Image guidance methods and apparatus for glaucoma surgery

Abstract

To provide image guidance methods and apparatus for glaucoma surgery.SOLUTION: An imaging probe 23 comprises a camera 25 or endoscope with an external detector array, and the probe is sized and shaped for surgical placement in an eye to image the eye from an interior of the eye during treatment. The imaging probe and a treatment probe can be coupled together with a fastener or contained within a housing. The imaging probe and the treatment probe can be sized and shaped to enter the eye through an incision 14 in the cornea and image one or more of the ciliary body band or the scleral spur. The treatment probe may comprise a treatment optical fiber or a surgical placement device to deliver an implant. A processor coupled to the detector can be configured with instructions to identify a location of one or more of the ciliary body band, the scleral spur, Schwalbe's line, or Schlemm's canal from the image.SELECTED DRAWING: Figure 3

Description

[Technical Field]

[0001] Related Applications This application claims the benefit under 35 U.S.C. §119(e) of U.S. Provisional Patent Application No. 62 / 869,267, filed July 1, 2019, and U.S. Provisional Patent Application No. 62 / 994,181, filed March 24, 2020, the entire disclosures of which are incorporated herein by reference. The subject matter of this application also relates to an international application entitled "Methods and Systems for OCT Guided Glaucoma Surgery," filed June 18, 2018, published as WO2018 / 232397, the entire disclosures of which are incorporated herein by reference. Related to PCT / US2018 / 038072. [Background technology]

[0002] background Conventional methods and devices for treating diseases, such as eye diseases, may be less than ideal in at least some respects. One example of a disease that can be difficult to treat is glaucoma. While some treatments can be successful, conventional approaches to treating glaucoma may be less than ideal in at least some respects. One approach to treating glaucoma is through minimally invasive glaucoma surgery ("MIGS"). In canal-based MIGS, small openings are created in the trabecular meshwork to allow fluid to flow into Schlemm's canal. These openings can be created in many ways, for example, by implant or laser. One approach is to use excimer laser trabeculotomy ("ELT"), in which an ultraviolet laser, such as an excimer laser, is used to create an opening in the trabecular meshwork to Schlemm's canal. Another approach is to place an implant that extends through the trabecular meshwork into Schlemm's canal. One potentially challenging aspect of canal-based MIGS procedures is aligning surgical instruments with Schlemm's canal, which can be approximately 200 micrometers ("μm") to 400 μm in diameter. In some cases, Schlemm's canal may not be easily visible, and the surgeon may attempt to estimate its location, which, in at least some cases, can be difficult and less than ideally accurate. In some implantation procedures, incorrect assessment of Schlemm's canal location may result, for example, in the implant not being fully positioned within the canal, potentially tearing the trabecular meshwork, and in some cases, dislodging the implant.

[0003] At normal intraocular pressure, Schlemm's canal is typically not visible from an internal view with a camera. When the pressure in the eye is low enough, blood can enter Schlemm's canal, improving visualization of the canal. However, after the trabecular meshwork is penetrated, blood from Schlemm's canal can enter the anterior chamber of the eye, making visualization of the trabecular meshwork more difficult than ideal. Summary of the Invention [Problem to be solved by the invention]

[0004] In light of the above, it would be beneficial to have improved methods and devices to assist surgeons in identifying the location of Schlemm's canal to facilitate the creation of an opening and placement of an implant within Schlemm's canal. [Means for solving the problem]

[0005] overview In some embodiments, the probe includes a treatment probe including a treatment element and an imaging probe that images the treatment element and the anatomical structure and adjacent structures targeted for treatment from inside the eye. In some embodiments, the treatment element includes one or more of an optical fiber or an implant. In some embodiments, the probe includes a camera and a treatment probe sized and shaped to be placed in the eye for surgery. In some embodiments, the elongated imaging probe includes a camera, and the camera includes one or more lenses and a detector sized to be placed in the eye. Alternatively or in combination, the imaging probe can include one or more lenses and one or more optical fibers, such as an optical fiber or an array of scanning optical fibers, arranged to transmit images. In some embodiments, the treatment probe and the imaging probe are coupled to each other by a fastener or the like to fix the rotation angle between the elongated shaft of the imaging probe and the treatment probe. In some embodiments, the camera and the treatment probe are housed together in a housing. The camera and treatment probe are sized and shaped to enter the eye through an incision in the cornea and image one or more of the ciliary body zonules, scleral spurs, trabecular meshwork, juxtacanalicular trabecular meshwork, Schlemm's canal, the inner wall of Schlemm's canal, trabecular meshwork compression, the site of the collector channel orifice visible from within the anterior chamber, the iris root, and other intraocular structures. The treatment probe can include an optical fiber or a surgical placement device for delivering an implant. The camera detector is sized and shaped for placement within the eye and is coupled to a processor configured with instructions to identify the location of one or more of the ciliary body zonules, scleral spurs, Schwalbe's lines, or Schlemm's canal from the image.

[0006] In some embodiments, the optical fiber coupled to the camera includes a beveled distal end, and the processor is configured by instructions to determine the orientation of the beveled end in response to an image from the camera. The processor can be configured by instructions to display markers corresponding to the location of one or more of the iris root, ciliary zonules, scleral spurs, Schwalbe's lines or Schlemm's canal, the treatment probe, and other anatomical landmarks / structures. The images and markers from the camera can be provided to the surgeon in many ways. In some embodiments, the images from the camera placed inside the eye can be shown on a heads-up display of a microscope, such as a surgical microscope, allowing the surgeon to view the image through the microscope's eyepieces, as well as view the eye from the front through the microscope and view the image of the eye from a camera inserted inside the eye. In some embodiments, one or more second cameras coupled to the microscope, such as a surgical microscope, provide microscopic images of the eye and are shown on a viewing device. Images from the second camera, the camera placed inside the eye, and the markers can be shown on a display, for example, sequentially or simultaneously, while being updated with the movement of the probe. These techniques can facilitate surgery and, in some embodiments, allow surgery to be performed without the use of a gonioscope.

[0007] Incorporation by Reference All patents, applications, and publications referenced and identified herein are incorporated herein by reference in their entirety and are to be considered as if separately referenced in this application and incorporated by reference in their entirety.

[0008] A further understanding of the features, advantages, and principles of the present disclosure will be obtained by reference to the following detailed description that describes illustrative embodiments and the accompanying drawings. [Brief explanation of the drawings]

[0009] [Figure 1]FIG. 1 shows a schematic cross-sectional view of the eye illustrating the anatomical structure.

[0010] [Figure 2] FIG. 2 shows a partial perspective view of the anatomy adjacent to the anterior chamber of the eye.

[0011] [Figure 3] FIG. 3 shows a schematic cross-sectional view of an eye illustrating a fiber optic probe and an imaging probe traversing the anterior chamber from a limbal puncture site toward the trabecular meshwork within the anterior chamber of the eye according to some embodiments.

[0012] [Figure 4A] FIG. 4A shows a partial schematic diagram of the anatomy of the anterior chamber angle of the eye showing Schlemm's canal, scleral spurs, and Schwalbe's lines.

[0013] [Figure 4B] FIG. 4B shows a partial view of the anatomy of the eye, representing an image acquired by an endoscope or other imaging system from a vantage point inside the eye.

[0014] [Figure 5A] FIG. 5A shows an exemplary image in which the probe is rotated relative to the target tissue overlaid with markers according to some embodiments.

[0015] [Figure 5B] FIG. 5B shows an exemplary image similar to FIG. 5A, in which the probe is rotationally aligned with the target tissue, according to some embodiments.

[0016] [Figure 6A] FIG. 6A shows an exemplary image overlaid with a treatment marker according to some embodiments, in which the implantation axis of the implant has been rotated relative to Schlemm's canal.

[0017] [Figure 6B]FIG. 6B shows an exemplary image overlaid with a marker indicating the implantation axis of an implant aligned with Schlemm's canal according to some embodiments.

[0018] [Figure 7] FIG. 7 illustrates an apparatus for eye surgery according to some embodiments.

[0019] [Figure 8] FIG. 8 shows an augmented image including the optical surgical microscope view and the internal camera view superimposed on the treatment marker.

[0020] [Figure 9A] FIG. 9A illustrates placement of an implant according to some embodiments.

[0021] [Figure 9A-1] FIG. 9A-1 shows an implant with engagement structures sized and shaped to receive prongs of an inserter to fix the angle of the implant's elongated axis relative to the axis of the camera.

[0022] [Figure 9B] FIG. 9B shows instruments for placement of a single implant in Schlemm's Canal and for placement of multiple implants in Schlemm's Canal according to some embodiments.

[0023] [Figure 10] FIG. 10 illustrates an example of a treatment probe and camera according to some embodiments.

[0024] [Figure 11] FIG. 11 shows a cross-sectional schematic view of an exemplary treatment probe and camera taken along line AA of FIG. 10 according to some embodiments.

[0025] [Figure 12A] FIG. 12A shows an example of a treatment probe and camera according to some embodiments.

[0026] [Figure 12B] FIG. 12B shows a cross-sectional schematic view of an exemplary treatment probe and camera taken along line BB of FIG. 12A according to some embodiments.

[0027] [Figure 13] FIG. 13 illustrates an example of a treatment probe and camera according to some embodiments.

[0028] [Figure 14] FIG. 14 is a flow diagram illustrating a method according to some embodiments.

[0029] [Figure 15] FIG. 15 illustrates an apparatus for eye surgery according to some embodiments.

[0030] [Figure 16] FIG. 16 shows an example of a treatment probe and fiber optic array coupled together by fasteners according to some embodiments.

[0031] [Figure 17] FIG. 17 shows a cross-sectional schematic view of an exemplary treatment probe and fiber optic array taken along line AA of FIG. 16 according to some embodiments.

[0032] [Figure 18A] FIG. 18A shows an example of a treatment probe and fiber optic array with an integrated housing according to some embodiments.

[0033] [Figure 18B] FIG. 18B shows a cross-sectional schematic view of an exemplary treatment probe and camera taken along line BB of FIG. 18A.

[0034] [Figure 19] FIG. 19 illustrates an example of a treatment probe and fiber optic array according to some embodiments.

[0035] [Figure 20] FIG. 20 illustrates an example of a treatment probe and fiber optic array according to some embodiments. DETAILED DESCRIPTION OF THE INVENTION

[0036] Detailed Description The following detailed description provides a further understanding of the features and advantages of the invention described in this disclosure through the embodiments disclosed herein. While the detailed description includes many specific embodiments, these are provided by way of example only and should not be construed as limiting the scope of the invention disclosed herein.

[0037] The methods and systems disclosed herein can enable more ophthalmologists to successfully perform MIGS procedures. For example, the disclosed methods and devices can enable surgery to produce more uniform and consistent openings, for example, to allow improved outflow of aqueous fluid from the anterior chamber of the eye into Schlemm's canal. In addition, the disclosed systems and methods can result in improved surgical outcomes by enabling surgeons to identify target locations for openings into Schlemm's canal intended to increase outflow. In some cases, the target locations can include tissue surfaces or layers, or locations in tissues, such as the trabecular meshwork, the juxtacanalicular meshwork (JCTM), the inner wall of Schlemm's canal, the outer wall of Schlemm's canal, the sclera, or any desired combination thereof.

[0038] The methods and devices disclosed herein can include a combination of microscopes, such as a surgical microscope imaging with a sensing device that allows the surgeon to simultaneously view real-time display images. Real-time display images include images that are updated during the procedure with minimal latency. For practical purposes, a real-time augmented display shows images, including video, as events occur. These augmented images allow the surgeon to view, target, and treat locations within the eye that cannot be easily visualized unaided using only a surgical microscope because they are located in areas within the eye where total internal reflection interferes with visualization in the microscope image. Such structures include the trabecular meshwork and Schlemm's canal. The methods and devices disclosed herein allow the surgeon to view angular structures that are obscured or blocked by total internal reflection. For example, the disclosed methods and devices can allow images or information of otherwise poorly visible or invisible structures, such as collector channel systems, to be visualized using a camera inserted into the eye, such as by using endoscopic camera technology. The surgeon can simultaneously view a real image of the eye, for example via an imaging system positioned adjacent to the treatment probe, along with a projected image overlaid on the eye's structures by placement of the image of the structure, such as a collector channel system; such images can be acquired prior to surgery or acquired in real time during surgery and can be aligned with visible structures or markers to enable the surgeon to identify and target the preferred surgical site. In this way, the image viewed by the surgeon includes a real (optical) and projected (virtual) image combined on a display to enhance visualization of the surgery and targeted treatment of such tissue.

[0039] In some embodiments, the endoscope includes imaging optics for forming an image of the target tissue on an external sensor array, such as a sensor array located on a probe handpiece or a sensor array located on the console of a surgical workstation. In embodiments with a sensor array located outside the eye, the endoscope can include one or more optical fibers, e.g., multiple optical fibers, for transmitting the image to the sensor array located outside the eye. In some embodiments, an image of the eye is formed on one or more ends of one or more optical fibers located inside the eye, and the image is transmitted via one or more optical fibers to the sensor array located outside the eye. Alternatively, the endoscope can include a camera with a sensor array, which is inserted into the eye as described herein.

[0040] The image from either or both the microscope and the endoscope can be presented to the surgeon in many ways. For example, the image can be overlaid on an image viewed through a monitor or similar viewing device, such as augmented or virtual reality glasses or goggles. In some embodiments, a real-time image from a camera inserted in the eye is presented on a binocular head-up display along with an optical image of the eye from a microscope, such as a surgical microscope, allowing the surgeon to view both the optical image and the image from the camera while looking through the microscope. In some embodiments, these images are registered to each other by a common element that allows the intraocular camera system image to be positioned relative to the microscope image. Additional information can also be provided to the surgeon, such as a virtual image of one or more symbols to indicate both distance and movement of otherwise invisible structures, such as from the probe tip to the trabecular meshwork to Schlemm's canal. In some embodiments, an in-situ camera can be used to identify the collector channels of the eye, allowing the surgeon to identify the site with these target locations displayed to the user (e.g., by using a graphical visual element such as a treatment fiducial marker) to assist in creating an opening in the trabecular meshwork at an appropriate location for increased flow. Some embodiments of the present disclosure encompass any of a variety of intraocular imaging modalities, including pre- and / or intra-operative images of the outflow system (e.g., Schlemm's canal and collector channels) that can be overlaid onto a microscopic image or view. Additionally, image analysis algorithms can be applied to recognize anatomical features within the eye during surgery, and a heads-up display can augment real-time imaging of recognized features, guides, locations, markers, etc. to assist the surgeon in completing the procedure. In some cases, one or more images captured by an imaging sensor located within the eye can be used to generate a virtual image of the angular structures.

[0041] Such a display can be coupled to a surgical microscope, for example, to present a monocular or binocular virtual and / or augmented image from the display visually combined with a binocular optical real image of the eye. The methods and apparatus disclosed herein are well suited for use in ELT procedures and implant devices, such as stent procedures that provide an opening for draining fluid from the eye. However, the provided systems and methods can also be applied to a variety of other surgical procedures that can utilize fiber optic-based imaging, such as any surgery using an endoscope.

[0042] In some embodiments, the endoscope comprises a stereoscopic endoscope configured to provide a user with a stereoscopic image of a treatment element from within the eye. The display can comprise a stereoscopic display for providing a user with a stereoscopic image of the treatment element to facilitate surgery within the eye.

[0043] Although particular reference is made to the treatment of glaucoma using excimer laser trabeculotomy ("ELT"), the methods and systems disclosed herein can be used in conjunction with many other types of surgery. For example, the embodiments disclosed herein can be used in conjunction with other surgical procedures, including endoscopic procedures for orthopedic, neurosurgical, neurological, ENT, abdominal, thoracic, cardiovascular, epicardial, intracardiac, and other applications, to name a few. The methods and devices disclosed herein can utilize in situ imaging to provide virtual visualization that improves targeting accuracy and allows surgeons to perform procedures in areas that cannot be easily visualized with a microscope or endoscope. Such applications include any endoscopic procedure in which virtual visualization is extended to a real image to aid in surgical accuracy in three-dimensional space, an example of which is an endovascular procedure in which blood vessels are curved or tortuous. As used herein, the term "in situ" in relation to imaging refers to an imaging sensor, such as any number of suitable camera systems, positioned at or in close proximity to the treatment site. In some cases, an in-situ imaging system is carried by the treatment probe and captures images along a path to or from the treatment site to allow the surgeon to view actual anatomical features.

[0044] Certain embodiments can also be used to treat and modify other organs, such as the brain, heart, lungs, intestines, skin, kidneys, liver, pancreas, stomach, uterus, ovaries, testes, bladder, ears, nose, mouth, bone marrow, adipose tissue, muscle, glandular and mucosal tissue, spinal cord and nerve tissue, soft tissue such as cartilage, hard biological tissue such as teeth, bone, and body cavities and passageways such as venous sinuses, ureters, colon, esophagus, bronchi, blood vessels, and throat. For example, the devices disclosed herein can be inserted through an existing body cavity or through an opening created in body tissue.

[0045] Referring to FIG. 1 , a brief overview of the anatomy of the eye E is provided for understanding the described embodiments. As shown schematically in FIG. 1 , the outer layer of the eye includes the sclera 17. The cornea 15 is a transparent tissue that allows light to enter the eye. Between the cornea 15 and the iris 19 is the anterior chamber 7. The anterior chamber 7 contains a constantly flowing, clear fluid called aqueous humor 1. The lens 4 is supported and moved within the eye by fibrous zonules connected to the ciliary body 20. The iris 19 is attached at its periphery to the scleral spine and includes a central pupil 5. The diameter of the pupil 5 controls the amount of light that passes through the lens 4 to the retina 8. Between the iris 19 and the ciliary body 20 is the posterior chamber 2.

[0046] As shown in Figure 2, the ocular anatomy further includes the trabecular meshwork (TM) 9, a triangular band of spongy tissue within the eye located anterior to the iris 19, which attaches to the scleral spur. The mobile trabecular meshwork is variable in shape and microscopic in size. The trabecular meshwork is roughly triangular in cross section and varies in thickness from approximately 100 to 200 μm. The trabecular meshwork is composed of various fibrous layers with micron-sized pores, forming a fluid pathway for aqueous humor to exit the anterior chamber. The trabecular meshwork 9 has been measured to be approximately 100 μm thick at its anterior edge, the Schwalbe line 18, the approximate junction of the cornea 15 and sclera 17.

