Patent Application
20230355441
The present invention pertains generally to the ophthalmic treatment of a patient's eye, and more particularly to a machine and method for semi-automated ophthalmic photomedical treatment of a patient's eye.
Presently, conditions such as diabetic retinopathy, vein occlusion and age-related macular degeneration have been treated with photocoagulation induced by visible laser light. While this type of visible laser light treatment may halt the progress of the underlying disease, it can be problematic.
One problem is that some ophthalmic treatments require the application of a large number of laser doses to the retina, which can be tedious and time consuming. Such treatments call for the application of each dose in the form of a laser beam spot applied to the target tissue for a predetermined amount of time. The physician is responsible for ensuring that each laser beam spot is properly positioned on the intended target tissue as well as away from sensitive areas of the eye such as the macula that could result in permanent unintended damage. Since some treatments can require hundreds of laser beam spots to treat the target tissues, the overall treatment time can be quite long and require great physician skill to ensure a precise and adequate treatment of the entire target tissue area is accomplished.
To reduce the treatment time needed for retinal photocoagulation, a system and method has been proposed for applying multiple laser spots automatically in the form of a treatment pattern of spots, so that an area of target tissue is efficiently treated by multiple spots pre-positioned on the tissue in the form of the pattern. See for example U.S. Pat. Nos. 7,452,080 and 7,766,903 and U.S. Publication No. 2007/0129775. However, rapid delivery of multiple beam spots in patterns raises new issues. For example, the exposure time is limited 02 because of possible eye movement, and even with short exposure times there can be patient eye movement at the moment the physician triggers the application of the treatment pattern that could result in the application of the treatment pattern to non-targeted tissue. Moreover, physicians typically identify the tissue locations to be targeted using pre-treatment images of the eye. Present systems and techniques for applying patterns of spots have no capability of ensuring the tissue targeted for treatment by the physician is the same as that identified in the pre-treatment images. Thus, the physician is solely responsible for ensuring the tissue about to be treated is the same tissue identified in the pre-treatment images, and that the stability of the eye position will allow an accurate application of the treatment pattern. Rapid eye movements called saccades cannot be adequately tracked or compensated for by physicians. Typical physician latency times are approximately 400 ms, and thus physicians usually can only move the laser aiming device at a 5 Hz rate (while eye movements are approximately 100 times faster). Anesthetizing eye muscles using an injection of an anesthetic agent behind the eye can stabilize the eye but carries a risk of perforating the eye, the optic nerve or the blood vessels, is quite painful, and could even cause death.
Accordingly, there is a need for a semi-automated ophthalmic laser treatment and method that compensates for patient eye movement, and/or can assist the physician in verifying and adjusting alignment of the treatment pattern to the target tissue identified in pre-treatment images of the eye.
The present invention solves the aforementioned problems by providing an ophthalmic treatment system for performing therapy on target tissue in a patient's eye that includes a light source for producing treatment light, a delivery system for delivering the treatment light to the patient's eye, a camera for capturing a live image of the patient's eye, and control electronics for controlling the delivery system, for registering a pre-treatment image of the patient's eye to the live image captured by the camera, wherein the pre-treatment image includes a treatment template that identifies target tissue within the patient's eye, and for verifying whether or not the delivery system is aligned to the target tissue defined by the treatment template. A trigger device is connected to the control electronics, wherein in response to both an activation of the trigger device and the verification that the delivery system is aligned to the target tissue, the control electronics are configured to control the delivery system to project the treatment light onto the patient's eye.
Additionally, a method of performing therapy on target tissue in a patient's eye, using an ophthalmic treatment system having a light source for producing treatment light and a delivery system for delivering the treatment light to the patient's eye, includes generating a pre-treatment image of the patient's eye, preparing a treatment template that identifies target tissue of the patient's eye using the pre-treatment image, aiming the light source delivery system to the patient's eye, generating a live image of the patient's eye, registering the pre-treatment image and the treatment template to the live image of the patient's eye, verifying whether or not the delivery system is aligned to the target tissue defined by the treatment template, and activating a trigger device that causes the delivery system to project treatment light onto the patient's eye if said delivery system alignment to the target tissue is verified.
Other objects and features of the present invention will become apparent by a review of the specification, claims and appended figures.
