Patent Grant
11338139
The present invention relates generally to the field of ophthalmic treatments for diseases of the eye. More particularly, the present invention is directed to systems and methods adapted to provide stimulus, such as by electrical stimuli, to the eye.
Therapy to prevent or reverse diseases of the eye is of great interest. As life expectancy expands, more and more of the population is at risk for age related macular degeneration (AMD). Meanwhile, smaller populations of young patients suffer from a variety of genetic diseases, including Stargardt's disease, that affect the retina of the eye. A wide variety of other vision disorders exist which can lead to partial or total blindness.
There is a continuing demand for new and alternative systems and methods to treat such disorders including by preventing, arresting or reversing disease progress, or at least by alleviating ongoing symptoms. In some examples, such systems may be aided by the inclusion of additional apparatuses, features and/or routines for determining whether therapy is effectively reaching its target. In some examples, verification of therapy is performed by monitoring patient characteristics during therapy delivery. In some examples, verification of therapy is achieved by having the patient perform tests before, during, and/or after therapy delivery.
The above summary of some embodiments, aspects, and/or examples is not intended to describe each embodiment or every implementation of the present disclosure. The figures and the detailed description which follows more particularly exemplify these embodiments.
The disclosure may be more completely understood in consideration of the following detailed description of various embodiments in connection with the accompanying drawings, in which:
While aspects of the disclosure are amenable to various modifications and alternative forms, specifics thereof have been shown by way of example in the drawings and will be described in detail. It should be understood, however, that the intention is not to limit aspects of the disclosure to the particular embodiments described. On the contrary, the intention is to cover all modifications, equivalents, and alternatives falling within the spirit and scope of the disclosure.
In some examples, new systems and methods for monitoring ocular modulation therapy as it is applied are disclosed. As used herein, ocular modulation refers to the treatment of the eye with a signal, delivered invasively, non-invasively, or minimally-invasively, to achieve a therapeutic benefit. Therapeutic benefit may include, for example and without limitation, improving or altering blood flow, upregulating or downregulating synthesis, degradation, binding, release or activity of proteins, enzymes, DNA, RNA, polysaccharides or other endogenous physiological or pathological biomolecules; and/or upregulating, downregulating, activating, deactivating physiological or pathological biopathways, etc. Ocular modulation may be combined with the administration of pharmaceuticals, exogenously derived biomolecules, cell therapy, or photo-, electro- or magneto-reactive or active particles, such as nanoparticles, before, during or after an electrical signal is applied.
In some examples, the devices and systems disclosed herein are suited for use in conjunction with exogenous and/or endogenous stem cell transplantation therapies. For example, a method may comprise delivery of electrical stimulation before, during, or after stem cell transplantation to improve cell survival, repair and/or replacement. In illustrations, the use of methods and systems disclosed herein may enhance native cell survival, transplanted cell survival, transplanted cell integration, and functional synapse formation and/or axon regeneration. Non-limiting examples of endogenous stem cell types which may be suitable for transplantation in combination with systems or devices of the present invention include Müller cells, retinal pigment epithelial cells (RPE cells) and ciliary pigmented epithelial cells (CPE). Non-limiting examples of exogenous stem cells suitable for transplantation according to some embodiments of the invention include neural stem cells (NSCs), mesenchymal stem cells (MSCs) derived from bone marrow, adipose tissue or dental pulp and stem cells from the inner cell mass of the blastocyst and induced pluripotent stem cells (iPSCs). See, for example, “Using Electrical Stimulation to Enhance the Efficacy of Cell Transplantation Therapies for Neurodegenerative Retinal Diseases: Concepts, Challenges, and Future Perspectives”, Abby Leigh Manthey, et al., Cell Transplantation, Vol. 26, pp. 949-965, 2017.
In some examples, combination of therapy systems of the invention with biological or pharmaceutical agents may provide improved efficacy or reduced side effects associated with such biological or pharmaceutical agents when administered alone. Pharmaceutical agents currently used to reduce the growth of new blood vessels in wet AMD include anti-angiogenics such Bevacizumab (Avastin®), Ranibizumab (Lucentis®) and Aflibercept (Eylea®), etc. While the benefit of these agents for mitigating symptoms associated with wet AMD are well-known, these agents also may have side effects including increased eye pressure, inflammation of the eye and others. A benefit of systems disclosed herein includes modulation of cytokines and other endogenous inflammatory factors involved in the inflammation process. In some embodiments it is foreseen that administration of anti-angiogenic agents listed above or other pharmaceuticals in combination with electrical therapy applied simultaneously with, before (e.g. 1, 2, 12, 24, 36, 48 and/or 96 or more hours before), or after (e.g. 1, 2, 12, 24, 36, 48 and/or 96 or more hours after), injection of such anti-angiogenics, at stimulation parameters used herein, may beneficially improve the efficacy and/or reduce the likelihood of side effects associated with administration of such agents.