[0047] The trabecular meshwork extends to approximately 200 μm at its base, where the trabecular meshwork and iris 19 attach to the scleral spur. The height of the trabecular meshwork can be approximately 400 μm. Passages through holes in the trabecular meshwork 9 lead to a very thin, porous tissue called the juxtacanalicular meshwork 13, which abuts the inner wall of a vascular structure, Schlemm's canal 11. The height of Schlemm's canal is approximately 200 μm, or approximately one-half the height of the trabecular meshwork. Schlemm's canal (SC) 11 is filled with a mixture of aqueous humor and blood components and connects to a series of collector channels (CC) 12, which drain the aqueous humor into the venous system. Because aqueous humor1 is constantly produced by the ciliary body and flows through the pupil into the anterior chamber, and from there through foramina in the TM and JCTM to the SC and aqueous veins, any obstruction within the trabecular meshwork, paracanalicular meshwork, or Schlemm's canal prevents aqueous humor from easily escaping the anterior chamber. Because the eye is essentially a closed globe, this results in increased intraocular pressure within the eye. Increased intraocular pressure can lead to damage to the retina and optic nerve, ultimately causing blindness.

[0048] The obstruction to aqueous humor outflow that occurs in most open-angle glaucoma (i.e., glaucoma characterized by a trabecular meshwork that is easily visible with a gonioscope) is typically localized in the region of the juxtacanalicular trabecular meshwork (JCTM) 13, located between the trabecular meshwork 9 and Schlemm's canal 11, and more specifically in the inner wall of Schlemm's canal.

[0049] For example, intraocular pressure gradually increases over time as obstructions develop in the juxtacanalicular trabecular meshwork 13. Therefore, the goal of current glaucoma treatment methods is to prevent damage to the optic nerve by reducing or slowing the progressive rise in intraocular pressure.

[0050] Referring to FIG. 3 , a side cross-sectional view of the internal anatomy of a human eye E is shown with a treatment probe according to some embodiments comprising a fiber optic probe 23 and a camera 25 coupled to the probe inserted into the eye. A small, self-sealing paracentesis incision 14 is made in the cornea 15. The anterior chamber may be stabilized with a chamber maintainer using a fluid flow or a viscoelastic substance. The fiber optic probe 23 and camera 25 may then be positioned and advanced through the incision 14 into the anterior chamber 7 until the distal end of the fiber optic probe 23 contacts and slightly compresses the desired target TM tissue.

[0051] Photoablation laser energy, produced by laser unit 31 (shown in FIG. 7 ), is delivered from the distal end of fiber optic probe 23, which is in contact with the tissue to be ablated. The tissue to be ablated can include trabecular meshwork 9, proximal trabecular meshwork 13, and the inner wall of Schlemm's canal 11. An opening is created in the proximal inner wall of Schlemm's canal 11, without perforating the distal outer wall of Schlemm's canal. In some embodiments, additional openings are also created in the target tissue. Thus, the resulting opening or openings are effective in restoring a relatively normal rate of aqueous humor drainage. The photoablation laser energy can include one or more types of laser energy, such as visible, ultraviolet, near-infrared, or infrared laser energy, and combinations thereof. In some embodiments, the laser energy includes 308 nm laser energy from a xenon chloride excimer laser. This laser can include, for example, pulsed energy or substantially continuous energy. In embodiments, the laser energy delivered from the probe includes, for example, femtosecond or picosecond laser energy.

[0052] The fiber optic probe 23 can include one or more optical fibers encapsulated by an encapsulating sheath. The diameter of a single optical fiber should be large enough to transmit enough optical energy to effectively cause photoablation of the target tissue. In some embodiments, the diameter of the optical fiber is within the range of approximately 4 to 6 μm. Single or multiple optical fibers can be used in bundles, for example, with diameters ranging from approximately 100 μm to approximately 1000 μm. The core and cladding of the optical fiber can be encased within an outer metal sleeve or shield. In some embodiments, the sleeve is made of stainless steel. In some embodiments, the outer diameter of the sleeve is less than approximately 100 μm. In some embodiments, this diameter can be as little as 100 μm, such as when smaller optical fibers are implemented with the laser delivery system. In some cases, the optical fiber can have a diameter of approximately 200 μm, and the fiber optic probe 23 can have a larger diameter, such as 500 μm, to encapsulate one or more optical fibers. In some embodiments, the sleeve can be flexible so that it can be bent or angled.

[0053] 4A and 4B illustrate internal structures of the eye as viewed by an endoscope, such as an endoscope with a camera inserted into the eye as described herein. Structures viewed by an endoscope inserted into the eye via the ab interno technique described herein include ciliary body zonules 302 and scleral spurs 304. In some embodiments, Schwalbe's lines 306 are visible by a camera inserted into the eye. In some embodiments, Schlemm's canal 308 is visible in the camera image depending on the intraocular pressure of the eye during surgery. In some embodiments, the intraocular pressure of the eye is high enough to restrict blood from entering Schlemm's canal 308, and Schlemm's canal may not be readily visible by an endoscope inserted into the eye as described herein, such as an endoscope with a camera inserted into the eye as described herein. Also, in some embodiments, Schwalbe's lines 306 may not be readily visible in images provided by an endoscope inserted into the eye, such as an endoscope with a camera inserted into the eye as described herein, or an external sensor array. The methods and devices disclosed herein may be well suited to identifying or estimating the location of eye structures that may not be readily visible from an endoscope inserted into the eye to assist a surgeon in placing a treatment probe.

[0054] 5A and 5B illustrate images shown on a head-up display from an in-situ camera according to some embodiments, along with markers presented on a display visible to the surgeon as described herein. The processor-identified location of the ciliary body zonules 302 and the processor-determined location of Schlemm's canal 308 are indicated by markers presented on a display visible to the surgeon. For example, the camera described herein can be advanced by a treatment probe 500 and can capture real-time imaging data during a procedure. The processor can use the real-time imaging data to determine the location of Schlemm's canal 308 in response to one or more of the ciliary body zonules 302, the iris root, or the scleral spur 304. To assist the surgeon in placing the probe in the trabecular meshwork adjacent to Schlemm's canal, the processor can be configured to display the estimated location of Schlemm's canal 308 with indicia, such as a marker, so that the surgeon can accurately place the probe in the trabecular meshwork above Schlemm's canal 308. This approach can be useful when Schlemm's canal 308 is not easily visible in the camera image. Alternatively or in combination, the processor can be configured to determine the location of Schlemm's canal 308 from the location of Schlemm's canal 308 shown in the image, for example, when Schlemm's canal 308 contains sufficient contrast to appear as in cataract surgery. While Figure 5A shows markers on real-time images from a camera inserted in the patient's eye, in some embodiments, the images are shown on a heads-up display without markers, and the orientation between the camera and the probe is fixed, allowing the surgeon to determine the orientation of the probe in response to the images.

[0055] FIG. 5A illustrates a treatment probe 500 shown in an image, which may include an optical fiber within a housing. In some embodiments, the camera includes an axis rotationally fixed relative to the axis of the probe. The camera may be attached to, carried by, or located within a housing shared with the treatment probe 500 to capture images of the treatment probe 500 during a procedure. The camera may assist a surgeon in delivering the treatment probe 500 to a target location, such as to perform a procedure, deliver and place an implantable device, or investigate an area of ​​interest within a patient. As shown, the treatment probe 500 is positioned proximate to Schlemm's canal 308 and the ciliary zonules 302. One or more of these anatomical features may be visible through the camera system and discernible by a user. According to some embodiments, the camera is coupled to a control unit, as described in further detail. The control unit may include a processor and instructions executable by the processor. In some embodiments, the instructions include one or more image analysis algorithms capable of detecting anatomical features and landmarks. In some cases, the control unit may identify anatomical features and enhance the camera view by overlaying information, such as markers, such as Schlemm's canal identifier 502, ciliary zonules identifier 504, or some other identifier or combination of identifiers, onto the camera imaging data described herein. For example, the control unit may recognize Schlemm's canal 308 and locate Schlemm's canal identifier 502 by executing one or more feature recognition algorithms. In some cases, the system may recognize Schlemm's canal 308 based on contrast differences in the analyzed images. For example, Schlemm's canal 308 may be identified based on a contrast difference of greater than 5%.Although Schlemm's canal can comprise a roughly circular structure in three-dimensional space when viewed from within the anterior chamber, Schlemm's canal can also resemble a line, which may be substantially straight or slightly curved depending on the camera's field of view and the angle at which the camera approaches the site.

[0056] In some embodiments, the control unit augments the camera imaging data by placing a Schlemm's canal identifier 502 that closely follows Schlemm's canal 308. The Schlemm's canal identifier 502 may resemble a line and can be updated to maintain its superimposed position relative to anatomical features even as the camera moves. At least some of the augmentation layer, or the graphical elements of the augmented image, can be mapped or matched to the optical image using object recognition or pattern matching techniques, such as feature point recognition, edge detection, classifiers, spatial pyramid pooling, convolutional neural networks, or any of a number of suitable object recognition algorithms or combinations of techniques. The Schlemm's canal identifier 502 can be placed on the image in substantially real time, with a latency of, for example, five video frames or less, for example, within the range of one to four video frames.

[0057] Alternatively, or in combination, the control unit can recognize and identify other anatomical features, such as the ciliary zonules 302, as shown. Here, the control unit augments the camera image data by overlaying a ciliary zonules identifier 504 to follow the general shape of the ciliary zonules 302. While the illustrated markers may be substantially straight, the markers may take other shapes and may be contoured to follow anatomical contours at the imaged site. Markers may indicate boundaries of selected anatomical features, such as Schwalbe's lines, scleral spurs, or Schlemm's canal 308, as desired. For example, multiple dashed lines may be used to indicate the estimated anterior and posterior boundaries of Schlemm's canal 308, with a centerline running along the location of the estimated center of Schlemm's canal as shown in the camera image. This approach may be useful when Schlemm's canal is not easily visible in the image viewed by the surgeon.

[0058] , distance, arrows, directions, text, or other information may also be used to augment the camera imaging data. In some embodiments, the system may use identifiable features to locate other features. For example, the system may identify scleral spurs, and the system may be able to identify the approximate location of Schlemm's canal 308 based on the recognized features, even if the image does not readily show Schlemm's canal 308, based on magnification, average distance, and feature size. For example, the processor may be configured with instructions to determine the location of Schlemm's canal 308 in response to identifying one or more of the ciliary body zonules 302 or scleral spurs and display the location on a subsequent image from the camera's detector array.

[0059] 5A, it is readily apparent that the camera is in a rotated orientation relative to Schlemm's canal 308. In some procedures, it can be helpful to orient the treatment probe 500 relative to Schlemm's canal 308. By using the methods and devices disclosed herein, a user can quickly determine whether the treatment probe 500 is rotationally aligned with one or more structures of the eye, such as one or more of the iris root, ciliary body zonules 302, scleral spur, or Schlemm's canal 308. A marker, such as Schlemm's canal identifier 502, can provide further useful information for aligning the treatment probe 500 with Schlemm's canal 308, which can be useful, for example, when Schlemm's canal 308 is not readily visible from the image of a camera array inserted into the eye.

[0060] 5B, after the user rotates the treatment probe 500 and camera, the camera image and associated data indicate that Schlemm's canal 308 and the associated Schlemm's canal identifier 502 are substantially horizontal. In some cases, if the Schlemm's canal identifier 502, and consequently the Schlemm's canal 308 itself, is horizontal, the user is confident that the treatment probe 500 is aligned with the Schlemm's canal 308. Of course, other marker information can be used or displayed to augment the camera imaging data and to assist the user in approximating and orienting the treatment probe 500 relative to any anatomical feature of interest.

[0061] 6A and 6B, a treatment probe 500 is shown in proximity to Schlemm's canal 308 and the zonules 302. As shown, the treatment probe 500 carries a device, such as an implant 620, to the treatment site. In some embodiments, the implant 620 includes an elongated implantation shaft 622 sized and shaped to extend along Schlemm's canal 308, and the implant 620 can be inserted into Schlemm's canal 308 by aligning the elongated implantation shaft 622 with the elongated axis of Schlemm's canal 308, which can aid in proper delivery of the implant 620. For example, the implant 620 can include a sharp end sized and shaped to penetrate the trabecular meshwork and slide along Schlemm's canal 308. A fixed orientation of the camera relative to one or more of the probe 500 or implant 620 can enable a user to align the implant with Schlemm's canal 308 by reference to structures shown in the image from the camera placed in the eye, such as by reference to one or more of the ciliary body zonules 302 or scleral spurs, without computer-generated markers, when Schlemm's canal 308 is not readily apparent in the image from the camera placed in the eye. In some embodiments, the control unit can enhance the camera image to show Schlemm's canal identifier 502 to assist the user in locating Schlemm's canal 308 and in determining the orientation of the treatment probe 500. As shown in FIG. 6A , the treatment probe 500, and therefore the implant 620, is misaligned relative to Schlemm's canal 308 and should be reoriented to properly deliver the implant.

[0062] 6B , the treatment probe 500 is rotated to match the orientation of Schlemm's canal 308. This can be done by observing the camera image data to verify that Schlemm's canal 308 is substantially horizontal. Alternatively, or additionally, the dilated camera image data can show Schlemm's canal identifier 502, which can be rotated by changing the orientation of the treatment probe 500 and camera until the Schlemm's canal identifier 502 is substantially horizontal. In some embodiments, the camera and treatment probe 500 are rotated until the elongated implantation axis 622 of the implant 620 is substantially parallel to the Schlemm's canal identifier 502, for example, within about 10 degrees, and in some embodiments, within about 5 degrees. In some cases, the treatment probe 500 and camera are rotated or repositioned until the elongated implantation axis 622 of the implant 620 is aligned with the Schlemm's canal identifier 502. This can increase the accuracy of implant delivery and placement, which can be useful when, for example, Schlemm's canal 308 is not easily visible in the image.

[0063] In some embodiments, additional identifiers or markers are overlaid to enhance the camera image data, some of which may include identification of other anatomical features, such as a ciliary zonules identifier 504, distances between anatomical features, sizes of anatomical features, distances of the distal tip of the probe from anatomical features, directional arrows, other instructions to aid in moving the treatment probe 500, along with other useful information.

[0064] Referring to FIG. 7 , a system 400 for assisting a physician in performing a surgical procedure on an eye E is illustrated, according to some embodiments. The surgical procedure can include inserting an elongated probe 23 into the eye through an opening, across the anterior chamber, and into a target tissue region, including the trabecular meshwork and Schlemm's canal. In some embodiments, the system 400 can include an optical microscope 409 for the surgeon to observe the eye in real time during the procedure. A camera input 401 receives a feed as an input from a camera 702 disposed within the eye. The camera input 401 is operably coupled to a processor 414 of a control unit 410. The processor of the control unit 410 can be configured with instructions to identify the location of eye structures and overlay indicia, such as markers, on the input camera image. The camera 702 disposed within the eye, along with the optical microscope 409, can provide the camera input 401 to the control unit 410. In some embodiments, a second camera 416 comprising a detector array is optically coupled to the surgical microscope 409 to receive optical images from the microscope 409 and to a processor 414 of the control unit 410. The control unit 410 receives image data from the camera 416, processes the image data, and provides visual image data on the heads-up display 407, overlaying the visual image data on the preceding optical image of the surgical microscope 409. The microscope 409 may comprise, for example, a binocular surgical microscope. The system 400 may include a camera 702 delivered in situ with the treatment probe 23 to provide imaging of one or more target locations before, during, or after the procedure. The probe camera 702 may comprise any suitable camera device and, in some cases, may comprise a CCD or CMOS imaging sensor carried on or within the endoscopic camera. Images captured by the camera may be processed by an image processor 412 of the control unit 410 to generate multiple augmented images that are visualized in real time by the physician.

[0065] The augmented image can be shown on the display of the heads-up display 407 and can be combined with an optical image from the microscope 409 by an internal beam splitter 420 to form a monocular or binocular image as known to those skilled in the art. As described herein, the microscope view can include one or more of, for example, an optical microscope image, a camera image from a camera 702 positioned within the eye, a microscope image and an overlaid virtual image, or a microscope image combined with an image captured by the camera 702 with or without an overlaid virtual image. When the microscope view includes an overlaid image, the overlaid image can be aligned with the microscope image using elements that enable such alignment. Similarly, when the view includes an image from a camera and an overlaid virtual image, the overlaid image can be aligned with the image from the camera using elements that enable such alignment.

[0066] The images can be provided to the surgeon in many ways. For example, the surgeon can view the images through an augmented reality display, such as glasses or goggles, and view the surgical site through a surgical microscope 409. In some embodiments, the surgeon views the images through a virtual reality display. Alternatively or in combination, the eye can be viewed through an external monitor, as described herein, and markings are placed on the image of the eye viewed through the external monitor. The images viewed by the surgeon can include, for example, monocular or stereoscopic images.

[0067] According to some embodiments, the surgeon may first observe a surgical instrument, such as the probe 23, in a microscope or video image from a surgical microscope. In some cases, the surgeon may alternatively or additionally observe an image showing the probe 23 captured by the camera 702. According to some embodiments, the surgeon may observe an image from the microscope 409 and an image captured from the camera 702 through the eyepiece of the microscope 409. Alternatively or in combination, the surgeon may observe an augmented image or view, where additional information is overlaid on one or more of the optical microscope image or the camera image. When an image captured by a camera is overlaid on an image from the microscope image, the surgeon may simultaneously observe both the microscope image and the overlaid camera image. Additionally, the image processor 412, as described herein, may detect anatomical features of the eye and overlay markers on the microscope image or the camera image to help guide the surgeon in identifying and locating these features. The augmented image may be presented to the physician through the microscope eyepiece(s) or eyepiece and / or the microscope display, and in some embodiments, may be viewed on a monitor screen. This can be useful, for example, to allow the surgeon to maintain a stereoscopic view of the surgical site through the microscope eyepieces while simultaneously viewing superimposed or adjacent images or information stereoscopically or monocularly. Real-time images and real-time procedural information captured in situ by camera 702 can be superimposed on the live view in one or both eyepieces. In some embodiments, the disclosed devices and methods provide real-time views, including real and augmented images, from both the outside and inside of the anterior chamber during these procedures.

