiments and clinical experience with a working prototype of a tonometer instrument such as shown in
Our new method preferably begins with a preliminary value of a detected light signal that the tonometer microprocessor is programmed to recognize. The preliminary value is preferably based upon preliminary contact of the prism applanation surface with a cornea at either bare contact pressure arising from surface tension of tears in the eye, or from a preferably very light predetermined prism pressing force.
The tonometer can be programmed to recognize that the preliminary value has occurred by noting the sudden reduction in the detected signal that occurs when the prism contacts the eye. Before this happens, all the light incident on prism applanation surface 31 is internally reflected, but when surface 31 contacts a cornea, a portion of the incident light is transmitted into the eye in the area of contact so that the detected light signal diminishes noticeably. The preliminary value signal can vary from eye to eye, as explained below, but can also serve as a starting point for an IOP determination.
Then instead of proceeding from the preliminary value to a measurement value, we proceed from the preliminary value through a range of values extending from the preliminary value. Any value at the end of the range extending from the preliminary value is not a fixed value, but is based only on distance from the preliminary value. To accomplish this, we program the microprocessor to operate actuator 15 to press prism applanation surface 31 against the cornea with increasing force applied during a time interval to change the detected light signal from the preliminary value through a range of values extending from the preliminary value. In doing this, microprocessor 50 preferably energizes actuator 15 to apply increasing prism force in predetermined increments that are applied in predetermined brief time intervals so that the detected light signal 26 varies in a step wise, sloped configuration as graphically illustrated in
Signal 26 then provides several ways of determining IOP. One way is to proceed with increasing prism pressure force for a predetermined number of increments or for a predetermined time interval resulting in a predetermined increase in prism pressing force above the preliminary value. We then program microprocessor 50 to determine IOP from the signal change reached at the end value of the predetermined range of prism force change values. By a similar method, the force change values can be continued until the detected light signal 26 reaches a predetermined departure from the preliminary value, with microprocessor 50 determining IOP from the total pressure force required to reach the end signal value. Such an end signal value differs from the previously suggested measurement signal value by being related to the preliminary signal value 27 rather than being an absolute or independent value.
Another way that microprocessor 50 can determine IOP from detected light signal 26 is by measuring or detecting the slope as signal 26 changes over a time or force interval. We have found that signal slope alone is enough for microprocessor 50 to make an accurate determination of IOP. We have also found that detected signal slope tends to roll off at higher prism forces, so we prefer using a linear mid-region or lower force region of detected signal 26 for an IOP determination.
From an ophthalmologically known relation between IOP and force used in applanating a corneal area we have been able to apply linear, logarithmic, and logistic regression analyses to calculate IOP from the signals produced by instrument 10. In these analyses we have used the slope of the detected signal as changes in prism force change corneal applanation area and cause a corresponding change in signal value. Especially logistic regression analysis, which allows us to consider several variables at a time, has been useful in making force-to-signal-to-IOP calculations. We have also corroborated these results by manometric comparisons and Goldman tonometer readings.
Microprocessor 50 is preferably not programmed to make sophisticated mathematical calculations itself. We prefer instead that signal analysis be done separate from microprocessor 50, which is then programmed or loaded with a look up table from which it can determine IOP based on signal values. In doing this, microprocessor 50 can be programmed to average an IOP determination made by different methods.
These IOP determining methods can also be combined or used in conjunction so that one determination corroborates another. Moreover, elapsed time required to reach an end value can serve as another corroborator of an IOP determination. All the IOP determining methods can be combined in a single instrument that determines IOP according to each method and corroborates by comparing elapsed time, force change and electrical signal change. Any differences in the IOP determinations can be averaged out, unless differences are unusually large, in which case the microprocessor can be programmed to repeat the measurement. In a similar way, if elapsed time casts doubt on the accuracy of an IOP determination, the examination can be repeated.
These methods of IOP determination, besides being simple, accurate and fast, have another important advantage. By monitoring signal change relative to a predetermined value 27 that is not fixed but is related to each eye being examined, these IOP determining methods automatically take into account variations in corneal curvature and thickness. Our previous IOP determining suggestions envisioned separate measurements of corneal curvature and corneal thickness and input of such measurements to adjust IOP determinations. This is no longer necessary with our present IOP determining methods, because the preliminary signal value 27 is not a fixed value but is allowed to vary with each eye being examined.
This variation is schematically illustrated in
The ophthalmological literature indicates that every 50 micrometer variation in corneal thickness produces a 1.5 mm Hg variation in measured IOP. This variation will automatically appear in preliminary value signal 27 to adjust the starting point for a predetermined range of values. Similar indications are available in the ophthalmological literature for the effects of differences in arching or curvature of the cornea. These two translate into differences in measured IOP, which are automatically compensated for by preliminary signal value 27.