A system and method for semi-automated, doctor-in-the-loop, ophthalmic treatment of target eye tissue is disclosed which accurately identifies tissue areas for treatment, aligns a light delivery system to those tissue areas for treatment, and adjusts alignment to compensate for patient eye movement during treatment.
Light output from therapeutic light source 26 first encounters a mirror 30 which reflects a fixed portion of the therapeutic light to a photodiode 32 to measure its power for safety and real time power adjustment purposes. The therapeutic light then encounters shutter 34, mirror 36, and mirror 38. Shutter 34 fundamentally serves to control the delivery of the therapeutic light, and can be used to rapidly gate and/or generally block the therapeutic light. Mirror 36 is an optional turning mirror, and mirror 38 is used to combine the therapeutic light with the alignment light from light source 20 to form combined alignment/therapeutic light beam 46, where alignment light from source 20 may be adjusted so that it is coincident with the therapeutic light downstream. It should be noted that the alignment light and the therapeutic light would typically not be produced simultaneously, and in that case mirror 36 in actuality combines beam paths for these two beams of light (i.e., alignment/therapeutic light 46 contains only alignment light at certain times and therapeutic light at other times). A mirror 40 is used to reflect a portion of the combined alignment and therapeutic light into photodiode 42 for additional measurement (and also provides redundant monitoring of the state of shutter 34).
A lens 44 can be used to focus the combined alignment/therapeutic light 46 prior to its entry into a scanner assembly 48. Lens 44 may be a single lens, or a compound lens. If lens 44 is a compound lens, it may be configured as a zoom lens assembly that adjusts the size of spots S, and therefore, pattern P. Another lens 50 can be placed one focal length away from the optical midpoint of the scanner assembly 48 to produce a telecentric scan (however this is optional). For systems including lens 50, a telecentric scan serves to maximize the scan speed, so long as the remaining optical elements are large enough to contain the entire scan. Most of the current available optical treatment contact lenses demand telecentric input.
Scanning assembly 48 preferably includes two optical elements 56 and 58 (e.g., mirrors, lenses, diffractive elements, rotating wedges, etc.), that can be individually tilted or moved in an orthogonal manner to deviate (deflect) the optical beam 46, and ultimately direct it towards the target tissue in the form of a pattern P (such as those shown in
Light 46 next encounters mirror 52, which reflects the light toward the target tissue in the patient's eye 1. Mirror 52 includes a high reflective coating that spectrally matches the outputs of the alignment and therapeutic light, yet allows visualization light coming from the target to pass through so that target area can be visualized through mirror 52. Preferably, the coating would be constructed to white balance the transmission through mirror 52, where the coating is more complicated. and makes the colors appear more natural instead of a pinkish result when using a green notch filter coating. Lens 50 may also be used to image the optical midpoint of the scanner assembly 48 onto mirror 52, to minimize the size of the mirror 52 in an attempt to increase the overall solid angle subtended by the visualization device. When mirror 52 is small, it may be placed directly in the visualization path without much disturbance. Mirror 52 may also be placed in the center of a binocular imaging apparatus, such as a Zeiss slitlamp biomicroscope, without disturbing the visualization.
An optional ophthalmic lens 60 may be placed directly before the eye to aid in visualization, such as might be done with any ophthalmoscope, slit lamp biomicroscope, fundus camera, SLO, or OCT system. Ophthalmic lens 60 may be a contact or non-contact lens, and may also be used in conjunction with lens 50 to provide for conjugate pupil planes such that the scanning pivots about the patient's iris, thus maximizing the system's retinal scan field. Visualization of the target tissue is preferably accomplished by directly viewing the retina through mirror 52 by the physician (e.g., using a slitlamp biomicroscope) as well as using a high frame rate camera 62 (e.g., CCD or CMOS camera) to create an electronic image from the light passing through mirror 52. The electronic image can be stored by the system, displayed on a graphical user interface (GUI) 54, and used by the control electronics 22 to confirm/adjust alignment as described below.