[0068] The optical microscope 409 can be operatively coupled to the endoscope inserted into the eye in many ways. The optical microscope 409 can comprise a binocular microscope, such as a stereo microscope, including imaging lens elements for imaging objects onto eyepiece(s) including the eyepiece 408. The endoscope disposed within the eye is configured to capture optical images of the eye and can comprise any of the endoscopes described herein. The optical images can be transmitted to the control unit 410 for processing. The endoscope can include optical elements (e.g., lenses, mirrors, filters, prisms, etc.) to form an image on the sensor array described herein. The sensor array can capture color images, grayscale images, etc., and can be introduced by and moved by the treatment probe 23, or the treatment probe 23 can move independently of the endoscope while maintaining rotational alignment with respect to the treatment probe 23. In some cases, the treatment probe 23 and endoscope described herein move together during insertion into the location of interest, and then the treatment probe 23 and endoscope described herein can move independently of one another while maintaining rotational alignment. The probe 23 can be the same treatment probe 500 as described herein according to various embodiments. The probe 23 can be configured with a handpiece 704 to allow insertion, manipulation, or removal of the probe 23 by a user, actuator, robotic arm, or the like.

[0069] Endoscopic images can be acquired at a suitable image frame resolution and / or image frame rate, which can include the resolution of a camera inserted into the eye or the optical resolution of an external sensor array optically coupled to a lens near the end of the endoscope. The image frame resolution can be defined by the number of pixels in a frame. The image resolution of the detector of the camera placed in the eye can include any of the following resolutions: 160 x 120 pixels, 249 x 250 pixels, 250 x 250 pixels, 320 x 240 pixels, 420 x 352 pixels, 480 x 320 pixels, 720 x 480 pixels, 1280 x 720 pixels, 1440 x 1080 pixels, 1920 x 1080 pixels, 2048 x 1080 pixels, 3840 x 2160 pixels, 4096 x 2160 pixels, 7680 x 4320 pixels, or 15360 x 8640 pixels. The resolution of an array detector, e.g., a detector placed in the eye or an external detector, can include a range defined by any two of the aforementioned pixel resolutions, e.g., a range of 160 x 120 pixels to 250 x 250 pixels, e.g., a resolution of 249 x 250 pixels. The imaging device or camera can have a pixel size smaller than 1 micron, 2 microns, 3 microns, 5 microns, 10 microns, 20 microns, etc. The camera inserted into the eye can have a footprint on the order of 2 mm x 2 mm, 1 mm x 1 mm, 0.8 mm x 0.8 mm, or less, suitable for insertion along the treatment probe 500. External sensor arrays can also include similar dimensions.

[0070] Images captured from a sensor array, such as a camera inserted into the eye or an external sensor array, can include a sequence of image frames captured at a specific capture rate. In some embodiments, the image sequence can be captured at a standard video frame rate such as approximately 24p, 25p, 30p, 43p, 48p, 50p, 60p, 62p, 72p, 90p, 100p, 120p, 300p, 50i, or 60i, or within a range defined by any two of the foregoing values. In some embodiments, the image sequence can be captured at a rate less than or equal to approximately one image every 0.0001 seconds, 0.0002 seconds, 0.0005 seconds, 0.001 seconds, 0.002 seconds, 0.005 seconds, 0.01 seconds, 0.02 seconds, 0.05 seconds, or 0.1 seconds. In some cases, the capture rate may vary depending on user input and / or external conditions (eg, lighting intensity) under the guidance of the control unit 410.

[0071] Images captured by a sensor array, such as a camera inserted in the eye or an external sensor array, can be captured in real time, so that the images are produced with reduced latency, i.e., a small delay between data acquisition and image rendering. Real-time imaging allows the surgeon to perceive a smooth flow of motion consistent with the surgeon's tactile movements of a surgical instrument (e.g., a thin probe and probe tip) during surgery. Real-time imaging can include providing images at a rate of about 30 frames per second (fps) or faster to mimic natural vision with its continuity of motion, and at twice that rate to avoid flicker (the perception of intensity fluctuations). In some embodiments, the latency can include the time interval between capturing an image from the camera and the information being presented to the user; such a time interval can be about 100 ms or less, e.g., 50 ms or less. In some embodiments, the latency includes no more than one or two frames of the image shown on the display.

[0072] In some embodiments, the optical microscope 409 can be coupled to an electronic display device 407. The electronic display 407 can comprise a heads-up display device (HUD). The HUD may or may not be a component of the microscope system 409. The HUD can be optically coupled into the field of view (POV) of one or both eyepieces 408. The display device can be configured to project an augmented image from the input 401 generated by the control unit 410 to the user or surgeon. The display device 407 can alternatively or additionally be configured to project an image captured by a camera to the user or surgeon. The display device can be coupled to the microscope through one or more optical elements, such as a beam splitter or mirror 420, such that a physician looking into the eyepiece 408 can perceive a camera image, an augmented image, or any combination rendered and presented by the display device 407 in addition to a real image. The display device can be visible to the surgeon or user through a single eyepiece. Alternatively, the HUD may be visible to the surgeon through eyepiece 408, for example as a stereoscopic binocular image combined with an optical image formed by components of a microscope.

[0073] The display device of the heads-up display 407 is in communication with the control unit 410. The display device can provide the user with augmented images created by the control unit 410 in real time. As described herein, real-time imaging can include capturing images without substantial latency, thereby enabling the surgeon to perceive a smooth flow of motion consistent with the surgeon's tactile movements of surgical instruments during surgery. In some cases, the display device 407 can receive one or more control signals from the control unit 410 to adjust one or more parameters of the display, such as brightness, magnification, alignment, etc. The image viewed by the surgeon or user through the eyepiece 408 can be a direct optical view of the eye, an image displayed on the display 407, or a combination of both. Thus, adjusting the brightness of the image on the HUD can affect the surgeon's view through the eyepiece. For example, processed information and markers shown on the display 407 can be balanced with a microscopic view of an object. A processor can process the camera image data, such as to increase the contrast of the image data so that visible features are more easily detectable or identifiable.

[0074] The heads-up display 407 may be, for example, a liquid crystal display (LCD), an LED display, an organic light emitting diode (OLED), a scanning laser display, a CRT, etc., as known to those skilled in the art.

[0075] Alternatively, or in combination, the display 407 can constitute an external display. For example, in some embodiments, the display 407 may not be perceptible through an eyepiece. The display 407 can comprise a monitor located in proximity to the optical microscope 409. The display 407 can comprise, for example, a display screen. The display 407 can comprise a light-emitting diode (LED) screen, an OLED screen, a liquid crystal display (LCD) screen, a plasma screen, or any other type of screen. The display device 407 may or may not include a touchscreen. The surgeon can simultaneously observe a real-time optical image of the surgical site and an image provided by the in-situ camera 702 on the display 407.

[0076] The resolution of the endoscope can be configured in many ways with appropriate optics and sensor resolution to image the target tissue with the appropriate resolution. The sensor array of the endoscopic camera or external sensor array can include a resolution suitable for observing the tissue structures of the eye as described herein, for example, a resolution in the range of less than 1 micron to 10 microns, e.g., about 3 to 6 microns. In some embodiments, the sensor array, such as the camera sensor array or external sensor array, includes a spatial resolution, e.g., an image spatial resolution, in the range of about 10 μm to about 80 μm with respect to the tissue contacting the angled distal end of the probe (or implant). In some embodiments, the resolution is in the range of about 20 μm to about 40 μm.

[0077] In some embodiments, the light present for the surgical microscope provides sufficient illumination. In some embodiments, the camera placed in the eye can be equipped with a suitable light source to provide an image with suitable brightness and focus, if necessary. In some embodiments, the camera placed in the eye can be equipped with light-emitting diodes (LEDs), optical fibers for illumination, or MicroLEDs. In some embodiments, one or more color filters can be applied to images captured by the camera to aid in isolating, locating, or otherwise identifying tissue structures of interest. The camera placed in the eye can be controlled at least in part by the control unit 410. Control of the camera 702 by the control unit can include, for example, activating the sensor array, setting parameters, focus, brightness, contrast, applying one or more filters, or customizable control parameters.

[0078] The camera placed in the eye can include a small image sensor with a high signal-to-noise ratio. The camera can include a lens and a sensor array. In some embodiments, one or more lenses of the camera include, for example, borofloat glass. The sensor array can have any suitable number of pixels arranged in an array of rows and columns. In some embodiments, the pixel array includes, for example, 249 x 250 pixels, which can include rolling shutter pixels. In some embodiments, the pixels have, for example, a 3 μm pitch, resulting in an optical area with a diameter of 1.06 mm.

[0079] The system 400 may further include a user interface 413. The user interface 413 may be configured to receive user input and provide output information to a user. The user input may relate to controlling a surgical instrument, such as the probe 23. The user interface 413 may receive input commands related to the operation of the optical microscope (e.g., microscope settings, camera acquisition, etc.). The user interface 413 may receive displays related to various operations or settings related to the camera. For example, user input may include target location selection, treatment fiducial marker selection, augmented image display settings, customizable display preferences, etc. The user interface 413 may include a screen, such as a touchscreen, and any other user-interactive external device, such as a handheld controller, a mouse, a joystick, a keyboard, a trackball, a touchpad, buttons, verbal commands, gesture recognition, a posture sensor, a thermal sensor, a touch capacitance sensor, a footswitch, or any other device.

[0080] In some embodiments, a camera placed in the eye is used to guide the probe 23 and visualize the target site. In some embodiments, the camera 702 can be configured to view the tissue and the probe tip. In some embodiments, the camera lens is positioned about 10 mm from the probe tip, for example, at least about 6 mm from the probe tip. These distances allow the probe tip to be seen on the camera image to target Schlemm's canal.

[0081] The control unit 410 can be configured to generate an augmentation layer containing the augmented information. The augmentation layer can be a substantially transparent image layer containing one or more graphical elements. The terms “graphical element” and “graphical visual element” can be used interchangeably throughout this application. The augmentation layer can be overlaid on the optical view of the microscope, the optical image, or a video stream, and / or displayed on a display device. In some embodiments, the augmentation layer is overlaid on the optical view of the microscope, such that the transparency of the augmentation layer allows the user to view the optical image with the graphical elements overlaid on it. In some embodiments, the augmentation layer can include real-time camera images or other information acquired by one or more of the cameras 702 or 416 positioned in the eye.

[0082] As described herein, fusion of optical microscope image data, camera image data, augmented information, or any combination can include incorporating the augmented information into the optical microscope image or the camera image data, or both. The augmented image data can include one or more graphical elements associated with depth information, target location, orientation information, tissue identification information, or various other supplemental information. The graphical elements can be overlaid onto the optical microscope image and / or the camera image, for example, by the beam splitter 708. The graphical elements can be overlaid directly onto the image of any object visible in the optical microscope image. The graphical elements can also include any shape, boundary, or outline surrounding the image of any object in the optical microscope image. The object can be, for example, an instrument (e.g., a probe) inserted into the eye, a portion of the probe, a target tissue, etc., as described herein.

[0083] In some embodiments, the graphical element can be configured to dynamically change as the position or orientation of the probe or instrument changes relative to the target location. For example, the graphical element can show the location of the distal tip of the probe shown in the optical image, or the relative location or spacing between tissues, such as the inner wall of the SC, the TM, etc. The graphical element can be configured to dynamically show, in substantially real time or near real time, the change in spacing between tissue walls or the distance between the tip and the target location on the optical image as the relative distance between the probe tip and the target location changes and / or when the probe tip presses against the tissue (e.g., the probe tip contacts the surface of the trabecular meshwork).

[0084] In some embodiments, the extended information can include an orientation of the probe relative to the target location. The graphical element can indicate the orientation of the probe relative to the target location. The graphical element can be configured to dynamically show the orientation of the probe relative to the target location on the optical image in substantially real time or near real time as the orientation between the probe and the target location changes. In some cases, the graphical element can indicate the orientation or axial location of the elongated probe. To indicate the orientation (e.g., direction), the graphical element can be provided in the form of an arrow or line. The graphical element can be configured to dynamically change based on the movement / advancement of the probe.

[0085] At least some of the augmentation layer, or graphical elements, can be mapped or matched to the optical image using object recognition or pattern matching techniques, such as feature point recognition, edge detection, classifiers, spatial pyramid pooling, convolutional neural networks, or any of a number of suitable object recognition algorithms or combinations of techniques. Feature points can be portions of the image (e.g., scleral landmarks, collector channel patterns, iris landmarks, etc.) that are uniquely distinguishable from the remainder of the image and / or from other feature points in the image. Feature points can be detected in portions of the image that are relatively stable under motion (e.g., when changing the illumination and brightness of the image).

[0086] Referring to FIG. 8 , an exemplary augmented image providing an augmented view 600 is shown. As described herein, the augmented image 600 can be viewed binocularly by a user or surgeon through the eyepieces of a microscope and can be displayed on a head-up display, an external display device, or a display coupled to a user interface. The augmented image or view can include an optical image 505 or a light path view through the eyepieces of an optical microscope. The optical image 505 can include a view from above the eye. The optical image 505 or optical view can show the front of the eye. The optical image 505 or optical view can further show the elongated probe 23. The augmented image or view 600 can include multiple graphical visual elements and one or more camera images 802 from a camera adjacent to or overlaid on the optical image 505, for example, by optically coupling a display to the optical path of the microscope via a beam splitter. The multiple graphical visual elements can include different shapes and / or colors corresponding to different objects, thereby allowing different objects shown in the optical image 505 to be easily distinguished from one another. For example, the camera image may be overlaid with the identification and location of Schlemm's canal, such as Schlemm's canal identifier 502, which may also provide an indication of the rotational orientation of the probe relative to the anatomical feature.

[0087] The plurality of graphical visual elements may include one or more treatment fiducial markers 601, 602, 603 mapped to one or more target locations. As discussed elsewhere herein, the treatment fiducial markers 601, 602, 603 may correspond to target locations that are optically invisible to the surgeon in the optical image from the surgical microscope. According to some embodiments, the target locations may be located ab interno, and treatment of the target locations may involve ab interno techniques. In some cases, the one or more target locations may be determined or identified based on pre-operative or intra-operative images. As discussed elsewhere herein, the pre-operative and / or intra-operative images may be acquired using, for example, ab interno and / or ab externo techniques. The treatment fiducial markers 601, 602, 603 may be registered to one or more camera images 802. In some embodiments, the probe may be observed through a view from a microscope, such as a surgical microscope. Additionally, a view from the probe may be superimposed on the microscope view, an augmented view may show the end of the probe, and the two images may be aligned or registered with each other. This provides the surgeon with additional visual information regarding the position, location, orientation, and direction of the probe relative to the anatomical markers. In some cases, the images from the microscope and the probe are aligned with each other, allowing for alignment of visible anatomical markers from both image sources in an overlaid or picture-in-picture image. In some instances, the images from the microscope and the probe are provided to the surgeon in real time, or the images are provided to provide real-time information to the surgeon during the procedure.

[0088] According to some embodiments, treatment fiducial markers or target locations can be selected based on locations within the target tissue region that would provide a significant increase in outflow following the formation of channels through the target tissue region (e.g., channels passing through the trabecular meshwork, the juxtacanalicular meshwork, and the inner wall of Schlemm's canal, thus providing fluid communication between the anterior chamber and Schlemm's canal). Such selection can be based on identifying specific regions within the collector channel network or area that are more dense, or that contain more blood vessels or a greater vascularity, or that are less obstructed, or that correspond to the circumferential drainage area provided by Schlemm's canal. During real-time imaging, one or more treatment fiducial markers 601, 602, 603 can be superimposed on the target locations on the microscope image, the camera image, or both, by detecting patterns of target locations identified from the preoperative image or the real-time camera image. In some cases, the user or surgeon can be prompted to select the target location(s) or treatment fiducial marker(s) via the user interface 413. In some cases, the user or surgeon can be prompted to rank or rank the target locations selected for treatment. Thus, a user or surgeon can specify the desired sequence in which target locations are to be treated during a surgical procedure. For example, a user or surgeon can specify that treatment reference marker 601 corresponds to the target location to be treated first, treatment reference marker 602 corresponds to the target location to be treated second, and treatment reference marker 603 corresponds to the target location to be treated third.

[0089] As discussed elsewhere herein, treatment fiducial markers can be selected based on locations (e.g., locations within the target tissue region) determined to correspond to larger collector channels, denser collector channel networks or areas, and / or greater outflow. In some cases, treatment fiducial markers can be selected in an automated manner. In some cases, treatment fiducial markers can be selected manually. The system can be configured to guide the surgeon to sequentially direct the laser fiber to each selected treatment fiducial marker. In some cases, multiple treatment fiducial markers can be presented simultaneously, such as at the beginning of a procedure, for a user to select a target location. In some cases, multiple treatment fiducial markers can be presented sequentially as the surgical procedure progresses.

[0090] The plurality of graphical visual elements may also include a probe line 604 coaxial with the elongated probe 23. The probe line 604 indicates the orientation of the probe relative to one or more target locations. The plurality of graphical visual elements may also include a distal tip marker 605 overlying the distal end of the elongated probe. Both the probe line and the distal tip marker may dynamically change location relative to the actual position and orientation of the elongated probe shown in the optical image or view 505 as the probe is moved within the anterior chamber of the eye. Thus, for example, a surgeon may use a microscope to view the probe 23 as it enters the anterior chamber and monitor the probe as it moves relative to the eye. A detection mechanism may detect the probe 23, and an automated system or processor may generate the probe line 604 in response to the detection. Similarly, the automated system or processor may generate a guide arrow 612.

[0091] The plurality of graphical visual elements may further comprise one or more guiding arrows or markers 612 extending from the distal tip marker 605 toward one or more treatment fiducial markers (e.g., marker 601). The one or more guiding arrows 612 may be configured to guide the physician in aligning the distal end of the elongate probe to point toward one or more target locations during a procedure, or to guide the physician in advancing the elongate probe toward one or more target locations during a procedure. As discussed elsewhere herein, the one or more target locations may be optically invisible to the surgeon within the microscope view 505, and overlaying a camera image may allow the surgeon to view a real-time image of the distal tip of the probe.