The variations in preliminary signal 27 due to corneal characteristics such as curvature and thickness do not matter in our present method of determining IOP, because change in detected light signal 26 or 26a, proceeds through a range extending from whatever preliminary value occurs. This automatically eliminates corneal curvature and thickness as possible variables in an IOP determination. The result is a more accurate IOP determination that does not have to be adjusted for corneal thickness or curvature and does not require any separate measurements of or adjustments for corneal thickness and curvature. This advantage can be especially important in examining eyes whose corneas have been modified for vision correcting purposes. The fact that such corneas can respond as thinner than normal does not prevent our tonometer from accurately measuring IOP.
We have also found that our tonometer instrument detects systolic pulses during eye examinations. Goldman tonometers, which are ubiquitous in opthalmological clinics, cannot make an IOP reading during a systolic pulse. Our instrument, in contrast, produces a detected light signal during both a diastolic phase and a systolic phase. This has led to several new ways of determining IOP, one of which is schematically graphed in
The process illustrated in
For the method illustrated in
The eye is subject not only to the IOP occurring in a diastolic phase, but also to the increased IOP that occurs during a systolic pulse when a bolus of blood flows into the eye. An IOP determination based only on a diastolic phase measurement therefore does not indicate the true pressure experienced by the eye over time. For example, a diastolic pressure might be 20 mm of mercury, while systolic pulse pressures reach 26 mm of mercury. A true IOP reading for all the pressure experienced by the eye over time should then include the systolic pulse pressures as a factor increasing the IOP over the diastolic phase pressure.
Broken line 29, as illustrated in
Microprocessor 50 can also be programmed to determine only a systolic IOP, which can be done by ignoring diastolic signal phase 26. For most purposes, though, an average, weighted average, or mean IOP determination based on both diastolic and systolic phase signals is preferred.
The ability of our instrument 10 to produce usable systolic pulse signals 28 can also be used to determine ocular blood flow (OBF). This is preferably determined from the height of systolic pulse signals 28 above diastolic base line 26. The ophthalmological literature includes suggestions for calculating ocular blood flow from ocular pulse pressure by using a Friedenwald equation or one of the suggested modifications of the Friedenwald equation. Most of these suggestions focus on the height of signal 28 above a diastolic base line 26, as we prefer. Some suggestions have also focused on a leading edge of signal 28, and at least one proposal, which we have not adopted, suggests that the area under the signal 28 above the diastolic baseline 26 be considered. The various forms of regression analysis can also be applied to ocular blood flow calculations, and these can be corroborated by clinical experience. Whatever calculations are used, the results are preferably translated into a look up table programmed into microprocessor 50 for use in outputting OBF information.
Another measurement that becomes possible from the availability of OPP signals 28 is a tonography measure of the effectiveness of the trabecular meshwork of the eye being examined. We prefer determining this from the downward or trailing slope 24 of the OPP signal 28 as it returns from a peak pressure back to the diastolic base line 26. Generally, a steeper downward slope 24 indicates an effective trabecular meshwork that quickly returns from an elevated OPP back to a diastolic level. Conversely, a more gradual and extended downward slope 24 indicates a trabecular meshwork that is more impaired and recovers more slowly from a systolic pulse pressure.
Methods of calculating tonography measures from applanation signals are also available in the ophthalmological literature. These generally agree that down slope 24 is a key ingredient for tonography calculations. Like the IOP, OPP, and OBF calculations, tonography measures can be refined by regression analyses and can be corroborated by clinical experience and by other measures; they are preferably translated into a look up table programmed into microprocessor 50.
The availability of a tonography measure, along with an OPP measure and an OBF determination gives a clinician considerably more information than has been available from tonometers. This additional information is valuable for both diagnostic and treatment purposes. Knowing the value of systolic pulse pressures and average or mean IOP gives information that is helpful in setting the aggressiveness of treatments used to reduce IOP. It can also help to determine whether to treat with drugs aimed at improving the effectiveness of the trabecular meshwork or whether to treat with drugs aimed at slowing down the production of ocular fluid. For example, using tonometer 10 to produce both an IOP determination and a tonography determination can affect a treatment method for an eye being examined. If the IOP determination is high enough to warrant treatment and the tonography determination is normal, then a clinician would treat the eye with a drug aimed at reducing production of aqueous fluid. On the other hand, if the IOP determination is high enough to warrant treatment and the tonography determination is subnormal, meaning that the trabecular meshwork of the eye is performing at a rate less than normal in removing aqueous fluid from the eye, then a clinician would treat the eye with a drug aimed at improving performance of the trabecular meshwork.
Knowing a measure of OBF can be relevant to these choices because some drugs can reduce ocular blood flow as a side effect. This must be guarded against so that OBF is not reduced enough to impair the health of the optic nerve and other eye components. Some drugs used in glaucoma treatment are either known or suspected of reducing OBF as a side affect, and having an OBF determination readily available can be used to avoid such drugs in a treatment aimed at reducing IOP.