Several different modes of energy delivery can be used including mechanical delivery (such as sonic energy, including for example, ultrasound), light-based delivery (such as by the delivery of collimated or non-collimated light of selected wavelengths, for example using a laser, a light emitting diode, etc.), electrical delivery (such as by the delivery of an electrical signal), and/or magnetic delivery (such as by generating a magnetic field or fields). In some examples, one mode of therapy delivery is used, while the same or a different mode is used to monitor therapy delivery. One component of several examples is the use of configurations that are adapted to provide enhanced tissue contact, enhanced therapy delivery, improved efficiency of energy delivery, targeted therapy locations, improved user comfort and/or compliance, and/or reduced likelihood of tissue injury or irritation.
In an illustrative example, a system includes output circuitry for delivering electrical stimuli to the eye of a patient. The output circuitry may include one or more output channels, operable independently to provide greater control over current output than is possible with a single output channel. By controlling output across more channels, the resultant field can be controlled in a manner that allows the physician to tailor therapy to the particular patient's anatomy. For example, when the target for therapy is in the back of the eye, shaping the developed field to ensure coverage of the therapeutic target can be better facilitated with a plurality of output channels. 2, 3, 4 or more channels for output currents may be provided. Other examples may have a single channel output.
In another illustrative example, impedance encountered by one or more electrodes may be monitored to ensure efficacy and safety. For example, where a pair (or more) electrodes are on a patient, a signal passing between the electrodes provides information about the impedance and hence contact/coupling of the electrodes to the patient, such as by delivering a controlled voltage and monitoring output current, or by delivering a controlled current and monitoring output voltage. In another example, if a patient is equipped with a three electrode system, having a pair or more output electrodes, and one or more indifferent electrodes, impedance encountered by the signal passing between the output electrodes can be monitored, while the electric field incurred at the indifferent electrodes may be measured as well, providing a larger picture of electrode contact conditions including both active and inactive electrode interfaces. In an example, two output electrodes may be, for example, an electrode patch for each of the left and right eyes. Alternatively, two patches may be used for one eye such as by having a medial and lateral patch located on either side of the eye, or superior and inferior patch located above and below one eye. A single patch may be provided with multiple contacts or electrodes, if desired, and, in some examples, the multiple contacts on a patch may be selectable. The indifferent electrode may be placed away from the eye, such as behind the ear, on the back of the head, on the back of the neck, on the shoulder, or on the patient's limb such as on the hand, arm, leg or foot.
For example, to perform impedance monitoring, a low amplitude signal may be used, having features that will not stimulate the patient, such as using a short pulse width or low amplitude well below a stimulus threshold, may be issued and monitored to avoid stimulus during the test. In other examples, impedance can be monitored using therapy-level signals. By such an approach, the system may determine whether the patient has properly placed each of the output electrodes and/or determine whether one of the output electrodes has come loose or is improperly positioned or located during a therapy session. Impedance can serve to indicate safety as, for example, if the patient has not placed an electrode well, the area of contact with the skin or other tissue may be reduced, increasing current density and potentially leading to burns. A very low impedance may indicate that, for example, when a conductive patch, such as a gel patch, is being used, the metal wire that is typically covered by the patch has become exposed directly to the tissue, which can again lead to irritation or burns. Impedance may also be used to determine whether therapy signals that have been delivered are in fact getting to the desired target tissue. For example, delivering a voltage signal when impedance is above a desired range may lead to ineffective therapy.
In another example, tissue impedance variation at the site of the electrode contact with the patient due to tissue hydration status or surface/contact moisture conditions can be measured. In some examples, adjustment of therapy delivery parameters can be made based on impedance testing to ensure consistent therapeutic delivery parameters are delivered to the eye.
Impedance monitoring can also be used to observe whether there are any changes to the patient anatomy during therapy delivery. For example, with various visual system diseases, the diseased or inflamed retinal cells eventually lose cell function, raising impedance at those cells, while causing other changes such as a drop in protein synthesis, reduced adenosine triphosphate levels, etc., eventually leading to cell death. Again returning to an example with two output electrodes and one indifferent electrode, impedance may be measured to inspect for changes in the impedance within the eye. Rather than passing current from one of the output electrodes to a remotely placed indifferent electrode (such as on the neck, torso or a limb), which will incorporate a large amount of tissue making the measurement potentially very noisy and subject to patient changes such as posture and hydration, a signal for monitoring therapy efficacy may be delivered from one output electrode to the other. In another example, with multi-contact output electrodes, the signal used to measure therapy progress may pass between two contacts on the same output electrode, making for a more local measurement.