[0092] For example, upon selection of a target location, a guiding arrow 612 can be generated from the distal end of the probe (or the distal tip marker 605) pointing toward the selected target location (or a corresponding treatment fiducial marker), allowing the physician to advance the probe parallel to or coaxially with the guiding arrow. One or more guiding arrows 612 can point radially from within the anterior chamber in different directions toward a target tissue region including the trabecular meshwork and Schlemm's canal. As discussed elsewhere herein, the height of Schlemm's canal is approximately one-half the height of the trabecular meshwork. In some cases, one or more guiding arrows can automatically appear when the distal end of the probe is positioned a predetermined distance from the target location, for example, when the distal end of the probe is positioned approximately 6 mm or less from the target location. Alternatively, one or more guiding arrows can appear in response to a user input indicating a target location selected from multiple target locations.

[0093] Unique anatomical identifiers can be superimposed on the microscope or camera image to assist the surgeon in locating the position and orientation of anatomical features. For example, Schlemm's canal identifier 502 can be provided as an overlay on the camera image to indicate the location and orientation of Schlemm's canal to the surgeon. As shown, the camera (and probe) is rotated relative to Schlemm's canal. Based on this real-time imaging, the surgeon can reorient the probe until Schlemm's canal identifier 502 is substantially horizontal and then the probe is aligned with Schlemm's canal. Other indicia, such as a horizontal marker, can also be superimposed, so the surgeon rotates the probe until the Schlemm's canal identifier is substantially parallel to the horizontal marker. In some embodiments, images from a camera placed in the eye are shown on a head-up display without markers, allowing the surgeon to rotate and manipulate the probe to align it with structures visible in the image, such as one or more of the ciliary body zonules 302, iris root 16, or trabecular meshwork 9, which can be useful, for example, for rotationally aligning the probe with Schlemm's canal for angled fiber optic implantation or laser procedures as described herein.

[0094] In some cases, a real-time or substantially real-time camera image may be overlaid on the microscope image in a picture-within-picture format. Alternatively or in combination, information derived from the camera image may be overlaid on the microscope image. In some embodiments, a marker or indicia may be overlaid on the microscope and / or camera image when the distal tip of the probe is within a predetermined distance of a selected target location.

[0095] Advantageously, embodiments of the present invention provide systems and methods that enable a surgeon to effectively and accurately move and position a surgical instrument or probe, such as an excimer laser trabeculotomy (ELT) device, throughout various desired or target locations within the peripheral anterior chamber by observing real-time images from an in-situ camera delivered by the treatment probe 500.

[0096] Embodiments of the present disclosure also enable surgeons to effectively and accurately move and position surgical instruments or probes, such as laser trabeculotomy ("ELT") devices, by observing real-time imaging data from cameras located in close proximity to the probes described herein.

[0097] 9A and 9B show examples of an implant 620 and an instrument that can be used to place the implant 620 within the trabecular meshwork, according to some embodiments. The implanted device 1220a can include a substantially elongated shape and can be any suitable implant, and can be the same implant 620 described elsewhere herein.

[0098] As illustrated in the anterior view of the eye depicted in Figure 9A, augmented information can be overlaid onto an optical view or image 505 of the eye and device, similar to methods described elsewhere herein. For example, one or more treatment fiducial markers 601 and an arrow or probe line 604 coaxial with the device 24 can be overlaid onto the optical image 505. The image shown in Figure 9A can be combined with an image from a camera positioned at the eye and provided on a head-up display as described herein.

[0099] In some embodiments, the implant 620 comprises an elongated structure extending along an elongated axis and is sized and shaped to be positioned by sliding the implant along Schlemm's canal, e.g., by means of a sharpened end 902 as described herein. The detector positioned in the eye can include an axis extending along a row or column of detectors, where the detector axis is aligned with the elongated axis of the implant 620 within about 5 degrees, e.g., within about 3 degrees, e.g., within about 2 degrees. For example, the axis of the camera 702 can include a row of detectors in the array, where the detector row can be aligned with the elongated axis of the implant, thereby detecting the elongated axis of the implant. Alternatively, the column of the detector array can extend along the elongated axis 904 of the implant. This can allow a user to know, for example, when the elongated axis 904 of the implant is aligned with Schlemm's canal.

[0100] A guiding arrow 612 may be displayed to guide the advancement direction and orientation of the instrument 24. In some cases, the camera 702 may be coaxial or housed within the housing of the instrument 24 to provide the relative position of the distal end of the instrument with respect to the treatment site. In some embodiments, the camera 702 is carried by the instrument.

[0101] In some embodiments, the elongate probe 24 can include one or more implants 1220a, such as implants mounted on the probe 24, that can be implanted within the trabecular meshwork 9 and configured to connect the anterior chamber to Schlemm's canal and create a permanent opening in the canal. Method and device embodiments described herein can be configured to assist a physician in advancing and implanting the one or more implants 1220a into a target location with the aid of graphical visual elements (e.g., treatment fiducial markers and arrows) aligned with a real microscope image of the eye or a real camera image of the eye, or a combination of these images. While the implant 1220a can be any suitable implant, in some cases the implant is an implant, and the term is used herein to refer to an implant delivered by the treatment probe 24. For example, the disclosed system can be configured to assist the physician in advancing and sliding the implant 1220a laterally into Schlemm's canal and permanently positioning the implant within Schlemm's canal with the aid of graphical visual elements (e.g., treatment fiducial marker 601, probe line 604, Schlemm's canal identifier, ciliary zonules identifier, and / or guide arrow 612) aligned with the microscopic image.

[0102] In some embodiments, one or more of the inserter or implant includes an engagement structure for aligning the elongated structure of the implant with the axis of the camera. As shown in FIG. 9A-1, the proximal portion of the implant can include a channel, such as a slot or groove 906, sized and shaped to receive a protrusion on the inserter to fix the angle of the elongated axis of the implant relative to the axis of the camera.

[0103] In some cases, the system can be configured to assist the physician in advancing multiple implants along the elongated shaft 604 of the elongated probe, depositing the multiple implants into Schlemm's canal, and permanently positioning the multiple implants within Schlemm's canal with the aid of a graphical visual element aligned with the microscope image. For example, as depicted in panel (1) of FIG. 9B , the elongated probe 1210b includes a housing 1212b and an insertion mechanism 1214b. The probe 1210b can be the same as other embodiments described herein and can be used with the systems and methods described herein. The insertion mechanism 1214b can include a stylet and an inserter housing configured to be inserted into the patient's eye. The stylet can include a distal tip that is visible by a camera inserted into the eye to facilitate placement. As described herein, the optical axis of the camera can extend substantially parallel to the elongated axis of the stylet, e.g., within about 2 degrees, or can be tilted relative to the stylet, so that the tip of the stylet appears approximately centered in an image from a camera placed in the eye as described herein, e.g., within about 20 pixels of the center of an image from a camera placed in the eye. The inserter housing 1215 can include a treatment probe 500 and a camera as described herein. As depicted in panel (2), an implant 1220b can be attached to an insertion mechanism 1214b, which can include a head 1222b, a chest 1224b, a flange 1226b, and an outflow orifice 1228b. A stylet tip 1217 on the insertion mechanism 1214b aids in aligning and inserting the implant. Panel (3) of FIG. 9B depicts two implants 1220b implanted in the trabecular meshwork 9, as viewed from the anterior chamber. As shown here, flange 1226b of each implant 1220b includes an inlet orifice 1227b that is in fluid communication with one or more outlet orifices (not shown).

[0104] These implants can be positioned in the eye using a head-up display and a camera positioned in the eye, as shown and described with reference to FIG. 9A. For example, the camera-guided embodiments discussed with reference to FIGS. 6A and 6B can be used to help guide the surgeon in implanting the implant at a target location within the trabecular meshwork corresponding to Schlemm's canal. In some cases, the target location can correspond to the location of a collector channel or can be based on the distribution or density of multiple collector channels. Referring again to FIG. 9B, as depicted in panel (4), when implant 1220b is implanted in the eye, flange 1226b is located within the anterior chamber 7, the chest (not visible) is located within the trabecular meshwork 9, and head 1222b is located within Schlemm's canal. The inlet orifice is in fluid communication with the outflow orifice, allowing aqueous humor to flow from the anterior chamber into Schlemm's canal.

[0105] The system can also be configured to assist the physician in positioning the implant within the anterior chamber angle 28 with the aid of a graphical visual element aligned with the microscope image, the camera image, or both. The in-situ camera imaging-guided embodiments disclosed herein are well suited to assisting the surgeon in delivering the implant (mounted on an elongated probe) to the anterior chamber angle. For example, the camera-guided embodiments discussed with reference to Figures 6A and 6B can be used to help guide the surgeon in placing the implant at a target location within the anterior chamber angle.

[0106] 10 , an exemplary treatment probe 500 and camera 1002 are illustrated, according to some embodiments. The camera 1002 is housed within a camera housing 1004 and includes a detector array 1006 and a lens 1008. As described elsewhere herein, the detector array 1006 can comprise an array having any suitable resolution, for example, within the range of 200×200 to 300×300 pixels.

[0107] A fastener 1010, such as a clip, has a fastener length 1011 and can be used to couple the camera housing 1004 to the fiber optic housing 1012. The fiber optic housing 1012 can include an optical fiber 1014 configured to deliver optical energy to a treatment site. The fiber optic housing 1012 and the optical fiber 1014 can comprise the treatment probe 500, and the camera 1002 and the camera housing 1004 can comprise the imaging probe 1000. The fiber optic housing 1012 can be configured with one or more structures that cooperate with the fastener 1010 to secure the fiber optic housing 1012 and the camera housing 1004 in a fixed relative rotational orientation. In other words, the fastener 1010 can secure the camera housing 1004 and the fiber optic housing 1012 together such that neither the camera housing 1004 nor the fiber optic housing 1012 can substantially rotate about a longitudinal axis independently of the other, e.g., by more than about 2 degrees. The fastener 1010 may be permanently attached to one of the camera housing 1004 or the fiber optic housing 1012 and selectively engage the other. Alternatively, the fastener 1010 may comprise separate portions configured to couple to the treatment probe 500 and the imaging probe 1000.

[0108] The distal end of the treatment probe 500 can be formed such that the beveled surface 1020 has an angle α with respect to the longitudinal axis of the treatment probe 500. In some embodiments, the distal end of the treatment probe 500, the distal end of the optical fiber 1014, or both, are beveled at an angle α of about 45 degrees to about 65 degrees, optionally in a range of about 50 degrees to about 60 degrees. In some embodiments, the angle α of the distal end of the treatment probe 500 is the same as the angle of the distal end of the optical fiber 1014. In some embodiments, the angle α of the distal end of the treatment probe 500 is within 10 degrees or less of the angle of the distal end of the optical fiber 1014.

[0109] While the illustrated embodiment shows a single optical fiber 1014, it should be understood that a bundle of optical fibers may also be used in the disclosed systems and methods. In some examples, the treatment probe 500 comprises a bundle of optical fibers, each optical fiber having a distal end at or about an angle to the distal end of the treatment probe 500.

[0110] In some embodiments, the camera housing 1004 can translate along its longitudinal axis in direction N independently of the fiber optic housing. In some cases, the translation distance of the camera housing 1004 is fixed, and thus there is a limit to the translation distance of the camera housing 1004 relative to the fiber optic housing 1012. In some embodiments, the distal end of the probe extends beyond the lens 1008 of the camera 1002 by a distance A that is in the range of about 2 mm to about 10 mm, or in the range of about 2.5 mm to about 5 mm. In embodiments in which the camera housing 1004 can translate independently of the fiber optic housing 1012, the translation distance can be limited by these dimensions, and thus the lens 1008 of the camera 1002 can be moved from about 2 mm to about 10 mm from the distal end of the fiber optic housing 1012.

[0111] Similarly, the detector array 1006 can be positioned a distance B from the distal end of the treatment probe 500. Distance B can be in the range of about 2.5 mm to about 10.5 mm, and optionally in the range of about 3 mm to about 6 mm. The camera housing 1004 can be limited within its translational range of motion relative to the fiber optic housing 1012, thus limiting the detector array 1006 to a limit of its longitudinal movement within the range of about 2.5 mm to about 10.5 mm. The movement limit can be provided by any suitable structure or mechanism, such as a slot, groove, protrusion, boss, stop, or the like.

[0112] The treatment probe 500 can be translated in direction M, and the camera housing 1004 can be fixed to the treatment probe 500, such that the camera housing 1004 is translated with the treatment probe 500. In some embodiments, as described herein, the camera housing 1004 can have a rigid attachment to the fiber optic housing 1012 and can be selectively released to provide a degree of freedom to translate along its longitudinal axis within translation limits.

[0113] The camera 1002 of the imaging probe 1000 can include an optical axis 1022. The optical axis 1022 can extend approximately parallel to the elongated axis of the optical fiber 1014, for example, within about 5 degrees. However, the optical axis 1022 can be tilted relative to the elongated axis of the treatment probe 500, as described herein. In some embodiments, the optical fiber 1014 comprises a tilted distal tip 1020. The rows and columns of the detector array 1006 can be aligned with the tilted distal tip of the probe, such that an image from a camera positioned in the eye is aligned with the tilted distal tip 1020 of the probe. The tilted distal tip 1020 can include a substantially flat surface that defines a surface normal vector 1024. The camera 1002 can be positioned relative to the surface normal vector 1024 in a number of ways. In some embodiments, the surface normal vector 1024 and the optical axis 1022 extend along a common plane. In some embodiments, the angled distal end 1020 points away from the optical axis 1022, e.g., the surface normal vector 1024 points away from the optical axis 1022. In alternative embodiments, the angled distal end 1020 points towards the optical axis 1022, e.g., the surface normal vector 1024 points towards the optical axis.

[0114] In some embodiments, the rows and columns of the detector array 1006 are aligned with the angled distal tip 1020 of the probe 500, such that the columns of the array extend in directions corresponding to the component of the surface normal vector 1024 that extends away from the elongated axis of the optical fiber. Alternatively, the rows and columns of the detector array 1006 can be rotated relative to the angled distal tip 1020 of the fiber, and a processor can be used to rotate the image shown to the surgeon so that the image of the eye from a camera placed in the eye is aligned with the angled distal tip 1020 of the probe.

[0115] Figure 11 is a cross-sectional schematic diagram of the probe 500 of Figure 10 taken along line AA. The probe 500 can have a camera 1002 comprising a camera housing 1004 and a lens 1008. A fiber optic housing 1012 can comprise one or more optical fibers 1014. The fiber optic housing 1012 can be attached to the camera housing 1004 in a manner that prevents independent rotation of either the camera housing 1004 or the fiber optic housing 1012.

[0116] According to some embodiments, a fastener 1010 can attach the fiber optic housing 1012 to the camera housing 1001. The fastener 1010 can comprise a clip that can be secured to a longitudinal groove in the fiber optic housing 1012. In some embodiments, the clip is attached to the camera housing 1004 and comprises an engagement structure 1102, such as, for example, a flat engagement surface, a slot, a key, a groove, an opening, a protrusion, or other suitable structure. In some embodiments, the clip couples the fiber optic housing 1012 to the camera housing 1004 at a fixed angular orientation.

[0117] In some embodiments, the camera housing 1004 or the fiber optic housing 1012, or both, have flat engagement surfaces to provide intimate surface contact between the camera housing 1004 and the fiber optic housing 1012 and to orient the fiber optic housing 1012 to receive a fastener.

[0118] Camera housing 1004 has a maximum dimension D in the range of about 0.8 mm to about 1.2 mm. Fiber optic housing 1012 has a maximum cross-sectional dimension E in the range of about 300 μm to about 600 μm. Although camera housing 1004 and fiber optic housing 1012 are represented generally as having a generally cylindrical cross-section, each housing can have any suitable cross-sectional shape, such as oval, hexagonal, octagonal, circular, or any suitable shape.

[0119] In some embodiments, the fastener 1010 can include a clip or opening for engaging one or more of the camera housing 1004, the inserter housing 1215, or the optical fiber housing 1012, and, if desired, the clip includes an engagement structure 1102 sized and shaped to receive the camera housing 1004, the inserter housing 1215, the optical fiber housing 1012, or a combination.

[0120] The fasteners can allow the camera housing 1004 to slide relative to the inserter housing 1215 or fiber optic housing 1012 while keeping the rotational orientation of the camera 1002 relative to the inserter housing 1215 or fiber optic housing 1012 fixed.

[0121] The imaging probe 1000 including the camera 1002 can be fastened to the treatment probe 500 by fasteners such that the rotational orientation of the camera 1002 relative to the rotational orientation of the instrument is fixed, i.e., the camera 1002 cannot rotate substantially, e.g., by more than 5 degrees, e.g., 2 degrees, e.g., 1 degree, independently of the treatment probe 500. In some embodiments, the rotational orientation is fixed by the use of cooperating structures that reduce the likelihood of relative rotation between the camera 1002 and the instrument. In some embodiments, a clip secures the camera 1002 or camera housing 1004 to the instrument to fix the rotational orientation, e.g., prevent the camera 1002 from rotating relative to the instrument. This can be achieved by any suitable structure or method, but in some examples is achieved by one or more clips that fix the rotation of the camera 1002 or camera housing 1004 relative to the probe 500 or optical fiber housing 1023. This can also be achieved by abutting the optical fiber of the instrument against a flat surface of the sensor array. In some embodiments, the fastener 1010 couples the inserter housing 1215 or the fiber optic housing 1012 to the camera housing 1004 at a fixed angular or rotational orientation. The fastener can include an engagement structure, which can be a flat surface, a slot, a key, a keyway, a groove, an opening, a protrusion, a boss, or some other suitable structure for fixing the orientation of one or more of the fiber optic housing 1012, the camera housing 1004, or the inserter housing 1215.

[0122] In some embodiments, the fastener 1010 comprises a clip that engages the camera housing 1004, the inserter housing 1215, or the fiber optic housing 1012, and in some cases, the clip engages the camera housing 1004, the inserter housing 1215, or the fiber optic housing 1012 to provide a fixed orientation. Alternatively or in combination, the fastener 1010 comprises an opening sized and shaped to receive the camera housing 1004, the inserter housing 1215, or the fiber optic housing 1012 and provide a fixed orientation. In some instances, the fastener 1010 allows the camera housing 1004 to slide relative to the inserter housing 1215 or the fiber optic housing 1012.