The mirrors, lenses and other optical elements between the light sources 20/26 and the patient's eye 1 form a delivery system 68 that can be controlled to deliver the alignment/treatment patterns to the intended target tissue. More specifically, scanner 48, under the control the control electronics 22, creates the alignment and treatment patterns P of the alignment and therapeutic light respectively, as discussed in further detail below with respect to
The alignment and treatment patterns generated by system 10 may be comprised of a single spot of light, multiple spots of light, a continuous pattern of light, multiple continuous patterns of light, and/or any combination of these, utilizing either or both continuous wave (CW) and pulsed light sources, for standard, selective, and/or sub-threshold therapies (i.e. therapies that do not result in any visible signs of treatment). In addition, the alignment pattern need not be identical to the treatment pattern, but preferably defines its location (e.g., its boundaries or its center, etc.) in order to assure that the therapeutic light is delivered only within the desired target area or at a location centered at a particular location. This may be done, for example, by having the alignment pattern provide an outline of the intended treatment pattern, or a point or cross-hairs showing a center position, This way, the spatial extent or center point of the treatment pattern may be made known to the physician, if not the exact locations of the individual spots themselves, and the scanning thus optimized for speed, efficiency and accuracy.
The alignment and treatment patterns are preferably formed as a pattern P of spots S of light projected onto the target tissue, as illustrated in
Thus, for the purposes of this disclosure, a “pattern” of light shall mean at least two spots S that do not completely overlap (or do not overlap at all), or one or more spots that move during a single pulse or with CW light resulting in a projected straight or curved line segment. Additionally, the alignment pattern need not be identical to the treatment pattern. For example, if a treatment pattern contains hundreds of spots, its location can be identified by less complicated indicia (e.g., alignment pattern of just a few spots showing boundaries and/or the center of the treatment. pattern). In fact, a single stationary alignment beam spot showing the center of the treatment pattern could be used. Simplified alignment patterns, or use of a single stationary alignment beam spot, can be projected more simply and quickly than trying to replicate the entire treatment pattern with the alignment light.
Typically, physicians use one or more pre-treatment images and/or two dimensional or three dimensional data sets of the patient's eye (images of the eye often taken well before the treatment—sometimes earlier by days and at a different clinical location using different equipment) to identify the precise locations of tissue to be targeted for treatment. During conventional treatment procedures, the physician must manually identify and target the patient's eye tissue that was previously identified using the pre-treatment images. If there is any mismatch between the tissue locations previously identified in the pre-treatment images and those targeted during treatment, then healthy tissue will end up being treated and intended target tissue will escape treatment. Therefore, to better compliment the physician's alignment of treatment pattern to the intended target tissue, the system 10 uses one or more pre-treatment images to produce a treatment template which is registered to a live image of the patient's eye to verify alignment, compensate for patient eye movement, and/or control varying dosages of treatment light even within the same treatment pattern.
In step 2, a treatment template is created which identifies what portion(s) of the tissue in the pre-treatment image should be treated. The treatment template is preferably constructed using an electronic computing device with a visual display and user inputs such as a joystick, mouse or other pointing device. This computing device could be separate from the treatment system, or can be integral to the treatment system. For example, the treatment template can be formed by loading the pre-treatment image into a conventional computer, and then digitally marking locations in that image which warrant treatment using the computer's display screen and conventional computer input devices (keyboard, mouse, joystick, touchscreen, etc.). Alternately, the pre-treatment image can be loaded into system 10 using an input port 66, where the computing device includes control electronics 22. The treatment template can then be generated using the GUI 54 and possibly one or more input devices 64.
Preferably, the computing device for creating the treatment template includes software or hardware tools for aiding the physician in marking locations on the image of the patient's eye for treatment. For example, the computing device can include tools for adding or subtracting spots from a treatment pattern, or allow the physician to outline an area for treatment in which a treatment pattern is added. Ideally the computing device will aid the physician in determining one or more treatment patterns for which the system 10 described above is capable of producing. The computing device could provide a library of sample treatment patterns of adjustable size and shape, to allow the physician to select, locate and adjust one or more treatment patterns to cover entire areas of the image for which treatment is warranted. Typical patterns could include but are not to be limited to: initial or fill-in pan retinal photocoagulation (PRP), grid treatment pattern, sector treatment pattern, patterns that “paint” a choroidal neovascular membrane, patterns that “paint” around a retinal hole or tear, or patterns that “paint” around automatically identified areas for treatment of microaneurysms, patterns required by a clinical trial, and/or custom patterns developed by an expert or frequent user. In developing treatment patterns, the computing device can be configured to automatically build treatment patterns that avoid certain areas of the image. For example, the computing device can be set to locate and avoid shapes or areas that are black (indicating previous treatment) or red (indicating large vessels or blood), or avoid physician designated areas such as the fovea and optic nerve. The computing device can also be configured to locate and target areas that are likely targets, such as a choroidal neovascular membrane, microaneurysms, or a central serous retinopathy leak. Spot size could vary by location. PRP spots could be larger in the periphery and smaller near the posterior pole, and could be evenly interspersed between previous spots determined by the black avoidance algorithm described above or a registered template from a previous treatment session.