In some examples, additional monitoring methods are used. In one example, a patient is provided with a visual interrogation apparatus, or may use a personal device such as a smartphone camera for visual interrogation. A photograph of the eye of the patient, during therapy and/or with or without visual stimulus, can be used to image the retina of the patient. By taking a photograph before a therapy session, and again after the therapy session, and comparing the two photos, the effect of therapy on the eye may be determined, giving useful data about the efficacy of the therapy session. Comparison may also be had to photos taken earlier in time, such as before any therapy was even prescribed or instructed. The “after” photo may be taken immediately after therapy session completion, or may be after some period of time, whether minutes, hours, days and/or weeks or months, have passed. It may be that a series of photos, such as photos taken within hours of treatment, and photos taken after weeks of treatment, or photos taken months after treatment, may be useful to determine disease progress.
As used herein, a therapy session should be understood as the performance, by a patient, of a therapy regimen. Typically the therapy regimen will be prescribed or instructed by a physician. An example therapy regimen may be to apply cutaneous patch electrodes, couple the electrodes to a pulse generator, and activate the pulse generator while wearing the electrodes for a period of time. The pulse generator may use various tools to monitor the duration that therapy is delivered, and whether good contact of the electrodes to patient skin is maintained during therapy, in order to confirm that the prescribed or instructed regimen was followed.
In some examples, therapy is delivered using a duty cycle, such as by delivering an output stimulus for a defined period of time, with stimulus “off” for a period of time. The duty cycle is defined as a percentage, by dividing the total time that therapy is on during a session by the total duration of the session, or may be determined for shorter intervals such as relative to a segment of the total therapy session. During “off” times, the described impedance measuring may take place, for example, to monitor contact as well as therapy progress or parameters. Impedance may be measured during stimulus delivery as well, if desired.
In another example, the patient may be prompted to engage in performance testing. For example, an application on a smartphone, or a screen provided in association with a pulse generator, may present images to the patient to test visual acuity or contrast sensitivity before, during and/or after a therapy session. In another example, the patient may be prompted to answer questions regarding the therapy session experience, and/or questions about patient status and behavior. For example, questions may request subjective input as to whether the patient is feeling well, anxious, tired, or wide awake, whether the patient believes himself or herself to be dehydrated, well hydrated, hungry, or sated, or whether the patient has consumed any medication, drug, or other substance that could affect therapy. Information regarding patient visual acuity status using traditional vision tests or modifications thereof suitable for administration from a personal device (such as a tablet computer or smartphone) or the therapy device may be provided. Tests may include, for example, a Snellen test, a random E test, a kinetic field test, a Goldmann test, an Amsler test, a Humphrey test, or other tests for contrast, visual acuity, visual field, tracking, color, brightness, peripheral field. Quality of life questions may also be provided by the patient interface, such as determining whether the patient feels he or she is seeing better, or whether the patient is engaging in more, less or different activities than previously. The information can be stored for future analysis or correlation with other information, or immediately correlated with other information provided including therapy delivery parameters. Such information may be communicated from the patient device (whether a smartphone, a dedicated controller or patient interface, or the therapy generator) to physician or manufacturer systems as desired.
In other examples information may include patient entered responses to electrically evoked phosphene thresholds (EPT) that may be correlated with electrical stimulation parameters, visual acuity, patient disease status or other information about the patient or the therapy. Furthermore, data on particular patterns or morphology (snow flakes, stars, lightening bolts) of the evoked phosphenes may be recorded. Information may also be collected from physician administered testing including Early Treatment Diabetic Retinopathy Study Charts (ETDRS Visual Acuity Tester), slit lamp biomicroscopy, fundus examination, tonometry, static and kinetic perimetries, electroretinogram (ERG) readings, electrooculography (EOG) readings for measuring the corneo-retinal standing potential that exists between the front and the back of the human eye, optical coherence tomograph (OCT) readings, flicker testing, etc. Such information may be obtained from the patient, through testing or query, and stored, conveyed, or analyzed for correlations, whether immediately or later, by the patient, physician, or manufacturer systems.
In some examples, new systems and methods are disclosed for providing the physician greater access to status and therapy history for a patient. As just indicated, various data may be gathered by the system before, during, and after a therapy session. The data may include impedance or other measurements, as well as image data, and therapy session data itself such as what stimulus amplitudes (or other variables or parameters) were applied, and for how long. In some examples, the pulse generator may be equipped with communications circuitry, such as cellular, WiFi or Bluetooth™ drivers and antennae, to transmit session data or any data related to other images and measurements to a remote server or directly to the physician. In an example, the pulse generator communicates to a patient's computer, tablet, or smartphone, which may have an app on it to communicate received data to a server or the physician. A physician may be notified when new information is available, if desired. In some examples, a physician may be able to access therapy session and other information that has been transmitted by the patient device (whether pulse generator or cell phone) when convenient, or when the patient visits the physician for a follow-up.