[0123] In some embodiments, the fastener 1010 fixes the distance between the distal end of the treatment probe 500 and the detector array 1006. The fastener 1010 can comprise a stop, a pair of stops, an interlocking mechanism, a nesting mechanism, a circumferentially extending channel, a circumferentially extending protrusion, an annular protrusion, an annular recess, or any other suitable structure that provides a stop to limit the relative distance between the distal end of the probe 500 and the detector array 1006. In some embodiments, the distance between the distal end of the probe 500 and the detector array is fixed, while in other cases there is relative movement therebetween up to the limit provided by the fastener.

[0124] FIG. 10 illustrates the length of the fastener 1010 extending along the elongate direction of the imaging probe 100 and the treatment probe 500. FIG. 11 illustrates a first direction transverse to the elongate direction of the treatment probe 500 and the imaging probe 1000. The fastener 1010 can be sized and shaped to extend around at least a portion of the camera housing 1004 and a portion of the inserter housing 1215 described herein or the fiber optic housing 1012 described herein. The fastener 1010 includes a first distance 1104 transverse to the camera housing 1004 and the inserter housing 1215 or the fiber optic housing 1012 and a second distance 1106 transverse to the camera housing 1004 and the inserter housing 1215 or the fiber optic housing 1012, as shown in FIG. 11 . The elongated distance 1011 of the fastener 1010 can include a third distance along the elongated axis of the camera housing 1004 and the inserter housing 1215 or the fiber optic housing 1012. In some embodiments, the second distance is smaller than the first distance, and the third distance is larger than both the second and first distances. In some embodiments, for example, the first distance is within a range of about 1.0 mm to about 2 mm, the second distance is within a range of about 0.8 mm to about 1.5 mm, and the third distance is within a range of about 2 mm to about 20 mm. In some embodiments, these ranges are smaller, for example, the first distance can be within a range of about 1.3 mm to about 1.7 mm, the second distance can be within a range of about 1.0 mm to about 1.3 mm, and the third distance can be within a range of about 2 mm to about 10 mm. The third distance along the elongated direction can be longer than the first transverse distance and the second transverse distance to add rigidity to the connection between the imaging probe and the treatment probe 500.

[0125] 12A and 12B , an example of a treatment probe 500 and camera 1002 housed within a housing 1202 is shown in accordance with some embodiments. The treatment probe 500 includes an integrated housing 1202 that houses an optical fiber and a camera. The camera 1002 can include a detector array 1006, a lens 1008, and circuitry for coupling the camera 1002 to a control unit described herein. The integrated housing 1202 can include an opening 1204 to allow the lens 1008 of the camera 1002 to view a feature of interest. An optical axis 1022 extends from the detector array 1006 through the lens 1008 toward the distal end of the probe. The optical fiber 1014 has a distal end spaced a distance from the lens 1008, as described above.

[0126] 12B is a cross-sectional schematic diagram of the probe of FIG. 12A taken along line BB. The integrated housing 1202 has a maximum dimension D selected to allow the probe to be inserted into the eye to access a treatment location, such as within the anterior chamber of a patient's eye. In some embodiments, the maximum dimension D is within a range of, for example, about 0.5 mm to about 3 mm, or about 1 mm to about 2 mm.

[0127] In some embodiments, the probe comprises a length within a range of about 10 mm to about 50 mm sized for insertion into the eye, and in some cases, the length of the probe is selected to allow the probe to reach and compress the trabecular meshwork with its beveled distal end within the patient's eye.

[0128] The optical fiber core 1206 and cladding can be encased by an optical fiber housing 1012. The optical fiber housing 1012 can comprise any suitable material, but in some cases is stainless steel. The optical fiber housing 1012 has a maximum cross-sectional dimension E in the range of about 300 μm to about 1000 μm. In some embodiments, the optical fiber housing 1012 has a diameter in the range of about 100 μm to about 500 μm, or 150 μm to about 300 μm, and optionally in the range of about 150 μm to about 250 μm. The camera housing 1004 can have a maximum cross-sectional dimension in the range of about 0.8 mm to about 1.2 mm. As shown in FIG. 12B, in some embodiments, the integrated housing 1202 houses both the camera 1002 and the optical fiber 1014 and can have any suitable cross-sectional shape and size. In some embodiments, the integrated housing 1202 is sized and shaped to deliver the camera 1002 and the optical fiber 1014 to the anterior chamber of the patient's eye, and more specifically, to deliver the optical fiber 1014 toward the trabecular meshwork to deliver laser energy to the trabecular meshwork. In some embodiments, the optical fiber 1014 comprises a beveled distal end to evenly encompass the trabecular meshwork to form one or more openings into Schlemm's canal.

[0129] FIG. 13 illustrates a probe 500 including an optical axis 1022 that is tilted relative to the elongated axis 1302 of the treatment probe 500. The probe 500 can be similar or identical to the probes illustrated and described in other figures and can share components with probe embodiments described herein. The tilted optical axis 1022 can reduce out-of-focus tissue movement as the probe 500 is advanced toward the target location and can facilitate movement of the treatment probe 500 toward the target tissue. While the treatment probe 500 is shown with an integrated housing 1202 that includes the camera 1002 and optical fiber 1014, the optical fiber 1014 and camera 1002 can be coupled to each other with a fastener described herein to tilt the optical axis 1022 relative to the distal end of the probe 500. The tilted optical axis 1022 can be combined with the implant placement devices described herein. For example, the optical axis 1022 can be directed toward the distal tip of the implant placement probe or toward the implant on the distal end of the probe.

[0130] In some embodiments, a prism 1304 is positioned along the optical path to deflect the optical axis 1022. The prism 1304 may comprise a separate optical element positioned along the optical path of a lens. Alternatively, the prism 1304 may be located on a surface of the lens. In some embodiments, the lens comprises a wedge to deflect the light along the optical path.

[0131] In some embodiments, the tilted optical axis 1022 of the camera 1002 can enable the camera 1002 to image an implant carried by the integrated housing 1202, with the implant approximately centered within the camera image. Alternatively or in combination, the tilted optical axis 1022 can enable the camera 1002 to image the distal tip of the optical fiber 1014 approximately centered within the image, allowing the surgeon to use the distal tip to aim the probe 500 at the treatment site. In some embodiments, the camera 1002 is slidable relative to the integrated housing 1202, thereby allowing the optical axis 1022 to move past or beyond the distal tip of the optical fiber 1014. For example, the imaging probe can be coupled to the treatment probe 500 by a slidable fastener as described herein. Alternatively, the camera 1002 can be slidable relative to the treatment probe 500 within the integrated housing 1202.

[0132] FIG. 14 illustrates a method 1500 for treating an eye according to some embodiments. At step 1502, the system receives multiple camera images from a camera or endoscope inserted into a patient's eye. In some embodiments, an endoscope with a lens and fiber optic array transmits light captured at the treatment site to a detector array outside the patient, which provides an image. At step 1504, user input is received identifying an anatomical location, such as one or more of the zonules, scleral spines, Schwalbe's lines, or Schlemm's canal. The user input can be provided by a user, such as a surgeon, via a touchscreen display and can identify the location of one or more of the zonules, iris root, scleral spines, Schwalbe's lines, or Schlemm's canal. At step 1506, a classifier or neural network is trained in response to the user input and the multiple camera images, where the camera images can additionally or alternatively include endoscopic images. The classifier or neural network, in some cases, is trained for feature recognition, such that the classifier or neural network can detect and identify anatomical features in a patient's eye, such as one or more of a ciliary body zonules, scleral spurs, Schwalbe's lines, or Schlemm's canal. The classifier or neural network can include any combination of suitable image processing algorithms. In some embodiments, the neural network includes a convolutional neural network known to those skilled in the art for training neural networks. The classifier can include any suitable classifier, such as machine learning, e.g., machine learning using Bayesian statistics, or supervised machine learning, e.g., random forests, known to those skilled in the art. Image processing algorithms, such as edge detection, can be used as input to the classifier. After the neural network and / or classifier are trained, the trained classifier or neural network can be used to identify eye structures and provide the markers disclosed herein.

[0133] At step 1508, a probe with a camera is placed in the eye to be treated. According to some embodiments, the probe with a camera comprises an endoscope or fiberscope to image the eye to be treated. As an alternative to placing the detector array in the eye, the detector array can be located outside the eye as described herein.

[0134] In step 1510, the processor receives images from a camera or endoscope placed in the eye. The images can be acquired at a desired frame rate. In some embodiments, the frame rate approximates smooth motion, such as about 15 fps, 20 fps, 25 fps, 30 fps, or more.

[0135] In step 1512, anatomical features, such as one or more of the ciliary zonules, scleral spurs, Schwalbe's lines, or Schlemm's canal, are identified, such as by using a neural network or a classifier.

[0136] In step 1514, the rotation angle of the camera or endoscope relative to one or more anatomical features is determined.

[0137] The rotation angle of the probe is determined in step 1516. In some embodiments, the rotation angle of the probe is fixed relative to the rotation angle of the camera or endoscope, so determining the rotation angle of the camera results in the same rotation angle of the probe.

[0138] In step 1518, an image of the eye from inside the eye provided by the endoscope is displayed on a heads-up display along with the optical image from the surgical microscope. The endoscope may include a camera inserted into the eye that provides the image, or an endoscope with an external sensor array that provides the image. This image may be presented as a picture-in-picture display and may be displayed through one or both eyepieces of the microscope. Although reference is made to a heads-up display, the display may comprise one or more of a two-dimensional display, e.g., a monitor, a surgical microscope heads-up display, an augmented reality display, a virtual reality display, a three-dimensional display, or a stereoscopic display, e.g., with depth perception.

[0139] At step 1520, markers are shown on an image from a camera or endoscope placed inside the patient. The markers may be overlaid on one or more of the ciliary body zonules, scleral spines, Schwalbe's lines, or Schlemm's canal. The one or more markers may be placed on an image used to identify tissue structures or on a subsequent image from the camera or endoscope inside the eye. In some cases, the markers are overlaid on an image from the camera or endoscope to present an augmented image.

[0140] The rotation angle of the camera, endoscope, or probe is indicated on the heads-up display in step 1522. The rotation angle can be a number, one or more lines, an angle relative to the horizon, or some other indicia indicating the rotation angle of the probe or camera, for example, a green light when the probe is rotationally aligned within a suitable tolerance, for example, within 5 degrees.

[0141] 14 may be performed by one or more of the circuits or processor instructions described herein, e.g., one or more of the processors or logic circuits of the systems described herein. The circuitry may be programmed to provide one or more steps, and the program may include program instructions stored on a computer-readable memory or programmed steps of a logic circuit having, e.g., programmable array logic or a field programmable gate array.

[0142] While Figure 14 illustrates a method according to some embodiments, those skilled in the art will recognize many variations and adaptations of the teachings disclosed herein. For example, method steps can be eliminated; additional steps can be provided; some of the steps can be repeated; some of the steps can include sub-steps; some of the steps can be repeated; and the order of the steps can be changed.

[0143] A convolutional neural network can be used to classify the image data, and this or an alternative machine learning algorithm can be applied to generate markers and other indicia that are used to augment images from an in-situ camera or endoscope, or from a surgical microscope, or both, resulting in an augmented image that allows a surgeon to quickly identify anatomical features and determine that a probe is properly aligned with the anatomical feature, such as for deploying an implantable device that requires proper alignment and / or orientation.

[0144] Referring to FIG. 15 , a system 400 for assisting a physician in performing a surgical procedure on an eye E with an endoscope 1530 is illustrated, according to some embodiments. The surgical procedure can include inserting an elongated probe 23 into the eye through an opening, across the anterior chamber, and into a target tissue region including the trabecular meshwork and Schlemm's canal. In some embodiments, the system 400 can include an optical microscope 409 for the surgeon to observe the eye in real time during the procedure. An endoscope input 1501 receives a feed as an input from an endoscope positioned within the eye. The feed can include an optical feed or an electrical feed, and combinations thereof. In some embodiments, the endoscope is coupled to the endoscope input 1501 by a flexible cable. The flexible cable can include an ordered array of optical fibers, the arrangement of the optical fibers being substantially fixed at both ends to transmit an image of the eye to the endoscope input 1501. A distal end of the optical fiber array can be substantially fixed relative to a lens that forms an image at the distal end of the optical fiber array, and a proximal end of the optical fiber array can be substantially fixed relative to a detector array that receives an image from the array of optical fibers. In some embodiments, a substantially fixed arrangement at both ends can allow rotation of the probe while maintaining the orientation of the image formed at the distal end of the optical fiber array relative to the image transmitted from the proximal end of the optical fiber array to the detector array.

[0145] The endoscope input 1501 is operably coupled to the processor 414 of the control unit 410. The endoscope input 1501 can comprise input from a sensor of a camera disposed within the eye or an external sensor array as described herein. The processor 414 of the control unit 410 can be configured with instructions to identify the location of eye structures and overlay indicia, such as markers, on the input endoscopic image. An endoscope disposed within the eye, along with an optical microscope 409, can provide the endoscope input 1501 to the control unit 410. In some embodiments, a camera 416 comprising a detector array is optically coupled to the optical microscope 409 to receive optical images from the surgical microscope and to the processor of the control unit 410. The control unit 410 processes images from the camera 416 and processes these images to provide visual image data on the heads-up display 407, which can overlay the visual image data on a preceding optical image from the surgical microscope. Although reference is made to a head-up display, the display 407 may comprise one or more of a two-dimensional display, e.g., a monitor, a head-up display of a surgical microscope, an augmented reality display, a virtual reality display, a three-dimensional display, or a stereoscopic display, e.g., with depth perception.

[0146] The microscope may comprise, for example, a binocular surgical microscope. The system 400 may include an endoscope 1530 delivered in situ with the treatment probe 23 to provide imaging of one or more target locations before, during, or after a procedure. The endoscope 1530 of the probe 23 may include any suitable imaging device, and in some cases, one or more optical fibers, such as an optical fiber array. A lens may focus light onto one or more optical fibers that carry imaging data from inside the eye to the endoscope input 1501. A detector array may be positioned within the endoscope input, the system handpiece, or elsewhere within the system to receive the light carried by the one or more optical fibers and convert the light into imaging data. In some embodiments, the detector array may be a CCD or CMOS imaging sensor located outside the patient's eye and may be housed in the endoscope handpiece, the endoscope input 1501, or the control unit 410. Images delivered by the endoscope and captured by the detector array may be processed by the image processor 412 of the control unit 410 to generate multiple augmented images that are visualized in real time by the physician.

[0147] The augmented image can be shown on the display of the heads-up display 407 and can be combined with an optical image from the microscope by an internal beam splitter 708 to form a monocular or binocular image as known to those skilled in the art. As described herein, the microscope view can include, for example, one or more of an optical microscope image, an image from an endoscope placed in the eye, a microscope image and an overlaid virtual image, or a microscope image combined with an image captured by the endoscope with or without an overlaid virtual image. When the microscope view includes an overlaid image, the overlaid image can be aligned with the microscope image using elements that enable such alignment. Similarly, when the view includes an image from an endoscope and an overlaid virtual image, the overlaid image can be aligned with the image from the endoscope using elements that enable such alignment.

[0148] The images can be provided to the surgeon in many ways. For example, the surgeon can view the images through an augmented reality display, such as glasses or goggles, and view the surgical site through a surgical microscope. In some embodiments, the surgeon views the images through a virtual reality display. Alternatively or in combination, the eye can be viewed through an external monitor, as described herein, and markings are placed on the image of the eye viewed through the external monitor. The image viewed by the surgeon can include, for example, a monocular image or a stereoscopic image.

[0149] According to some embodiments, the surgeon may first view a surgical instrument, such as a probe, in a microscope or video image from a surgical microscope. In some cases, the surgeon may alternatively or additionally view an image showing the probe captured by the endoscope. According to some embodiments, the surgeon may view an image from the microscope and an image captured by the endoscope through the microscope's eyepiece. Alternatively or in combination, the surgeon may view an augmented image or view, where additional information is overlaid on one or more of the optical microscope image or the endoscopic image. When an image captured by the endoscope is overlaid on an image from the microscope, the surgeon may simultaneously view both the microscope image and the overlaid endoscopic image. Additionally, the image processor 412, as described herein, may detect anatomical features of the eye and overlay markers on the microscope or endoscopic image to help guide the surgeon in identifying and locating these features. The augmented image may be presented to the physician through the microscope's eyepiece(s) or eyepiece and / or the microscope's display, and in some embodiments, may be viewed on a monitor screen. This can be useful, for example, to allow a surgeon to maintain a stereoscopic view of the surgical site through the microscope eyepieces while simultaneously viewing superimposed or adjacent images or information stereoscopically or monocularly. Real-time images and real-time procedural information captured in situ by the endoscope can be superimposed on the live view in one or both eyepieces. In some embodiments, the disclosed devices and methods provide real-time views, including real and augmented images, from both the outside and inside of the anterior chamber during these procedures.

[0150] The optical microscope 409 can be operatively coupled to the endoscope inserted into the eye in many ways. The optical microscope 409 can comprise a binocular microscope, such as a stereo microscope, with imaging lens elements for imaging objects onto eyepiece(s) comprising the eyepiece 408. The endoscope disposed within the eye is configured to capture optical images of the eye. The optical images can be transmitted to the control unit 410 for processing. The endoscope disposed within the eye can comprise optical elements (e.g., lenses, mirrors, filters, prisms, etc.). The endoscope can capture color images, grayscale images, etc., and can be introduced by and moved by the probe, or the probe can move independently of the endoscope while maintaining rotational alignment with the probe. In some cases, the probe and endoscope move together during insertion into the location of interest, and then the probe or endoscope can move independently of the other while maintaining rotational alignment.

[0151] Although reference is made to the endoscope and treatment probe 500 being inserted through the same incision, in some embodiments the endoscope and treatment probe 500 are inserted through different incisions, with the endoscope positioned to image the target tissue. For example, the imaging probe can be inserted through a first incision and the treatment probe 500 can be inserted through a second incision, or vice versa.