Treatment template generation need not be limited to identifying and controlling just treatment locations. Dosage control information can also be embedded into the treatment template, and used by the system 10 to automatically vary the dosage (power, spot size and duration) of treatment light for various locations within the targeted tissue. This can be an automated function performed by the computing device, or manually performed by the physician, or a combination of the both. For example, laser energy absorption is generally a function of pigmentation. Tissues that are lighter in color or are more reflective will generally require a higher dosage of treatment light. In contrast, tissues that are dark are more absorptive, and will generally require a lower dosage of treatment light. In generating the treatment template, pigmentation and reflectance/absorption characteristics can be used by the computing device and/or the physician to determine the proper dosage for each spot or location within the targeted tissue. By including this information in the treatment template, the system 10 can then use this information to automatically adjust the laser power, and/or dwell time to provide the optimal treatment dosage at each location within the targeted tissue (even on a real time spot-by-spot basis for a treatment pattern containing hundreds of spots). Although the absorption measurement would be optimal if determined at a wavelength near the intended treatment wavelength, melanin is a broadband absorber, and rod and cone pigments are also cumulatively green absorbers (near the most widely used treatment wavelengths), which means that imaging at the exact treatment wavelength may not be needed for many procedures employing automated dosage control. Automated dosage control will result in producing greater accuracy and safety, enabling more precise subthreshold treatment and reducing the likelihood of Bruch's membrane rupture and bleeding.
The treatment template represents a digital overlay for the pre-treatment image that defines locations and dosages of treatment, including the precise treatment pattern(s) and dosages within such treatment pattern(s). The treatment template can be incorporated into the same digital file containing the pre-treatment image, or typically stored as a separate digital file. Using a treatment template allows the physician to take his or her time to precisely define exactly where treatment spots or patterns will be applied, and at what dosages, by careful analysis of the pre-treatment image outside of the patient's presence (and possibly even outside of any clinical environment), The treatment template can even be “digitally signed” by the physician and indelibly archived for risk management purposes. The treatment template can also serve as an operation report after treatment.
In step 3, the pre-treatment image and treatment template are loaded into system 10 via input port 66, and preferably stored in a storage device 22a (e.g., hard drive, flash non-volatile memory, CD, DVD, etc.) that is contained within or connected to control electronics 22. Input port 66 can be a port for receiving electronic files from a storage device (i.e., CD/DVD disk, flash memory key, etc.), or a network connection for receiving electronic files over a network, or even provide a direct connection to the computing device used to generate the treatment template. If the system 10 is used to generate the treatment template, then this loading step would be omitted, as the pre-treatment image data would have been previously loaded into system 10, and the treatment template would have been created internally by system 10.
In step 4, the delivery system 68 is aligned to the patient's eye. This can be accomplished by the physician holding and aligning the lens 60 (preferably a contact lens) to the patient's eye (which solves image optimization, obliquity, reflections from the contact lens, pupil size, pupil decentration, corneal & lens opacities, and astigmatism problems), and/or by manipulating the alignment of the delivery system 68 via one or more input devices/controls 64 and/or GUI 54 while directly viewing the target tissue or using the real-time image from camera 62 as a guide. When the delivery system 68 is generally aligned to the patient's eye, camera 62 will capture a live image of the patient's eye, which is sent to control electronics 22 and displayed on GUI 54 or another display device.
In step 5, system 10 registers the pre-treatment image and treatment template to the live image from camera 66, so that the system 10 can precisely determine where on the pre-treatment image and treatment template the delivery system is presently aimed to. This image registration can be accomplished using affine transform or other stretching or morphing algorithms which match the two-dimensional video amplitudes of the live image from camera 62 to the two-dimensional video amplitudes of the pre-treatment image. This process involves stretching or morphing the pre-treatment image so as to create a best fit with. the live image. Optionally, feature recognition techniques can be used to perform the image registration. As long as the alignment of the delivery system in step 4 is close to the intended target tissue (i.e., so there is substantial overlap between the pre-treatment and live images), the system 10 will recognize the live image and register the pre-treatment image to it.