The therapy output in some examples is of sufficiently low voltage and/or current to allow a patient's device, such as a smartphone, tablet or computer, to serve as the pulse generator. For example, currents may be 10 milliamps or less, and more typically 5 milliamps or less, with voltages under 32 volts (which may require a step-up voltage circuit) or under lesser voltages, such as under 5 volts, using frequencies and pulse widths as described below. In one example, a standard connector, such as a USB Port or speaker port (or company specific proprietary connector), may be used as a power source and communications link for a pulse generator, which can simply plug into a patient device to receive power and control signals, and also to provide feedback signals such as sensed impedance. For example, an output of less than one volt, or less than one milliamp of controlled current, may be provided, with a pulse rate in the range of 0.05 Hertz up to as much as 20,000 Hertz, or 0.1 Hertz up to 1,000 Hertz. In some examples, the pulse rate may be up to 300 Hz, or in the range of 10 to 30 Hz.
Outputs may be in the range of 100 nanoamps, or 100 nanowatts, or 100 nanovolts, or lower, if desired, up to the range of microamps, microwatts, or microvolts, or up to the range of milliamps, milliwatts, or millivolts, or higher. In some examples, the impedance encountered may call for voltage or power to exceed 1 volt and/or 1 watt, though current in many cases will remain below 1 amp. In an example, the maximum current may be 10 milliamps. In some examples, voltage may be as high as 1 volt, or as high as 50 volts. The duty cycle of any therapy output may be controlled as well, for example, between 10% to 100% duty cycle may be use.
Pulse widths of as short as a few nanoseconds, for example as short as 10 nanoseconds, up to 1 second, or more or less, may be used; in some examples, the pulse width is defined in a microsecond range, for example, between 10 and 100 microseconds. In other examples, a millisecond level pulse width may be used, such as between 1 and 100 milliseconds, for example, 10 milliseconds, delivered at 10 to 30 Hz.
Charge balance may be maintained on the tissue interface electrodes by, for example, using a biphasic waveform, or by using a monophasic waveform and switching polarity occasionally or periodically. A sequence of therapy may be delivered with one or more of frequency, amplitude, pulse width, waveform type (i.e. monophasic or biphasic, current controlled or voltage controlled, etc.) changing within different parts of a session. The output waveform may be tailored to a range of expected impedances such as between 10 ohms and 1 gigaohm, or 500 ohms to 10 megaohms, or 1 to 100 kilohms, for example. In some examples, the output waveform may be defined in part by a maximum charge per pulse, for example, less than a set quantity of coulombs (such as less than 500 nC at a load of 500 ohms, for example).
Some examples comprise a physician interface device that can be used to program a pulse generator which the patient can then take home. The programming provided by the physician may define the therapy regimen by setting parameters for stimulus delivery.
If desired the patient may be allowed to modify one or more stimulus delivery parameters, such as by raising or lowering the amplitude of stimulus.
In various examples, the condition to be treated may include one or more of the following: macular degeneration, inherited retinal disease, presbyopia, diabetic retinopathy, and glaucoma. In further embodiments, the condition to be treated may include one or more of the following: retinitis pigmentosis, Stargardt's, CMV-retinitis, Best's disease, macular dystrophy, optic neuritis, ischemic anterior optic neuritis, Usher's syndrome, Leber's congenital amaurosis, cone-rod dystrophy, cone dystrophy, choroideremia and gyrate atrophy, central retinal artery occlusion, central retinal vein occlusion, branch retinal artery occlusion, branch retinal vein occlusion, central serous chorioretinopathy, cystoid macular edema, ocular histomplasmosis, ocular toxoplasmosis, retinopathy of prematurity, amblyopia, strabismus, nystagmus, cataracts, refractive errors, and/or corneal conditions including corneal lesions and abrasions including surgical wounds, as well as dry eye, conditions amenable to nerve stimulation including by stimulation of the facial nerve, and any other ophthalmic, eye, or vision-related condition, disease, disorder, abnormality or damage.