[0152] The endoscopic image can be acquired at a suitable image frame resolution, which can be defined by the number of pixels in a frame. The image resolution of a detector receiving light transmitted by one or more optical fibers of an optical fiber array of an endoscope disposed within the eye can include any of the following resolutions: 160 x 120 pixels, 249 x 250 pixels, 250 x 250 pixels, 320 x 240 pixels, 420 x 352 pixels, 480 x 320 pixels, 720 x 480 pixels, 1280 x 720 pixels, 1440 x 1080 pixels, 1920 x 1080 pixels, 2048 x 1080 pixels, 3840 x 2160 pixels, 4096 x 2160 pixels, 7680 x 4320 pixels, or 15360 x 8640 pixels. The resolution of the array detector coupled to the endoscope can be within a range defined by any two of the aforementioned pixel resolutions, e.g., within a range of 160 x 120 pixels to 250 x 250 pixels, e.g., a resolution of 249 x 250 pixels. The imaging device can have a pixel size smaller than 1 micron, 2 microns, 3 microns, 5 microns, 10 microns, 20 microns, etc. The detector array can have a footprint of approximately 2 mm x 2 mm, or 1 mm x 1 mm, 0.8 mm x 0.8 mm, or less, or any other desirable size, for detecting light transmitted by the optical fiber array.

[0153] Images from the endoscope can include a sequence of image frames captured at a specific capture rate. In some embodiments, the image sequence can be captured at a standard video frame rate such as approximately 24p, 25p, 30p, 43p, 48p, 50p, 60p, 62p, 72p, 90p, 100p, 120p, 300p, 50i, or 60i, or within a range defined by any two of the aforementioned values. In some embodiments, the image sequence can be captured at a rate less than or equal to approximately one image every 0.0001, 0.0002, 0.0005, 0.001, 0.002, 0.005, 0.01, 0.02, 0.05, or 0.1 seconds. In some cases, the capture rate can vary depending on user input and / or external conditions (e.g., lighting intensity) under the guidance of the control unit 410.

[0154] Images captured by an endoscope can be captured in real time, so that the images are produced with reduced latency, i.e., a small delay between data acquisition and image rendering. Real-time imaging allows the surgeon to perceive a smooth flow of motion consistent with the surgeon's tactile movements of surgical instruments (e.g., elongated probes and probe tips) during surgery. Real-time imaging can include providing images at a rate greater than 30 frames per second (fps) to mimic natural vision with its continuity of motion, and at twice that rate to avoid flicker (the perception of intensity fluctuations). In some embodiments, the latency can include the time interval between capturing an image from within the endoscope and the information being presented to the user; such a time interval can be approximately 100 ms or less, e.g., 50 ms or less. In some embodiments, the latency can include one or two frames or less of an image shown on a display. In some instances, the terms "endoscope" and "fiberscope" can be used interchangeably. A fiberscope is a flexible fiber optic bundle that can be used to observe or capture images by transmitting light from a distal end of the fiber optic bundle to a location at a proximal end of the fiber optic bundle by total internal reflection. In some cases, a detector array can be positioned at the proximal end of the fiber optic bundle to capture imaging data corresponding to a location near the distal end of the fiber optic bundle. In some cases, an endoscope can include an imaging bundle, an illumination bundle, one or more energy delivery bundles, or any combination.

[0155] In some embodiments, the optical microscope 409 can be coupled to an electronic display device 407. The electronic display 407 can comprise a heads-up display device (HUD). The HUD may or may not be a component of the microscope system 409. The HUD can be optically coupled to one or both of the eyepieces within the field of view (POV). The display device can be configured to project an augmented image from the input 507 generated by the control unit 410 to the user or surgeon. Alternatively, or additionally, the display device 407 can be configured to project an image captured by the endoscope to the user or surgeon. The display device can be coupled to the microscope through one or more optical elements, such as a beamsplitter or mirror 420, such that a physician looking through the eyepiece 408 can perceive an endoscopic image, an augmented image, or any combination rendered and presented by the display device 407 in addition to the real image. The display device can be visible to the surgeon or user through a single eyepiece. Alternatively, the HUD may be visible to the surgeon through eyepiece 408, for example as a stereoscopic binocular image combined with an optical image formed by components of a microscope.

[0156] The display device of the head-up display 407 is in communication with the control unit 410. The display device can provide the user with augmented images created by the control unit 410 in real time. As described herein, real-time imaging can include capturing images without substantial latency, thereby enabling the surgeon to perceive a smooth flow of motion consistent with the surgeon's tactile movements of surgical instruments during surgery. In some cases, the display device 407 can receive one or more control signals from the control unit to adjust one or more parameters of the display, such as brightness, magnification, alignment, etc. The image viewed by the surgeon or user through the eyepiece 408 can be a direct optical view of the eye, an image displayed on the display 407, or a combination of both. Thus, adjusting the brightness of the image on the HUD can affect the surgeon's view through the eyepiece. For example, processed information and markers shown on the display 407 can be balanced with a microscopic view of an object. A processor can process the endoscopic image data, such as to increase the contrast of the image data so that visible features are more easily detectable or identifiable.

[0157] The heads-up display 407 may be, for example, a liquid crystal display (LCD), an LED display, an organic light emitting diode (OLED), a scanning laser display, a CRT, etc., as known to those skilled in the art.

[0158] Alternatively, or in combination, the display 407 can constitute an external display. For example, in some embodiments, the display 407 may not be perceptible through an eyepiece. The display 407 can comprise a monitor located in proximity to the optical microscope. The display 407 can comprise, for example, a display screen. The display 407 can comprise a light-emitting diode (LED) screen, an OLED screen, a liquid crystal display (LCD) screen, a plasma screen, or any other type of screen. The display device 407 may or may not comprise a touchscreen. The surgeon can simultaneously observe a real-time optical image of the surgical site and an image provided by the in situ endoscope from the display 407.

[0159] The endoscope inserted into the eye can include a fiber optic array suitable for capturing images with a resolution for viewing tissue structures of the eye as described herein, for example, providing images having a resolution in the range of less than 1 micron to 10 microns, e.g., in the range of about 3 to 6 microns. In some embodiments, the endoscope can have a spatial resolution in the range of about 10 μm to about 80 μm with respect to tissue adjacent to the tissue contacting the angled distal end of the probe, and optionally, the resolution is in the range of about 20 μm to about 40 μm.

[0160] In some embodiments, the light present for the surgical microscope provides sufficient illumination. In some embodiments, the endoscope placed in the eye can be equipped with a suitable light source to provide an image with suitable brightness and focus, if necessary. In some embodiments, the endoscope placed in the eye can be equipped with a light-emitting diode (LED), one or more optical fibers for illumination, such as a lighting bundle, or a MicroLED. In some embodiments, one or more color filters can be applied to images captured by the endoscope to aid in isolating, locating, or otherwise identifying tissue structures of interest. The endoscope placed in the eye can be at least partially controlled by a control unit. Control of the endoscope by the control unit can include, for example, activating a detector array for image capture, controlling illumination, setting parameters, focus, brightness, contrast, applying one or more filters, or customizable control parameters.

[0161] An endoscope placed in the eye can be coupled to an image sensor with a high signal-to-noise ratio. The endoscope can include a lens and an optical fiber array, which is coupled to a sensor array or detector array. In some embodiments, one or more lenses of the endoscope include, for example, borofloat glass. The sensor array can have any suitable number of pixels arranged in an array of rows and columns. In some embodiments, the pixel array includes, for example, 249 x 250 pixels, which can include rolling shutter pixels. In some embodiments, the pixels have, for example, a 3 μm pitch, resulting in an optical area with a diameter of 1.06 mm.

[0162] The system 400 may further include a user interface 413. The user interface 413 may be configured to receive user input and output information to a user. The user input may relate to control of a surgical instrument, such as the probe 23. The user input may relate to operation of the optical microscope (e.g., microscope settings, image acquisition, etc.). The user input may relate to various operations or settings related to the image capture system. For example, the user input may include selection of a target location, selection of treatment fiducial markers, display settings for augmented images, customizable display preferences, etc. The user interface may include a screen, such as a touchscreen, and any other user-interactive external device, such as a handheld controller, a mouse, a joystick, a keyboard, a trackball, a touchpad, buttons, verbal commands, gesture recognition, a posture sensor, a thermal sensor, a touch capacitance sensor, a footswitch, or any other device.

[0163] In some embodiments, an endoscope placed in the eye is used to guide the probe 23 and visualize the target site. In some embodiments, the endoscope can be configured to view the tissue and the probe tip. In some embodiments, the lens of the endoscope is positioned at a distance of about 10 mm from the probe tip, for example, at least about 6 mm from the probe tip. These distances allow the probe tip to be viewed on the endoscopic image to target Schlemm's canal.

[0164] The control unit 410 can be configured to generate an augmentation layer containing the augmented information. The augmentation layer can be a substantially transparent image layer containing one or more graphical elements. The terms “graphical element” and “graphical visual element” can be used interchangeably throughout this application. The augmentation layer can be overlaid on the microscope's optical view, optical image, or video stream and / or displayed on a display device. The transparency of the augmentation layer allows the user to view the optical image with the graphical elements overlaid on it. In some embodiments, the augmentation layer can include real-time endoscopic images or other information acquired by one or more of the endoscopes or cameras 416 positioned in the eye.

[0165] As described herein, fusion of optical microscope image data, endoscopic image data, enhanced information, or any combination can include incorporating enhanced information into the optical microscope image or the endoscopic image data, or both. The enhanced image data can include one or more graphical elements associated with depth information, target location, orientation information, tissue identification information, or various other supplemental information. The graphical elements can be overlaid onto the optical microscope image and / or the endoscopic image, for example, by the beam splitter 708. The graphical elements can be overlaid directly onto the image of any object visible in the optical microscope image. The graphical elements can also include any shape, boundary, or outline surrounding the image of any object in the optical microscope image. The object can be, for example, an instrument (e.g., a probe) inserted into the eye, a portion of the probe, a target tissue, etc., as described herein.

[0166] 16, an exemplary treatment probe 500 and endoscope 1600 are illustrated, according to some embodiments. The endoscope 160 is housed within an endoscope housing 1602 and includes a lens 1608 and a fiber optic array 1604. As described elsewhere herein, for example, the detector array receiving light from the fiber optic array 1604 can comprise an array having any suitable resolution, for example, within the range of 200x200 to 300x300 pixels.

[0167] A fastener 1010, such as a clip, can be used to couple the endoscope housing 1602 to the treatment fiber optic housing 1012. The treatment fiber optic housing 1012 can at least partially house a treatment fiber optic 1014 configured to deliver optical energy to a treatment site. The fiber optic housing 1012 and the treatment fiber optic 1014 can comprise components of the treatment probe 500, and the endoscope and endoscope housing 1602 can comprise components of an imaging probe. The fiber optic housing 1012 can be configured with one or more structures that cooperate with the fastener 1010 to secure the treatment fiber optic housing 1012 and the endoscope housing 1602 in a fixed relative rotational orientation. In other words, the fastener 1010 can secure the endoscope housing 1602 and the fiber optic housing 1012 together such that neither the endoscope housing 1602 nor the fiber optic housing 1012 can substantially rotate about a longitudinal axis independently of the other, for example, by more than about 2 degrees. The fastener 1010 may be permanently attached to one of the endoscope housing 1602 or the fiber optic housing 1012 and selectively engage the other. Alternatively, the fastener 1010 may comprise separate portions configured to couple to the treatment probe 500 and the imaging probe 1000.

[0168] The distal end 1020 of the treatment probe 500 can be formed such that the beveled surface is angled relative to the longitudinal axis of the treatment probe 500. In some embodiments, the distal end of the treatment probe 500, the distal end of the treatment optical fiber, or both, are beveled at an angle α of about 45 degrees to about 65 degrees, optionally at an angle α in the range of about 50 degrees to about 60 degrees. In some embodiments, the angle α of the distal end of the treatment probe 500 is substantially the same as the angle α of the distal end of the treatment optical fiber. In some embodiments, the angle α of the distal end of the treatment probe 500 is within 10 degrees or less of the angle α of the distal end of the optical fiber.

[0169] While the illustrated embodiment shows a single treatment optical fiber 1014, it should be understood that a bundle of treatment optical fibers can also be used in the disclosed systems and methods. In some examples, treatment probe 500 comprises a bundle of treatment optical fibers, each having a distal end at or about an angle to the distal end of treatment probe 500.

[0170] In some embodiments, the endoscope housing 1602 can translate in direction N along its longitudinal axis independently of the treatment fiber optic housing 1012. In some cases, the translation distance of the endoscope housing 1602 is fixed, and thus there is a limit to the translation distance of the endoscope housing 1602 relative to the treatment fiber optic housing 1012. In some embodiments, the distal end of the probe 1606 extends beyond the endoscope lens 1008 by a distance A that is within a range of about 2 mm to about 10 mm, or within a range of about 2.5 mm to about 5 mm. In embodiments in which the endoscope can translate independently of the treatment fiber optic housing, the translation distance can be limited by these dimensions, and thus the endoscope lens can be moved from about 2 mm to about 10 mm from the distal end of the fiber optic housing. The travel limit can be provided by any suitable structure or mechanism, such as a slot, groove, protrusion, boss, stop, or the like.

[0171] The treatment probe 500 can be translated in direction M, and the endoscope housing 1602 can be fixed to the treatment probe 500, such that the endoscope housing 1602 is translated with the treatment probe 500. In some embodiments, as described herein, the endoscope housing 1602 can optionally have a rigid attachment to the fiber optic housing 1012, which attachment can be released to provide a degree of freedom to translate along its longitudinal axis within translation limits.

[0172] In some embodiments, the endoscope 1600 of the imaging probe 1000 includes an optical axis 1022. The optical axis 1022 can extend approximately parallel to the elongated axis of the treatment optical fiber 1014, for example, within about 5 degrees. In some embodiments, the treatment optical fiber 1014 includes a beveled distal end 1020, as described herein. The imaging optical fiber array 1604 can include individual optical fibers, each aligned with the beveled distal end 1020 of the treatment probe 500, such that an image from the endoscope 1600 positioned in the eye is aligned with the beveled distal end 1020 of the treatment probe 500. The beveled distal end 1020 of the treatment probe 500 can include a substantially flat surface that defines a surface normal vector 1024. The endoscope 1600 can be positioned relative to the surface normal vector 1024 of the treatment probe 500 in a number of ways. In some embodiments, the surface normal vector 1024 of the treatment probe 500 and the optical axis 1022 of the imaging probe 1000 extend along a common plane. In some embodiments, the angled distal surface 1020 of the treatment probe 500 points away from the optical axis 1022 of the imaging probe 1000, e.g., the surface normal vector 1024 points away from the optical axis 1022. In alternative embodiments, the angled distal surface 1020 points towards the optical axis 1022, e.g., the surface normal vector 1024 points towards the optical axis 1022.

[0173] In some embodiments, the individual fibers of the imaging optical fiber array 1604 are aligned with the angled distal end 1020 of the treatment probe 500, such that the imaging optical fiber array 1604 extends in a direction corresponding to the component of the surface normal vector 1024 that extends away from the elongated axis of the optical fiber. Alternatively, the individual fibers of the imaging optical fiber array 1604 can be rotated relative to the angled distal end 1020 of the treatment fiber, and a processor can be used to rotate the image shown to the surgeon so that the image of the eye from an endoscope placed in the eye is aligned with the distal end of the angled treatment probe 500. Although reference is made to a treatment probe 500 having optical fibers 1014, the treatment probe 500 can comprise a probe having an implant as described herein, and a processor is used to rotate the image shown to the surgeon.

[0174] In some embodiments, the individual fibers of the imaging optical fiber array 1604 are constrained from individual rotation about their elongated axes. That is, the individual fibers are not free to rotate. This restraint can aid in forming and capturing images at the proximal end of the optical fiber array 1604. Additionally, in some embodiments, the imaging optical fiber array 1604 as a whole is constrained from rotation relative to the optical fiber housing 1012, thus helping to ensure that images provided to the surgeon represent the correct orientation of the endoscope housing 1602 relative to the optical fiber housing 1012.

[0175] Figure 17 is a cross-sectional schematic diagram of the probe of Figure 16 taken along line AA. The imaging probe can have an endoscope 1600 with a lens 1008 and a fiber optic array 1604. The endoscope housing 1602 can include one or more optical fibers, such as the fiber optic array 1604. The treatment fiber optic housing 1012 can be attached to the endoscope housing 1602 in a manner that prevents independent rotation of either the endoscope housing 1602 or the fiber optic housing 1012.

[0176] According to some embodiments, a fastener 1010 can attach the treatment fiber optic housing 1012 to the endoscope housing 1602. The fastener 1010 can comprise a clip that can be secured to a longitudinal groove in the treatment fiber optic housing 1012. In some embodiments, the clip is attached to the endoscope housing 1602 and comprises an engagement structure such as, for example, a flat engagement surface, a slot, a key, a groove, an opening, a protrusion, or other suitable structure. In some embodiments, the clip couples the treatment fiber optic housing 1012 to the endoscope housing 1602 at a fixed angular orientation.

[0177] In some embodiments, the endoscope housing 1602 or the treatment optical fiber housing 1012, or both, have flat engagement surfaces to provide intimate surface contact between the endoscope housing 1602 and the optical fiber housing 1012 and to orient the optical fiber housing 1012 to receive a fastener.

[0178] In some embodiments, the endoscope housing 1602 has a maximum dimension D that allows the endoscope housing 1602 to be inserted into a patient's eye, and the maximum dimension D can be in the range of about 0.8 mm to about 1.2 mm. The treatment fiber optic housing 1012 can have a maximum cross-sectional dimension E that is in the range of about 300 μm to about 600 μm, and in some embodiments, dimension E is less than dimension D. Although the endoscope housing 1602 and the treatment fiber optic housing 1012 are schematically represented as having a generally cylindrical cross-section, each housing can have any suitable cross-sectional shape, such as oval, hexagonal, octagonal, circular, or any suitable shape.

[0179] In some embodiments, the fastener 1010 can include a clip or opening for engaging one or more of the endoscope housing 1602, the inserter housing 1215, or the treatment optical fiber housing 1012, and, if desired, the clip includes an engagement structure sized and shaped to receive the endoscope housing, the inserter housing 1215, the optical fiber housing, or a combination.

[0180] The fastener 1010 can allow the endoscope housing 1602 to slide relative to the inserter housing 1215 or treatment optical fiber housing 1012 while keeping the rotational orientation of the endoscope 1600 fixed relative to the inserter housing 1215 or optical fiber housing 1012.