Some drugs are also known to improve blood circulation generally, and these can be used if an OBF determination indicates that ocular blood flow of an eye being examined could advantageously be increased. This is the case with normal pressure glaucoma that impairs an optic nerve by reducing OBF while an IOP determination remains normal. A clinician having tonometer 10 to make determinations of both IOP and ocular blood flow can diagnose that deterioration of an optic nerve is caused by subnormal ocular blood flow, without any increase in IOP. The appropriate treatment based on the low ocular blood flow determination provided by tonometer 10 would then be aimed at improving ocular blood flow, rather than reducing IOP. Drugs now exist that improve blood flow generally, and these can be tried and the results monitored by rechecking the eye for both IOP and OBF. Drugs may also be developed that will aim especially at increasing OBF to the eyes while minimally affecting blood flow elsewhere.
Since OBF determinations have not previously been readily available to clinicians treating eyes for glaucoma, the effect of an OBF determination on eye treatment strategies has not been generally known. The ability of instrument 10 to provide such OBF information has many uses including monitoring an eye under treatment to be sure that the treated eye is not suffering from reduced ocular blood flow, which would call for a change in drugs being used in treatment. Having an OBF determination available from instrument 10 can also be beneficial in verifying that a drug aimed at increasing OBF in an eye experiencing normal pressure glaucoma has actually improved OBF. Knowing a tonography measure of the effectiveness of the eye's trabecular meshwork can also help monitor treatment determinations. For example, this can be used to determine the effectiveness of drugs intended to improve the working of the trabecular meshwork.
OPP and OBF, as measured by instrument 10, can be relevant to the health of other organs beside the eyes. Blood flow from the heart to the aorta and to the carotid arteries proceeds upward above the neck, not only to the eyes, but also to the brain and other important organs. If blood flow in the carotid and other arteries serving the head is constricted, evidence of this may appear in an OPP or OBF measurement readily made available by instrument 10. More specifically, health ramifications of a sub-normal OPP or OBF measured in one or both eyes can imply potential problems or cardiovascular events such as transient ischemic attack (TIA) or cerebral vascular accident (CVA).
Previous tonometers have not been able to produce OPP and OBF signals, so their use has been limited to diagnosing eye problems. The fast and inexpensive availability of OPP and OBF measurements made possible by tonometer 10 allows OPP or OBF measurements to indicate possible cardiological problems for the head, generally. Ultrasonic examination of ocular blood flow in carotid arteries is available, but is a cumbersome and expensive test compared with the OPP and OBF information that is quickly gained from use of instrument 10. As previously explained for IOP calculations, tonometer 10 is preferably programmed with look-up tables allowing it to distinguish between and indicate to a tonometer user whether OPP and OBF for a measured eye are normal or subnormal. If instrument 10 detects sub-normal blood flow to one or both eyes, then an ultra sound evaluation and possible treatment are indicated and might be able to forestall stroke risks such as TIA or CVA.
The OPP and OBF determinations available from instrument 10 also allow comparison of pulse pressure and flow to the two eyes of a single patient. An OPP or OBF that is subnormal for one eye and normal for another can indicate possible constriction of blood flow in an artery leading to the sub-normal eye. This can indicate that further testing such as an ultrasound examination of the appropriate carotid artery, is appropriate.
The signals shown in
The embodiment of
The embodiment of
The prism pressure force used to elevate the IOP to test the accommodating ability of the eye's trabecular meshwork is preferably sufficient to depress an ocular pulse signal during the predetermined interval that the prism force is applied. This results in the accommodation attempted by the trabecular meshwork to arise from the elevated IOP caused by the prism force as distinct from periodic accommodations following systolic pulses.
When elevated prism force is removed at the end of signal 37, the IOP of the previously pressurized eye reduces for a brief interval until the eye re-accommodates. During this interval a subsequent determination of diastolic IOP is made as represented by signal 39 showing that the IOP is reduced, and the eye has become temporarily softer. The difference between the higher IOP determined from signal 36 and the lower IOP determined from signal 39 gives a measure of the effectiveness of the trabecular meshwork of the eye. The healthier the eye, the greater will be the amount that the subsequent IOP is reduced from the preceding IOP.
This procedure is analogous to a known way of determining tonography by measuring IOP of an eye, and then while a patient is lying down, placing a weight on a patient's eye for an interval after which the IOP is again measured. Such a method is cumbersome and time consuming, since the patient has to lie down, and a weight has to be placed on the eye and then removed in between IOP determinations. By the method illustrated in
This is a continuation-in-part of co-pending application Ser. No. 10/178,987, filed 25 Jun. 2002, entitled “Method and Apparatus for Examining an Eye”. The aforementioned application is incorporated herein by reference.
| Number | Date | Country | |
|---|---|---|---|
| Parent | 10178987 | Jun 2002 | US |
| Child | 11420971 | May 2006 | US |