In some examples, the mechanism of operation may comprise the application of transocular electrical and/or light-based stimulus to modify transmembrane potentials of cells or within cells, to modify ion and molecule levels or distributions, to modify (such as increasing or reducing) alkalinity in desired spatial locations, to modify (such as by increasing or decreasing) the production of select chemicals (such as hydrochloric acid), to cause motive effects on ions or molecules such as by attracting oxygen to the treated region, to cause vasorelaxation or vasoconstriction, to reduce or arrest local hemorrhage, to sedate, to increase tonicity of local tissues, to counteract sepsis, to produce fibroplasia, or to reduce neuromuscular spasticity or irritability. Such stimulus may act on cells which have become dormant, without yet suffering cellular death, in the stimulated region, potentially acting to delay or even reverse the disease process, triggering an increase in adenosine triphosphate levels and/or increasing or initiating protein synthesis; triggering increases or changes in neurotropic agents such as ciliary neurotrophic factor (CTNF) and/or brain-derived neurotrophic factor (BDNF); growth factors such as insulin growth factor-1 (IGF-1), fibroblast growth factor-2 (FGF-2); immune mediators including cytokines; neuroprotective genes such as B-cell lymphoma-2 (BCL-2), BAX, or tumor necrosis factor genes; or other cellular products. Another example may take the form of a method of stimulating a Müller cell to upregulate neurotrophic factors, to downregulate inflammatory factors, or to support new cell growth, such as may occur if electrical or other stimulation is used to induce a subset of neural progenitor or stem cells to regenerate photoreceptors and/or neurons in and around the eye.
The therapy generator may include input and output circuitry, which may be combined into a single unit, or may be provided as separate circuit elements, including a control out 12 that can generate and deliver stimulus to the patient via the patient coupling 20. The control out 12 may provide stimulus in an electrical form, for example, with control over frequency, pulse width and/or amplitude, for example, as well as inter-pulse delay, patterning, and any other suitable feature. In an example, the output is delivered in electrical form with delivery of a series of pulses, such as square waves (though other shapes, such as a sinusoid, may be used). Output electrical stimulus may be delivered using one or more channels for therapy output in one or more of voltage controlled or current controlled form.
In an illustrative example, the output stimulus takes the form of a series of square waves delivered at a relatively higher frequency (1 kHz to 100 kHz, for example), modulated at a lower frequency (1 Hz to 1 kHz), in which the lower frequency for modulation is varied over time. The square waves may be biphasic, or they may be monophasic with periodic polarity switching. In an example, a 10 kHz square wave of a pulse width 48 microseconds is a carrier, and is modulated at different frequencies (about 0.3 to about 300 Hz) for different durations within a therapy session, such as described in U.S. Pat. No. 7,251,528, the disclosure of which is incorporated herein by reference. Rather than a square wave, a sinusoid or other shape may be used. In another example, the carrier wave may be varied within a range of 10-30 Hz.
In another example, a square wave or sinusoidal wave, or other wave shape, is delivered using a 10 milliseconds, biphasic waveform (5 milliseconds positive phase, 5 milliseconds negative phase), with the biphasic waveform called at a frequency in the range of about 0-300 Hz, or 0.3-0.5 to 300 Hz, or in a range of about 10-30 Hz, or at a frequency of 20 Hz.
In some examples, optical output, such as a light output generated by a laser (such as using a vertical cavity surface emitting laser, light emitting diode, or any other suitable optical output generating device, may be provided. Again, the wavelength of such output can be controlled or selectable, as by using a pulsed or shuttered output at a selected frequency, if desired. Other outputs, such as a sonic or magnetic field output may be provided in some examples. Sonic output may be generated by providing a transducer in the therapy generator 10 or by powering a transducer in a patient coupling apparatus. Magnetic field output may be generated by providing an electrical signal to an inductor provided in the vicinity of the targeted tissue, such as using inductors placed in the patient coupling. Any of these stimulus modalities may be combined in patterns for sequential output or may be delivered simultaneously, as desired.
The therapy generator 10 and patient interface 30 may be provided in a single unit, such as a custom hardware or via a smartphone. In some examples, therapy generator 10 is provided as an add-on to an off the shelf patient interface 30, such as by having the therapy generator coupled to a smartphone using a wire or cord that couples to a plug (such as a USB, mini-USB, or headphone port). In an example, the therapy generator 10 is a separate hardware element having its own power supply and including a communication module, such as an RF, WiFi, or Bluetooth™ communications module to communicate with the patient interface 30. Some examples may use a therapy generator 10 that is wearable by the patient, such as in a head worn apparatus (a headband, hat, glasses frame, eyepiece, goggles, partial facemask, or earpiece, for example), a neck worn apparatus, or an apparatus that may be worn on a cuff on a limb, or held by a harness on the torso, as variously disclosed in U.S. Prov. Pat. Apps. 62/774,093, filed 30 Nov. 2018 and titled HEAD WORN APPARATUSES FOR VISION THERAPY, 62/832,134, filed 10 Apr. 2019 and titled SYSTEMS AND INTERFACES FOR OCULAR THERAPY, 62/861,658, filed 14 Jun. 2019, titled WEARABLE MEDICAL DEVICE, 62/867,421, filed 27 Jun. 2019 and titled SYSTEMS AND INTERFACES FOR OCULAR THERAPY, 62/873,450, filed 12 Jul. 2019 and titled OCULAR THERAPY MODES AND SYSTEMS, and/or 62/884,890, filed 9 Aug. 2019, titled WEARABLE MEDICAL DEVICE, the disclosures of which are incorporated herein by reference. The therapy generator 10 may additionally or alternatively comprise circuitry and functionality, at least in part, as disclosed in U.S. Pat. No. 7,251,528, titled TREATMENT OF VISION DISORDERS USING ELECTRICAL LIGHT AND/OR SOUND ENERGY, the disclosure of which is incorporated herein by reference.