[0181] The imaging probe comprising the endoscope 1600 can be fastened to the treatment probe 500 by fasteners such that the rotational orientation of the endoscope relative to the rotational orientation of the instrument is fixed, i.e., the endoscope 1600 cannot rotate substantially, for example, by more than 5 degrees, for example, 2 degrees, or for example, 1 degree, independently of the treatment probe 500. In some embodiments, the rotational orientation is fixed by the use of cooperating structures that reduce the likelihood of relative rotation between the endoscope 1600 and the treatment probe 500. In some embodiments, a clip secures the endoscope 1600 to the treatment probe 500 to fix the rotational orientation, for example, preventing the endoscope 1600 from rotating relative to the instrument (e.g., the treatment probe 500). This can be achieved by any suitable structure or method, but in some examples is achieved by one or more clips that fix the rotation of the endoscope relative to the probe. This can also be achieved by abutting the instrument's optical fiber against a flat surface of the endoscope 1600. In some embodiments, the fastener 1010 couples the inserter housing 1215 or the optical fiber housing 1012 to the endoscope housing 1602 at a fixed angular or rotational orientation. The fastener 1010 can include an engagement structure, which can be a flat surface, a slot, a key, a keyway, a groove, an opening, a protrusion, a boss, or some other suitable structure for fixing the orientation of one or more of the optical fiber, the endoscope, or the inserter housing 1215.

[0182] In some embodiments, the fastener 1010 comprises a clip that engages the endoscope housing 1602, the inserter housing 1215, or the procedural fiber optic housing 1012, and in some cases, the clip engages the endoscope housing 1602, the inserter housing 1215, or the fiber optic housing 1012 to provide a fixed orientation. Alternatively or in combination, the fastener comprises an opening sized and shaped to receive the endoscope housing 1602, the inserter housing 1215, or the procedural fiber optic housing 1012 and provide a fixed orientation. In some instances, the fastener allows the endoscope housing 1602 to slide relative to the inserter housing 1215 or the fiber optic housing 1012.

[0183] In some embodiments, the fastener fixes the distance between the distal end of the treatment probe 500 and the lens of the endoscope 1600. The fastener 1010 can comprise a stop, a pair of stops, an interlocking mechanism, a nesting mechanism, a circumferentially extending channel, a circumferentially extending protrusion, an annular protrusion, an annular recess, or any other suitable structure that provides a stop for limiting the relative distance between the distal end of the probe 1606 and the lens 1008 of the endoscope. In some embodiments, the distance between the distal end of the probe 1606 and the lens 1008 is fixed, while in other cases there is relative movement therebetween up to the limit provided by the fastener.

[0184] FIG. 16 illustrates the length of the fastener extending along the elongated direction of the imaging probe and treatment probe 500. FIG. 17 illustrates a first direction transverse to the elongated direction of the treatment probe 500 and imaging probe. The fastener can be sized and shaped to extend around at least a portion of the endoscope housing 1602 and a portion of the inserter housing 1215 or the treatment fiber optic housing 1012 described herein. The fastener 1010 can include a first distance transverse to the endoscope housing 1602 and the inserter housing 1215 or the fiber optic housing 1012 and a second distance transverse to the endoscope housing and the inserter housing 1215 or the fiber optic housing, as shown in FIG. 17. The elongated distance of the fastener can include a third distance along the elongated axis of the endoscope housing 1602 and the inserter housing 1215 or the fiber optic housing 1012. In some embodiments, the second distance is less than the first distance, and the third distance is greater than the second and first distances. In some embodiments, for example, the first distance is in the range of about 1.0 mm to about 2 mm, the second distance is in the range of about 0.8 to 1.5 mm, and the third distance is in the range of about 2 mm to about 20 mm. In some embodiments, these ranges are smaller, for example, the first distance can be in the range of about 1.3 to about 1.7 mm, the second distance can be in the range of about 1.0 to 1.3 mm, and the third distance can be in the range of about 2 mm to about 10 mm. The third distance along the elongate direction can be longer than the first transverse distance and the second transverse distance to add stiffness to the connection between the imaging probe and the treatment probe 500.

[0185] 18A and 18B , an example of a treatment probe 500 and an endoscope 1600 housed within an integrated housing 1202 is shown, according to some embodiments. The treatment probe 500 includes an integrated housing 1202 that houses an optical fiber 1014 and an endoscope 1600. The endoscope 1600 can include a lens 1008, an optical fiber array 1604, a detector array, and circuitry for coupling the endoscope 1600 to a control unit as described herein. The integrated housing 1202 can include an opening to allow the lens 1008 of the endoscope 1600 to view a feature of interest. An optical axis 1022 extends through the lens 1008 toward the distal end of the probe 1606. The treatment optical fiber 1014 has a distal end spaced a distance from the lens 1008, as described herein.

[0186] 18B is a cross-sectional schematic diagram of the probe of FIG. 18A taken along line BB. The integrated housing 1202 has a maximum cross-sectional dimension D selected to allow the probe to be inserted into the eye to access a treatment location, such as within the anterior chamber of a patient's eye. In some embodiments, the maximum dimension D is within a range of, for example, about 0.5 mm to about 3 mm, or about 1 mm to about 2 mm.

[0187] In some embodiments, the probe comprises a length within a range of about 10 mm to about 50 mm sized for insertion into the eye, and in some cases, the length of the probe is selected to allow the probe to reach and compress the trabecular meshwork with its beveled distal end within the patient's eye.

[0188] The core 1206 and cladding of the treatment optical fiber can be encased by an optical fiber housing 1012. The optical fiber housing 1012 can comprise any suitable material, but in some cases is stainless steel. The optical fiber housing 1012 has a maximum cross-sectional dimension E that can be in the range of about 300 μm to about 600 μm. In some embodiments, the optical fiber housing 1012 has a diameter in the range of about 100 μm to about 300 μm, optionally in the range of about 150 μm to about 250 μm. The endoscope housing 1602 can have a maximum cross-sectional dimension in the range of about 0.8 mm to about 1.2 mm. As shown in FIG. 12B, in some embodiments, the integrated housing 1202 houses both the endoscope 1600 and the treatment optical fiber 1014 and can include any suitable cross-sectional shape and size. In some embodiments, the integrated housing 1202 is sized and shaped to deliver the endoscope 1600 and the optical fiber 1014 to the anterior chamber of the patient's eye, and more specifically to deliver the optical fiber 1014 toward the trabecular meshwork to deliver laser energy to the trabecular meshwork. In some embodiments, the treatment optical fiber 1014 comprises a beveled distal end 1020 that uniformly encompasses the trabecular meshwork to form one or more openings into Schlemm's canal.

[0189] FIG. 19 illustrates a probe including an optical axis 1022 that is tilted relative to the elongate axis of the treatment probe 500. The tilted optical axis 1022 can reduce out-of-focus tissue movement as the probe is advanced toward the target location and can facilitate movement of the treatment probe 500 toward the target tissue. While the treatment probe 500 is shown having an integrated housing 1202 with the endoscope 1600 and treatment optical fiber 1014, the treatment optical fiber 1014 and endoscope 1600 can be coupled to each other with a fastener described herein to tilt the optical axis 1022 relative to the distal end of the probe 1606. The tilted optical axis 1022 can be combined with the implant placement devices described herein. For example, the optical axis 1022 can be directed toward the distal tip of the implant placement probe or the implant on the distal end of the probe.

[0190] In some embodiments, a prism 1304 is positioned along the optical path to deflect the optical axis 1022. The prism 1304 can comprise a separate optical element positioned along the optical path of a lens. Alternatively, the prism 1304 can be located on a surface of the lens 1008. In some embodiments, the lens 1008 comprises a wedge to deflect the light along the optical path 1022. In some embodiments, the lens 1008 comprises a decentered lens with the prism 1304 to deflect the optical axis 1022.

[0191] In some embodiments, the tilted optical axis 1022 of the lens 1008 can enable the endoscope 1600 to image an implant carried by the integrated housing 1202, with the implant approximately centered within the endoscopic image. Alternatively or in combination, the tilted optical axis 1022 can enable the endoscope 1600 to image the distal tip 1606 of the treatment optical fiber 1014 or its housing approximately centered within the image, allowing the surgeon to use the distal tip 1606 to direct the probe to the treatment site. In some embodiments, the endoscope 1600 is slidable relative to the integrated housing 1202, thereby allowing the optical axis 1022 to move past or beyond the distal tip 1606 of the optical fiber 1014. For example, the imaging probe can be coupled to the treatment probe 500 by a slidable fastener as described herein. Alternatively, the endoscope 1600 can be slidable relative to the probe 500 within an integrated housing.

[0192] FIG. 20 illustrates a probe 500 including one or more illumination optical fibers, including an illumination bundle 2000. In some embodiments, one or more of the illumination optical fibers include multiple fiber bundles. For example, a probe can include the illumination bundle 2000, an optical fiber array, and a fiber bundle corresponding to the optical fibers. Each of these devices can be formed from one or more optical fibers used to transmit light by total internal reflection. The fibers used by any embodiment described herein can be individually formed from any suitable material, such as glass, quartz, fused silica, or plastic. The optical fibers can include a core surrounded by a transparent cladding material with a lower refractive index and are designed to transmit light entering one end of the optical fiber to a second end of the fiber. For example, the proximal ends of some of the fibers can be coupled to a light source and used to provide illumination to the distal end of the treatment probe 500, while other fibers can be used to transmit light from a treatment site within a patient to a detector array that captures the light and generates a digital image. In some cases, one or more of the optical fibers can be connected to an energy source and used to transmit laser energy to the treatment site.

[0193] The illumination bundle 2000 can include one or more illumination optical fibers used to deliver light to the treatment site and provide illumination for imaging purposes. The optical fiber array 1604 can include one or more optical fibers used to transmit light from the treatment site to a detector array, which generates digital images of the treatment site, which can be provided to a user or surgeon as described herein. A lens 1008 can focus the light onto the distal ends of the individual fibers comprising the optical fiber array 1604. The optical fiber 1014 or a bundle of optical fibers can be used to deliver energy, such as for cutting, ablating, cauterizing, or some other purpose at the treatment site. The illumination bundle 2000, the optical fiber array 1604, and the optical fiber 1014 can be disposed within a common housing and configured for delivery to a treatment site, such as into a patient's eye.

[0194] The illumination bundle 2000 may be disposed in a common housing with the optical fiber array 1604. Alternatively or additionally, the illumination bundle 2000 may be disposed in a common housing with the optical fibers 1014. In some cases, the illumination bundle 2000 may provide illumination from various locations on the treatment probe 500 and / or the imaging probe.

[0195] The housing described herein can house the treatment optical fiber 1004, the endoscope 1600, and one or more illumination optical fibers and can further fix the rotational orientation between the endoscope 1600, the treatment optical fiber 1004, and one or more illumination optical fibers 2000. The endoscope can include an ordered arrangement of fiber bundles. In some cases, the ordered arrangement of the fiber bundles is maintained from the distal end of the fiber bundle to the proximal end of the fiber bundle. In some cases, the ordered arrangement remains consistent at the distal and proximal ends of the fiber bundle, and in some cases, the ordered arrangement is not maintained at locations between the distal and proximal ends. The ordered arrangement of the fiber bundles allows light entering the distal end of the fiber bundle to maintain its orientation and preserve the orientation of an image captured at the proximal end of the fiber bundle, such as by a detector array.

[0196] In some embodiments, an imaging system is delivered to a treatment site within a patient, such as within the patient's eye. The imaging system can include components disposed within the patient and can additionally or alternatively include components external to the patient. A camera is one example of an imaging system. The camera can be positioned at a treatment site within the patient, as described herein. An endoscope is another example of an imaging system. Some components of the endoscope, such as a lens and the distal end of the fiber bundle, can be located at the treatment site, while other components of the endoscope, such as a detector array and the proximal end of the fiber bundle, can be located remotely from the treatment site, e.g., outside the patient. The imaging system can be coupled to an apparatus for eye surgery described herein, which can be a wired or wireless connection.

[0197] This disclosure includes the following numbered sections, which are part of this disclosure. Each section may be combined with one or more other sections to the extent consistent with the teachings disclosed herein.

[0198] Item 1. A device for treating eyes, a probe sized for insertion into the eye, the probe comprising a camera with a lens and an array detector, the array detector comprising a plurality of rows and columns; an implant located near the distal end of the probe, the implant having a distal portion sized and shaped for insertion into Schlemm's canal; and a processor coupled to the array detector, the processor configured with instructions to determine a location of Schlemm's canal in response to an image of one or more of a ciliary body zonules, scleral spurs, or Schwalbe's lines of the eye.

[0199] Item 2. A device for treating eyes, a probe sized for insertion into the eye, the probe comprising a camera with a lens and an array detector, the array detector comprising a plurality of rows and columns; an implant located near the distal end of the probe, the implant comprising a distal portion sized and shaped for insertion into Schlemm's canal of the eye, the distal portion extending along an elongated insertion axis, the distal end coupled to the camera in a fixed rotational orientation relative to the angled distal end of the fiber; and a processor coupled to the array detector, the processor configured with instructions to determine an angular orientation of an elongated insertion axis in response to an image of one or more of a ciliary body zonules, scleral spurs, or Schwalbe's lines of the eye.

[0200] Item 3. A device for treating eyes, a probe sized for insertion into the eye, the probe comprising an optical fiber and a camera, the camera comprising a lens and an array detector, the array detector comprising a plurality of rows and columns; and a processor coupled to the array detector, the processor configured with instructions to determine a location of Schlemm's canal in response to an image of one or more of a ciliary body zonules, scleral spurs, or Schwalbe's lines of the eye.

[0201] Item 4. A device for treating eyes, A laser, a probe comprising a camera and an optical fiber, the camera comprising a lens and an array detector, the array detector comprising a plurality of rows and columns, the optical fiber coupled to a laser, the optical fiber having angled distal and proximal ends, the distal end coupled to the camera at a fixed rotational orientation relative to the angled distal end of the fiber; and a processor coupled to the array detector, the processor configured with instructions to determine an angular orientation of the angled distal end of the fiber in response to an image of one or more of a ciliary body zonules, scleral spurs, or Schwalbe lines of the eye.

[0202] Item 5. The device of any one of items 6 or 9, wherein the processor is configured to display the angular orientation of the tilted distal end of the fiber relative to the distal tip on a heads-up display of a surgical microscope.

[0203] Clause 6. The device of any one of clauses 6 or 9, wherein the angular orientation of the angled distal end includes one or more of a rotation angle about the elongated axis of the probe or a rotation angle about the elongated axis of the camera.

[0204] Clause 7. The device of any one of clauses 2, 6, 8 or 9, wherein the processor is configured with one or more of a convolutional neural network, a machine learning algorithm, or an edge detection algorithm to identify one or more of the ciliary body zonules or scleral spurs and determine angular orientation.

[0205] Clause 8. The device of any one of clauses 2, 6, 8 or 9, wherein the processor is configured by instructions to display the boundary of the ciliary zonules on the display, and optionally the boundary of the ciliary zonules is indicated by a plurality of markers positioned along a curve.

[0206] Clause 9. The device of any one of clauses 2, 6, 8 or 9, wherein the processor is configured by instructions to display the boundary of the scleral spur on the display, and optionally the boundary of the scleral spur is indicated by a plurality of markers positioned along a curve.

[0207] Clause 10. The apparatus of any one of clauses 2, 6, 8 or 9, wherein the image on the array detector includes an image of Schwalbe's lines, and the processor is configured with instructions to determine the location of the Schwalbe's lines in response to the image.

[0208] Clause 11. The device of any one of clauses 2, 6, 8 or 9, wherein the image on the array detector includes a visible image of Schlemm's canal, and the processor is configured with instructions to determine the location of Schlemm's canal in response to the visible image of Schlemm's canal, and optionally, the visible image of Schlemm's canal includes a contrast of greater than 5 percent (%).

[0209] Clause 12. The device of any one of clauses 2, 6, 8, or 9, wherein the processor is configured by instructions to determine the location of Schlemm's canal in response to one or more of the ciliary body zonules or scleral spurs and display this location on a subsequent image from the detector array.

[0210] Clause 13. The apparatus of any one of clauses 2, 6, 8 or 9, wherein the probe comprises a maximum lateral dimension in the range of 0.5 mm to 3 mm, optionally in the range of 1 mm to 2 mm.

[0211] Item 14. The device of item 20, wherein the probe includes a maximum cross-sectional dimension in a longitudinal distance within a range of 10 mm to 50 mm to access the trabecular meshwork of the eye and compress the trabecular meshwork with the beveled distal end.

[0212] Item 15. The device of item 2, further comprising an inserter housing and a camera housing that houses the camera in a fixed rotational orientation, the inserter housing housing one or more movable components coupled to the implant.

[0213] Item 16. The device of item 6, further comprising an inserter housing and a camera housing that houses the camera in a fixed rotational orientation, the inserter housing housing one or more movable components coupled to the implant.

[0214] Item 17. The device of item 8, further comprising an optical fiber housing that houses the optical fiber in a fixed rotational orientation, and a camera housing that houses the camera.

[0215] Item 18. The device of item 9, further comprising an optical fiber housing that houses the optical fiber in a fixed rotational orientation, and a camera housing that houses the camera.

[0216] Item 19. The apparatus of any one of items 22, Error! Reference source not found, 23 or 24, further comprising a fastener for coupling the inserter housing or the optical fiber housing to the camera housing in a fixed angular orientation configuration, wherein one or more of the fastener, the inserter housing, the optical fiber housing or the camera housing comprises an engagement structure for fixing the angular orientation, optionally wherein the structure comprises one or more of a flat engagement surface, a slot, a key, a groove, an opening or a protrusion, optionally wherein the angular orientation comprises a fixed orientation and wherein the fastener comprises the engagement structure.

[0217] Clause 20. The device of clause 25, wherein the fastener comprises one or more clips or openings for engaging one or more of the camera housing, the inserter housing, or the optical fiber housing, and optionally the clip comprises an engagement structure sized and shaped to receive one or more of the camera housing, the inserter housing, or the optical fiber housing, and optionally the fastener comprises an opening, and the opening is sized and shaped to receive one or more of the camera housing, the inserter housing, or the optical fiber housing in a fixed orientation.