Registration will likely not require megapixel images from camera 62, where resolutions as low as 512×512 or VGA (640/480) will likely prove to be sufficient (thus reducing cost and enabling higher frame rates and lower processing bandwidth than megapixel cameras). Camera 62 would typically include a monochromatic sensor with high fill factor (100%) to improve photon efficiency, or a progressively scanned sensor for better image processing. Camera 62 can include infrared or visible sensing which detects the retinal image from the white light illumination commonly used by physicians to illuminate and visualize the target tissue with the slitlamp biomicroscope. The frame rate of camera 62 should be significantly higher than video rates, as an unrestricted eye requires approximately 1 kHz for stabilization of saccadic movements. High viscosity coupling fluid and flanged lens contact with high surface area can be used to somewhat decrease saccadic velocities of the patient's eye.
It is desirable that the system maintain proper registration in the event of patient eye movement, meaning that the system 10 would preferably detect and track eye movement while maintaining registration. One non-limiting example of image registration that can track eye movement is to use pipeline processing (preferably using image processing on FPGA silicon such as done by Xilinix) implementing Chi square algorithms (which have been shown to be effective for retinal tracking). This process can be accomplished by comparing the two-dimensional video amplitude of the current frame of the live image of the patient's eye to that of the previous frame, to determine the directionality and amplitude of any movement. For example, the current frame image can be moved iteratively, for example, one pixel to the right, where a calculation is made to determine if there is a fit. This is repeated with movements left, up and down, until the best fit or match is achieved. Once the best fit is achieved, the amount of eye movement can be determined by how many XY pixel movements were needed to achieve the best fit/match. Those pixel movement adjustments are then applied to the treatment template positioning via movable mirrors to maintain proper registration with the live image.
It is preferable that the physician confirm that proper registration between the live camera image and the treatment template (built on the pretreatment image) has been achieved. This can be accomplished by using GUI 54, which can visually display an overlay of the live image and the treatment template. This overlay image will provide the visual confirmation the physician needs that registration was performed properly, and the system is ready to deliver the treatment pattern(s). Thus, while the system 10 locks registration in automatically once the physician aligns the delivery system 68 at or close to the intended targeted tissue, the registration should be visually confirmed by the physician before treatment begins.
Once registration is achieved, the overlaid visual display of the live image and the pre-treatment image may indicate to the physician that further manual alignment may be necessary to better center the delivery system alignment to the target tissue as defined by the treatment template. Misalignment may also be caused by movement of the patient's eye. Thus, there may be additional alignment of the delivery system 68 to the patient's eye by the physician both during and after the image registration of step 5. Alignment confirmation can be performed in several different ways. The physician can manipulate delivery system alignment until the target tissue defined by the treatment template is within view of the display showing the image overlay, within a particular area on the display, or even in the center of the display. Alternately, an aiming beam can be directed to the eye that visually illustrates the alignment of the delivery system, whereby the physician adjusts alignment until the aiming beam is within (or even centered with respect to) the treatment pattern defined by the treatment template. Or, an alignment pattern as described above with respect to
After registration has been confirmed, and any additional alignment by the physician is completed so that the delivery system 68 is aligned at or near the proposed treatment area, the physician activates treatment in step 6 by triggering an input device/control 64 (e.g. a foot pedal, a finger switch, or any other equivalent trigger device), where the system 10 applies the treatment pattern to the patient's eye. While the system could rely solely on the physician's alignment (and simply be configured to prevent treatment if the alignment is or becomes too misaligned relative to the target tissue defined by the treatment template), it is preferable that the system 10 actively manipulate alignment before and during treatment to achieve and/or maintain alignment of the delivery system 68 to the target tissue. More specifically, when the physician triggers treatment, the system 10 confirms that delivery system 68 is accurately aimed at the intended targeted tissue (as defined by the treatment template). If it is not, the system 10 (via control electronics 22) will search for the area designated for treatment, and if found will adjust the alignment of the delivery system 68 until it is aligned to that intended target tissue (i.e. such that the treatment pattern will be projected onto the eye tissue at the same locations and dosages as defined by the treatment template). Moreover, as the treatment pattern is being applied to the eye tissue, the alignment of the delivery system 68 will be constantly adjusted as needed to compensate for any eye movement detected by the system (i.e., the system will track real-time movements of the eye and make appropriate corrections to the alignment of the delivery system 68). With this technique, the physician need only align the delivery system 68 close to the intended target tissue (course adjust), where the system 10 will automatically complete and verify the alignment (fine adjust) using the treatment template and then automatically apply the treatment pattern to the eye tissue.