The patient coupling 20 may include a wearable apparatus such using patches or goggles that the patient can wear on the skin. In some examples, one or more patches are worn or applied near the eye. If desired, an electrode may be placed under the skin, directly on the skin, on the eyelid, or beneath the eyelid. An electrode may, if desired, be placed in the sinus cavity or elsewhere on the patient. In general, the patient coupling 20 will typically be non-invasive, that is, without breaching the skin of the patient. A wearable contact lens may be used, if desired. A return electrode or indifferent electrode may be placed elsewhere on the patient such as on the back of the neck, at the base of the skull, on the shoulder, arm, hand, or chest of the patient. Patient couplings may include electrodes disposed near or at the eye/eyelid on wearable patches for skin contact, electrodes (which may be wettable) that contact the tissue surrounding the eye including the canthus and/or conjunctiva, wearable frames, partial facemasks, goggles, as well as remote electrodes elsewhere on the head or on the neck, torso, limb or extremity of the patient, as well as internal to the patient such as in the sinus cavity. A variety of illustrative electrode positions and apparatuses to hold electrodes in desired positions are disclosed in U.S. Prov. Pat. Apps. 62/774,093, 62/832,134, 62/861,658, 62/867,421, 62/873,450, and/or 62/884,890, as well as U.S. Pat. No. 7,251,528, the disclosures of which are incorporated herein by reference.
The patient interface 30 may include, for example, one or more buttons or other controls, a speaker and/or microphone, a screen, a touchscreen, or any other suitable interface for communication with a patient to facilitate patient control over the therapy generator. For example, the patient may turn therapy on or off, or may be allowed to control stimulus output by modifying a selected type of stimulus output, or by changing amplitude of output to ensure comfort and observable efficacy. For example, a patient may be able to directly observe whether an electrical therapy is having an effect by determining whether phosphenes (a phenomenon whereby the patient can observe a ring or spot of light produced by pressure on the eyeball or direct stimulation of the visual system other than by light) appear when therapy is on. In some examples, the generation of phosphenes is desirable during therapy, and so the patient may be encouraged to adjust amplitude (such as by raising it) until phosphenes are observed. In other examples, the presence of phosphenes may be deemed to indicate that amplitude is above a desired level, and the patient may provide feedback to indicate that phosphenes are observed and therapy amplitude or other control of energy output may be reduced. User interface designs, functionality and concepts may also be as disclosed in U.S. Prov. Pat. Apps. 62/774,093, 62/832,134, 62/861,658, 62/867,421, 62/873,450, and/or 62/884,890, as well as U.S. Pat. No. 7,251,528, the disclosures of which are incorporated herein by reference.
For example, a combination therapy may comprise an electrical stimulus delivered at a level that is below that required to generate phosphenes electrically, while an output of a sonic nature may be used to generate pressure in the eyeball to cause a phosphene to be observed. If desired, the sonic output would be used to confirm appropriate contact between the patient coupling and the target tissue.
In addition to using the patient interface to obtain data during therapy to indicate that the therapy is being received, the patient interface may be used before, after, or intermediate to therapy sessions to observe patient status such as by using visual tests to determine if there are changes in patient visual capabilities. Queries or tests may be generated by the patient interface to determine how the patient performs in certain tests, to measure patient behavior or skills, or to obtain quality of life observations from the patient.
In some examples, the therapy generator may also obtain feedback as indicated at 14 using the patient coupling. For example, the impedance during or between stimulus outputs may be observed such as by sampling such impedance(s). Thermal feedback may also be obtained, as well as visual feedback as by, for example, generating an optical output to be delivered into the eye and observing characteristics of the reflected signal. Such feedback 14 may be obtained for the purposes of, but is not limited to, determining whether the patient coupling 20 is adequate (for example, whether goggles or patches are correctly placed or worn) or to determine any immediate changes to patient physiology (such as a change in patient impedance). In an example, patient coupling impedance may be sampled between stimulus outputs using a lower amplitude or pulse width output to confirm coupling efficiency, while patient physiology may be measured during stimulus outputs; the coupling impedance may be local such as by having two electrodes on the same patch and determining impedance between the two relatively closely spaced electrodes, while the stimulus impedance may be more global by measuring impedance between a first patch and a second patch or an indifferent electrode placed remotely from the targeted tissue. Such feedback may be used within a therapy session to alert the patient to a lack of proper contact or placement of the patient coupling, and/or to track longer term usage and/or progress.