The true precision of the above described technique is achieved by the physician creating a detailed template showing exactly where treatment should occur and at what dosages, coupled with a system that uses that template to achieve and maintain alignment while applying the predetermined dosages of therapeutic light to the target tissue. Precision is also achieved because it is the actual tissue that is being treated (as opposed to the pupil, iris, or another adjacent tissue) that is also being imaged for alignment and dosage control. Moreover, because the system can manipulate the delivery system alignment to track moving target tissue, longer exposure times can be used to better project or paint patterns or moving spots onto the target tissue for more uniform treatment.
There are other advantages and uses for the treatment templates described above. The treatment template from one treatment session can be stored, and used later during a subsequent treatment session as an accurate indicator of past treatment locations. For example, in a PRP fill-in re-treatment, the treatment template from an earlier treatment session can be used to define and target tissue locations in-between previous laser treatments. Generic treatment templates can also be generated for widespread use among many candidate patients. For example, ophthalmic experts can prepare treatment templates for specific studies or optimized specialized treatment. These generic treatment templates can be mapped to specific patient geometries with some modifications, where the generic aspect of the intended treatment is retained.
The search range within the pre-treatment image and treatment template, and/or the amount of fine adjust applied to the delivery system 68, is reduced by including the physician's course alignment adjustment first, especially if the physician continuously attempts to bring the target tissue into alignment while the system corrects for eye movement as well. The above described system and technique increase precision, safety, and efficiency while reducing the risk of RPE creep caused by thermal diffusion, thus allowing the physician to safely treat tissues closer to sensitive areas such as the foveal avascular zone, the macula, previous laser marks, etc.
There are many applications for the semi-automated treatment system and technique described above, including treatment of microaneurysms for diabetic macular edema (using small, bright red dots as the identifier in the image), diabetic retinopathy and vein occlusions, branch retinal vein occlusion (BRVO), central retinal vein occlusion (CRVO), diabetic macular edema, focal extra-foveal or peripapillary choroidal neovascular membranes (CNV), central serous retinopathy (CSR) leaks, retinal angiomatous proliferation (RAP) lesions, retinal breaks, teleangectasia, or feeder vessels (typically identified by ICG, high frame rate angiography).
It is to be understood that the present invention is not limited to the embodiment(s) described above and illustrated herein, but encompasses any and all variations falling within the scope of the appended claims. For example, while the scanner 48 is ideal for making the necessary (fine) alignment adjustments, other optical elements in the delivery optical chain can be moved or used to otherwise implement the fine position adjustment of the treatment pattern before it is applied. Additionally, while lasers are the preferred light sources for the treatment and/or alignment light, any appropriate light sources can be utilized. It should be noted that therapeutic light can be for diagnosis and/or treatment purposes. While scanning assembly is described as forming both an alignment pattern and a treatment pattern, it could simply pass along an aiming beam from the alignment light source to visually indicate a center or other position of the treatment pattern or a simple treatment beam. The functionality of the control electronics can be implemented entirely by one or more electrical components, and/or include one or more components or modules found in software and/or firmware.
The present application is a Continuation of U.S. patent application Ser. No. 17/169,297 filed Feb. 5, 2021 (Allowed); which is a Continuation of U.S. patent application Ser. No. 16/529,221 filed Aug. 1, 2019 (now U.S. Pat. No. 10,925,768); which is a Continuation of U.S. patent application Ser. No. 11/868,387 filed Oct. 5, 2007 (now U.S. Pat. No. 10,398,599); the full disclosures which are incorporated herein by reference in their entirety for all purposes.
| Number | Date | Country | |
|---|---|---|---|
| Parent | 17169297 | Feb 2021 | US |
| Child | 18143864 | US | |
| Parent | 16529221 | Aug 2019 | US |
| Child | 17169297 | US | |
| Parent | 11868387 | Oct 2007 | US |
| Child | 16529221 | US |