One or more of the therapy generator 10 or patient interface 30 may include Bluetooth™, cellular or WiFi circuitry for communicating by a communication intermediary 40 to a manufacturer interface and/or physician interface. The communication intermediary may be the Internet, for example, though in other examples, communication intermediary may simply be a medium, such as air, through which communication signals are sent as would be the case with Bluetooth™ and various other RF technologies. Infrared or other communication modalities may be used as desired. The manufacturer interface 50 and physician interface 60 may be used to obtain various metrics regarding the use and efficacy of the therapy generator. For example, patient interface tests and feedback may be obtained, as well as records of amplitudes or other patient controlled (to the extent such control is allowed) characteristics of the delivered therapy. Duration and frequency of therapy sessions may be observed. Information in the manufacturer interface for one patient may be placed in a database to allow observation across a population, potentially allowing for later comparison of patient outcomes to patient usage to optimize therapy regimens. The physician interface 60 may be useful to the physician to better manage a given patient's usage and determine if the patient is responding to therapy. For example, a patient who does not respond to therapy may not respond due to the patient's unique physiology, while another patient may not respond simply because the device is not being used correctly (poor patient coupling usage, misplacement, or broken product), or therapy not being used enough, or other patients may require that the applied therapy be changed, for example, to a wider or narrower pulse width, a higher or lower frequency, a different wave type (sinusoid instead of square, or current controlled instead of voltage controlled), or with different amplitude.
In some examples the physician interface 60 may be used to manage what therapy outputs the therapy generator can provide, as well as to determine how much control, if any, the patient can have over the therapy.
In some examples, the system may be designed to continuously self-optimize by collecting, interrogating and acting upon identified learnings from patient and product interaction and information. Functional connectivity of the therapy generator and/or patient interface 30 to the physician interface 60 may provide for ease of use and reliability to drive patient satisfaction and compliance. Digital connectivity may provide communication and information collection. Communication in the example shown may include patient-to-doctor, doctor-device and/or patient-device communication. Real time and/or continuous communication and data collection combined with robust patient compliance may enhance the likelihood and extent of successful outcomes for individual patients and across the patient population.
In some examples, the features of a user interface may provide an interactive experience to the patient by, for example, providing or receiving voice commands to and from the user. The system may comprise computer readable media, which may be non-transitory, to store executable instruction sets including voice recognition and/or voice emulation/generation capabilities, in one or several languages, to add to ease of use. It may be noted, for example, that the likely patient for such systems may already be visually impaired, such that the use of voice commands and activation may be particularly helpful in some examples. In further examples the user interface may be additionally tailored to low vision or blind patients by providing text narration, texture or tactile-based features, braille text and using human factors approaches to aid the user.
It is envisioned that therapy sessions may be performed, for example, weekly, daily, or twice daily, or at other intervals, as desired, and may last for several minutes, such as up to 30 minutes or more. During therapy, the pulse generator 100 may also be adapted to provide the user with other functionality, such as audio output to listen to music or use a cellular telephone, if desired.
Some examples will use the bipolar approach of
Another approach to a combination therapy may be to deliver two different types of therapy to a patient each using electrical signals, such as by delivering a first therapy that targets the front of the eye by using electrode combinations that are located on the patients face, near the eye, such as on the eyelid, canthus, conjunctiva, cheek, nose, temple or forehead as shown in
Next, optionally, the system may define the phosphene test 310. In some examples, the phosphene threshold test to be performed may use, as a starting point, therapy parameters that are in use, in which case the system can define the phosphene threshold test such as by setting test parameters (amplitude, pulse width, and/or frequency, for example) in relation to the parameters that are in use. In an example, the test definition may use the same amplitude, pulse width and/or frequency as the therapy setting in use. In other examples, the phosphene threshold test may be predefined by the system, such as by starting with a fixed frequency or pulse width and adjusting amplitude from a default low to high setting in a ramped sequence, for example.
The system then delivers a test pattern, as indicated at 320. A test pattern may be delivered after first performing safety and/or electrode placement tests, if desired and as shown in
A closed loop test 326 may be performed instead. When a phosphene is generated, the system may sense the occurrence of the phosphene by observing neural signaling that is generated by the optic nerve in response to the phosphene, which is transmitted to the brain of the patient. A closed loop test would not necessarily rely upon the voluntary response of the patient to the stimulus, potentially making a more reliable test.
When phosphenes are observed, the system can observe that the combination of parameters that is associated with phosphene observation form a phosphene threshold. It should be understood that some patients may experience phosphene thresholds that are defined by a plurality of factors, including which electordes are in use, amplitude of the signal, pulse width, and frequency of the signal. Thresholds may be defined as a single threshold in a system that holds some variable fixed, such as by using a single frequency and pulse width, with a single combination of output electrodes, to define the phosphene threshold one dimensionally in terms of signal amplitude. In other examples several thresholds may be defined for different combinations of electrode selection, frequency, pulse width, pulse shape, or other factors. Each of these ways of defining the phosphene threshold may be performed within element 330.
Therapy parameters are then set, as indicated at 340. Therapy parameters may take several forms. In some examples, subthreshold stimulus may be applied as indicated at 342, by, for example, reducing therapy amplitude (current, voltage or power, for example) at some percentage of the determined threshold, such as a 75%, 80%, 85%, 90%, 95%, or 99% of the determined threshold. A subthreshold therapy 342, set close to but below the phosphene threshold, may allow the user to perform other activities during therapy without phosphenes interfering with vision, such that user may perform light chores, exercise, or watch television, for example. In other examples, therapy may be delivered at the threshold 344, or at suprathreshold levels 346, as it may be that the phosphenes themselves, representing firing of the neural system in the eye, aid in ensuring beneficial cellular responses to the disease condition. A suprathreshold therapy level may be, for example, 110%, 125%, 150%, 200% or other level set relative to the phosphene threshold, with the percentage referring to output amplitude, pulse width, or both. In other example, frequency or other parameter, such as slew rate, may be adjusted as well.
Some illustrative embodiments comprise systems configured for treating a patient having a vision disorder comprising configured for treating a patient having a vision disorder comprising a pulse generator (
Some illustrative embodiments comprise systems configured for treating a patient having a vision disorder comprising a pulse generator (
Some illustrative embodiments comprise a system configured for treating a patient having a vision disorder comprising a pulse generator (
While the above description primarily focuses on a wearable, non-invasive system, other examples may include an electrode or lead that extends into the patient, such as into the eye socket, to lie against the eye itself. In another example, an implantable system may be provided that has one or more electrodes on either side of the eye, or in back and front, or within the eye itself. Some implantable or semi-implantable systems may include one or more transducers to receive sonic, RF, or magnetic wave energy and convert to one or more of sonic or electrical waveforms to deliver therapy such as by providing an implantable seed that is attached in or on the eye, or near the eye, and receives an applied field energy and converts the field energy to a local stimulus, either in or near the retina.
The drawings illustrate generally, by way of example, but not by way of limitation, various embodiments discussed in the present document. The drawings are not necessarily to scale. The drawings show, by way of illustration, specific embodiments in which the invention can be practiced. Such examples can include elements in addition to those shown or described. Moreover, the present inventors also contemplate examples using any combination or permutation of those elements shown or described (or one or more aspects thereof), either with respect to a particular example (or one or more aspects thereof), or with respect to other examples (or one or more aspects thereof) shown or described herein.
In the event of inconsistent usages between this document and any documents so incorporated by reference, the usage in this document controls. In this document, the terms “a” or “an” are used, as is common in patent documents, to include one or more than one, independent of any other instances or usages of “at least one” or “one or more.” Moreover, in the following claims, the terms “first,” “second,” and “third,” etc. are used merely as labels, and are not intended to impose numerical requirements on their objects.
Method examples described herein can be machine or computer-implemented at least in part. Some examples can include a computer-readable medium or machine-readable medium encoded with instructions operable to configure an electronic device to perform methods as described in the above examples. An implementation of such methods can include code, such as microcode, assembly language code, a higher-level language code, or the like. Such code can include computer readable instructions for performing various methods or method steps. The code may form portions of computer program products. Further, in an example, the code can be tangibly stored on one or more volatile, non-transitory, or non-volatile tangible computer-readable media, such as during execution or at other times. Examples of these tangible computer-readable media can include, but are not limited to, hard disks, removable magnetic or optical disks, magnetic cassettes, memory cards or sticks, random access memories (RAMs), read only memories (ROMs), and the like.
The above description is intended to be illustrative, and not restrictive. For example, the above-described examples (or one or more aspects thereof) may be used in combination with each other. Other embodiments can be used, such as by one of ordinary skill in the art upon reviewing the above description. Various features may be grouped together to streamline the disclosure, however, this should not be interpreted as intending that an unclaimed disclosed feature is essential to any claim. Rather, inventive subject matter may lie in less than all features of a particular disclosed embodiment. Thus, the following claims are hereby incorporated into the Detailed Description as examples or embodiments, with each claim standing on its own as a separate embodiment, and it is contemplated that such embodiments can be combined with each other in various combinations or permutations. The scope of the invention should be determined with reference to the appended claims, along with the full scope of equivalents to which such claims are entitled.
The present application claims the benefit of and priority to U.S. Prov. Pat. App. No. 62/739,810, filed Oct. 1, 2018, the disclosure of which is incorporated herein by reference.
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