[0218] Clause 21. The device of clause 25, wherein the fastener is configured to allow the camera housing to slide relative to the inserter housing or optical fiber housing while fixing the orientation of the camera relative to the inserter housing or optical fiber housing, and optionally the engagement structure comprises one or more elongated engagement structures to maintain the angle when the camera housing is sliding relative to the inserter housing or optical fiber housing, and optionally the elongated engagement structures comprise one or more of one or more axially elongated grooves, one or more axially elongated flat surfaces, or one or more axially elongated protrusions.

[0219] Clause 22. The device of clause 25, wherein the fastener is configured to fix the distance between the distal end of the probe and the array detector, and optionally, the engagement structure comprises one or more of a stop, a pair of stoppers, a linking mechanism, a nesting mechanism, a circumferentially extending channel, a circumferentially extending protrusion, an annular protrusion, or an annular recess.

[0220] Item 23. The device described in Item 25, wherein the camera housing includes a maximum distance within the range of approximately 0.8 to 1.2 mm, the optical fiber housing includes a maximum distance within the range of approximately 300 um to approximately 600 um, the fastener is sized and shaped to extend around at least a portion of the camera housing and a portion of the inserter housing or optical fiber housing, the fastener includes a first distance across the camera housing and the inserter housing or optical fiber housing, a second distance across the camera housing and the inserter housing or optical fiber housing, and a third distance along the elongated axis of the camera housing and the inserter housing or optical fiber housing, wherein the second distance is smaller than the first distance and the third distance is larger than the second distance and the first distance.

[0221] Item 24. The device according to Item 29, wherein the first distance is within a range of about 1.0 mm to about 2 mm, the second distance is within a range of about 0.8 to 1.5 mm, and the third distance is within a range of about 2 mm to about 20 mm, and the first distance is optionally within a range of about 1.3 to about 1.7 mm, the second distance is optionally within a range of about 1.0 to 1.3 mm, and the third distance is optionally within a range of about 2 mm to about 10 mm.

[0222] Item 25. The device of item 9, further comprising a housing for housing the optical fiber and the camera, the housing comprising a beveled distal end.

[0223] Clause 26. The apparatus of clause 31, wherein the beveled distal end of the housing extends circumferentially around at least a portion of the beveled distal end of the optical fiber.

[0224] Item 27. The device described in Item 31, wherein the beveled distal end of the housing and the beveled distal end of the optical fiber are beveled at angles within about 10 degrees of each other, and optionally the beveled distal ends form a coplanar surface.

[0225] Clause 28. The apparatus of clause 31, wherein the detector array includes a surface having a flat edge, and the optical fiber extends along the flat-edged surface of the detector array.

[0226] Item 29. The device of any one of the preceding items, wherein the array detector includes a number of pixels along columns in the range of about 200 pixels to about 500 pixels and a plurality of pixels along rows in the range of about 200 pixels to about 500 pixels, and optionally, the number of pixels along rows is in the range of about 200 to about 300 pixels and the number of pixels along columns is in the range of about 200 pixels to about 300 pixels.

[0227] Item 30. The device of any one of the preceding items, wherein the camera provides a spatial resolution within a range of about 10 um to about 80 um with respect to tissue adjacent to the tissue contacting the beveled distal end of the probe, and optionally the resolution is within a range of about 20 um to about 40 um.

[0228] Item 31. The device of any one of the preceding items, wherein the distal end of the probe extends beyond the most distal lens of the camera by a distance in the range of about 2 mm to about 10 mm, optionally in the range of about 2.5 mm to about 5 mm.

[0229] Item 32. The device of any one of the preceding items, wherein the distal end of the probe extends beyond the most distal lens of the camera by a distance in the range of about 2 mm to about 10 mm, optionally in the range of about 2.5 mm to about 5 mm, and optionally the distance is dimensioned to visualize a portion of the distal end of the probe in an image of one or more of the ciliary body zonules or scleral spurs or Schwalbe's lines.

[0230] Item 33. The device of any one of the preceding items, wherein the array detector is positioned at a distance from the distal end of the probe, the distance being within a range of about 2.5 mm to about 10.5 mm, optionally within a range of about 3 mm to about 6 mm.

[0231] Clause 34. The device of any one of the preceding clauses, wherein the angled end includes an angled surface for contacting the trabecular meshwork of the eye, the angled end includes a surface normal vector pointing away from the camera, and one or more of the rows or columns are aligned within about 5 degrees of a transverse component of the surface normal vector, and optionally the transverse component of the surface normal vector extends in a direction transverse to the optical fiber.

[0232] Item 35. The device of any one of the preceding items, wherein the optical fiber comprises an elongated axis of the optical fiber, the elongated axis extending along the direction of propagation of light along the optical fiber, and the beveled distal end intersecting the axis at an angle within the range of about 45 degrees to about 65 degrees, optionally with an angle within the range of about 50 degrees to about 60 degrees.

[0233] Clause 36. The device of any one of the preceding clauses, further comprising a rotation angle between the distal end of the probe and one or more of the rows or columns of the detector array, wherein the processor is configured by instructions to determine an angle between the angled end of the elongated insertion shaft or fiber and one or more of the ciliary zonules or scleral spurs of the eye in response to an image and the rotation angle of one or more of the ciliary zonules or scleral spurs of the eye.

[0234] Clause 37. The device of any one of the preceding clauses, wherein the processor is configured by instructions to determine a rotational orientation angle between the elongated insertion shaft or the tilted distal end of the optical fiber and one or more of the rows or columns of the detector array.

[0235] Item 38. The device of any one of the preceding items, wherein the optical fiber comprises a core and a cladding, the cladding having a diameter in the range of about 100 micrometers (um) to about 300 um, optionally in the range of about 150 um to about 250 um.

[0236] Clause 39. The device of any one of the preceding clauses, wherein the optical fiber comprises a plurality of optical fibers, each optical fiber having an angled distal end, the distal ends aligned to engage the eye tissue at similar angles within a range of about 10 degrees.

[0237] Item 40. The device of any one of the preceding items, further comprising a surgical microscope for observing the anterior portion of the eye from outside the eye, the surgical microscope comprising a plurality of eyepieces for a user to observe an optical image of the anterior portion of the eye formed by the plurality of lenses, the surgical microscope comprising a head-up display for showing an image from the camera when the camera is placed in the eye so that the user observes the anterior image of the eye during surgery and observes the image of the eye from the camera in real time, and optionally the image from the camera includes one or more markers indicating the location of one or more of the ciliary body zonules, scleral spurs, or Schlemm's canal.

[0238] Item 41. The device of any one of the preceding items, further comprising a surgical microscope for observing the anterior portion of the eye from outside the eye, the surgical microscope comprising a plurality of eyepieces for a user to observe an optical image of the anterior portion of the eye formed by the plurality of lenses, and the surgical microscope comprising a head-up display for showing an image from the camera when the camera is placed in the eye so that the user observes the anterior image of the eye during surgery and observes the image of the eye from the camera in real time, and optionally the image from the camera on the head-up display includes an image of the implant.

[0239] Clause 42. The device of any one of the preceding clauses, wherein the camera includes an optical axis, the optical axis of the camera is aligned with a tissue engagement structure on the probe within about 5 degrees, and the tissue engagement structure comprises one or more of: a distal end of the probe shaped to contact the trabecular meshwork; a beveled distal end of the probe shaped to contact the trabecular meshwork; a stylet sized and shaped to penetrate the trabecular meshwork; the stylet tip; an implant on the distal end of the probe; or a sharp end of an implant on the distal end of the probe.

[0240] Clause 43. The device of any one of the preceding clauses, wherein the imaging system (e.g., a camera, scope, probe, fiber, etc.) is configured to display images of the anatomical structures within the eye and the probe positioned within the eye, and is further configured to provide updated images simultaneously with movement of the probe.

[0241] As detailed above, the computing devices and systems described and / or illustrated herein broadly represent any type or form of computing device or system capable of executing computer-readable instructions, such as those contained within the modules described herein. In their most basic configurations, these computing device(s) may each include at least one memory device and at least one physical processor.

[0242] As used herein, the terms "memory" or "memory device" generally refer to any type or form of volatile or non-volatile storage device or medium capable of storing data and / or computer-readable instructions. In one example, a memory device may store, load, and / or maintain one or more of the modules described herein. Examples of memory devices include, but are not limited to, random access memory (RAM), read-only memory (ROM), flash memory, hard disk drive (HDD), solid-state drive (SSD), optical disk drive, cache, one or more variations or combinations thereof, or any other suitable storage memory.

[0243] Additionally, as used herein, the term “processor” or “physical processor” generally refers to any type or form of hardware-implemented processing unit capable of interpreting and / or executing computer-readable instructions. In one example, a physical processor can access and / or modify one or more modules stored within the aforementioned memory devices. Examples of physical processors include, but are not limited to, a microprocessor, a microcontroller, a central processing unit (CPU), a field programmable gate array (FPGA) implementing a soft-core processor, an application-specific integrated circuit (ASIC), a portion of one or more of these, a variation or combination of one or more of these, or any other suitable physical processor.

[0244] While depicted as separate elements, the method steps described and / or illustrated herein may represent portions of a single application. Additionally, in some embodiments, one or more of these steps may represent or correspond to one or more software applications or programs that, when executed by a computing device, can cause the computing device to perform one or more tasks, such as method steps.

[0245] Additionally, one or more of the devices described herein can convert data, physical devices, and / or representations of physical devices from one form to another. For example, one or more of the devices listed herein can receive image data of a sample to be converted, convert the image data, output the conversion results to determine a process, perform a process using the conversion results, and store the conversion results to result in an output image of the sample. Additionally or alternatively, one or more of the modules listed herein can execute on a computing device, store data on the computing device, and / or otherwise interact with the computing device to convert any other part of the processor, volatile memory, non-volatile memory, and / or physical computing device from one form of computing device to another form of computing device.

[0246] As used herein, the term "computer-readable medium" generally refers to any form of device, carrier, or medium capable of storing or carrying computer-readable instructions. Examples of computer-readable media include, but are not limited to, transmission-type media such as carrier waves, and non-transitory media such as magnetic storage media (e.g., hard disk drives, tape drives, and floppy disks), optical storage media (e.g., compact discs (CDs), digital video discs (DVDs), and BLU-RAY discs), electronic storage media (e.g., solid-state drives and flash media), and other distribution systems.

[0247] Those skilled in the art will recognize that any process or method disclosed herein can be modified in many ways. The process parameters and sequence of steps described and / or illustrated herein are given for illustrative purposes only and can be changed if desired. For example, although the steps illustrated and / or described herein may be shown or discussed in a particular order, these steps do not necessarily have to be performed in the order illustrated or discussed.

[0248] The various exemplary methods described and / or illustrated herein can also omit one or more of the steps described or illustrated herein or can include additional steps in addition to those disclosed. Furthermore, the steps of any method disclosed herein can be combined with any one or more steps of any other method disclosed herein.

[0249] The processors described herein may be configured to perform one or more steps of any of the methods described herein.

[0250] Unless otherwise stated, the terms "connected to" and "coupled to" (and their derivatives) as used in this specification and claims should be interpreted to allow for both direct and indirect (i.e., via other elements or components) connections. Additionally, the terms "a" or "an" as used in this specification and claims should be interpreted to mean "at least one of." Finally, for ease of use, the terms "including" and "having" (and their derivatives) as used in this specification and claims are interchangeable with the word "comprising," and are intended to have the same meaning as the word "comprising."

[0251] The processors disclosed herein may be configured with instructions to perform any one or more steps of any of the methods disclosed herein.

[0252] It will be understood that terms such as "first," "second," and "third" can be used herein to describe various layers, elements, components, regions, or sections without reference to any particular order or sequence of events. These terms are only used to distinguish one layer, element, component, region, or section from another layer, element, component, region, or section. A first layer, element, component, region, or section described herein can also be referred to as a second layer, element, component, region, or section without departing from the teachings of the present disclosure.

[0253] As used herein, the term "or" is used inclusively to refer to items in alternatives and combinations.

[0254] As used herein, letters such as numbers refer to like elements.

[0255] Although reference is made to imaging probes comprising multiple optical fibers, in some embodiments, the imaging probe comprises a single optical fiber. For example, the imaging probe can comprise a single optical fiber configured to deflect light from the eye in a scanning pattern to image the eye. The optical fiber can be configured to transmit light to multiple locations to generate an image of the interior of the eye, or can be configured to deflect and receive light from multiple locations.

[0256] The embodiments of the present disclosure have been shown and described herein and are provided by way of example only. Numerous adaptations, modifications, variations, and substitutions will occur to those skilled in the art without departing from the scope of the present disclosure. Several alternatives and combinations of the embodiments disclosed herein can be utilized without departing from the scope of the present disclosure and the invention disclosed herein. Accordingly, the scope of the invention disclosed herein is to be defined solely by the scope of the appended claims and their equivalents. In certain embodiments, for example, the following are provided: (Item 1) 1. A device for treating an eye, comprising: a probe comprising an endoscope and a treatment element; a processor coupled to the probe, the processor configured with instructions to determine a position of Schlemm's canal or an angular orientation of the treatment element, the position data being updated concurrently with movement of the probe. (Item 2) 2. The apparatus of claim 1, wherein the treatment element comprises an implant located near the distal end of the probe, the implant comprising a distal portion sized and shaped for insertion into Schlemm's canal. (Item 3) Item 10. The device of item 1, wherein the processor is configured with instructions to determine the location of Schlemm's canal in response to an image of one or more of the ciliary body zonules, scleral spurs, or Schwalbe's lines of the eye. (Item 4) Item 10. The device of item 1, wherein the processor is configured by instructions to determine the location of the trabecular meshwork in response to an image of one or more of the ciliary body zonules, scleral spurs, or Schwalbe lines of the eye. (Item 5) Item 10. The device of item 1, wherein the processor is configured with instructions to determine compression of the trabecular meshwork in response to an image of one or more of the ciliary body zonules, scleral spurs, Schwalbe's lines, or a change in the position of the probe relative to the trabecular meshwork. (Item 6) Item 10. The device of item 1, wherein the treatment element comprises an implant located near the distal end of the probe, the implant comprising a distal portion sized and shaped for insertion into Schlemm's canal of the eye, the distal portion extending along an elongate insertion axis, the distal end coupled to the endoscope in a fixed rotational orientation relative to the distal end of the fiber. (Item 7) 7. The apparatus of claim 6, wherein the processor is configured with instructions to determine an angular orientation of the elongated insertion shaft in response to an image of one or more of a ciliary body zonules or scleral spurs or Schwalbe's lines of the eye. (Item 8) Item 10. The device of item 1, wherein the probe further comprises a treatment optical fiber. (Item 9) Item 10. The apparatus of item 1, further comprising a laser. (Item 10) Item 10. The apparatus of item 1, wherein the endoscope comprises a lens and further comprises an optical fiber array coupled to the lens to transmit images to an array detector, the array detector comprising a plurality of rows and columns. (Item 11) and a treatment optical fiber, the treatment optical fiber coupled to a laser, the treatment optical fiber having angled distal and proximal ends, the distal end coupled to an array of optical fibers in a fixed rotational orientation relative to the angled distal ends of the fibers. , the device according to item 1. (Item 12) Item 12. The apparatus of item 11, wherein the processor is configured to display the angular orientation of the tilted distal end of the fiber relative to the distal end on a display, and optionally the display comprises one or more of a two-dimensional display, a microscope heads-up display, an augmented reality display, a virtual reality display, a three-dimensional display, or a stereoscopic display. (Item 13) Item 12. The apparatus of item 11, wherein the angular orientation of the angled distal end corresponds to an angle of rotation about an elongated axis of the probe. (Item 14) Item 14. The apparatus of any one of items 2 to 13, wherein the processor is configured with one or more of a convolutional neural network, a machine learning algorithm, or an edge detection algorithm to identify the one or more of the ciliary body zonules or the scleral spurs or Schwalbe's lines and determine the angular orientation. (Item 15) 14. The apparatus of any one of items 2 to 13, wherein the processor is configured with instructions to display a boundary of the zonules on a display, and optionally the boundary of the zonules is indicated by a plurality of markers located along a curve. (Item 16) 14. The apparatus of any one of items 2 to 13, wherein the processor is configured with instructions to display a boundary of the scleral spur on a display, and optionally the boundary of the scleral spur is indicated by a plurality of markers located along a curve. (Item 17) 14. The apparatus of any one of items 2 to 13, wherein the images on one or more of the detector or array detector include images of Schwalbe's lines, and the processor is configured with instructions to determine locations of Schwalbe's lines in response to the images. (Item 18) 14. The apparatus of any one of items 2 to 13, wherein the image on one or more of the detectors or array detectors includes a visible image of Schlemm's canal, and wherein the processor is configured with instructions to determine a location of Schlemm's canal in response to the visible image of Schlemm's canal, and wherein, optionally, the visible image of Schlemm's canal includes a contrast greater than 5 percent (%). (Item 19) 14. The apparatus of any one of items 2 to 13, wherein the processor is configured with instructions to determine a location of Schlemm's canal in response to the one or more of the ciliary body zonules or the scleral spurs or Schwalbe's lines, and to display the location on subsequent images from one or more of the detectors or detector arrays, the images being updated simultaneously with probe movement. (Item 20) 14. The apparatus of any one of items 2 to 13, wherein the probe comprises a maximum lateral dimension in the range of 0.5 mm to 3 mm, optionally in the range of 1 mm to 2 mm. (Item 21) 21. The device of claim 20, wherein the probe includes a maximum cross-sectional dimension in a longitudinal distance within a range of 10 mm to 50 mm for accessing the trabecular meshwork of the eye and compressing the trabecular meshwork with a beveled distal end. (Item 22) 3. The apparatus of claim 2, further comprising an inserter housing and a camera housing that houses a camera in a fixed rotational orientation, the inserter housing housing one or more movable components coupled to the implant. (Item 23) 9. The device of item 8, further comprising a treatment optical fiber housing that houses the treatment optical fiber in a fixed rotational orientation, and a camera housing that houses a camera. (Item 24) 10. The device of item 9, further comprising a treatment optical fiber housing that houses the treatment optical fiber in the fixed rotational orientation, and a camera housing that houses a camera. (Item 25) 26. The device of any one of items 22, 23, 24, or 25, further comprising a fastener for coupling the inserter housing or the treatment optical fiber housing to the camera housing in the fixed angular orientation configuration, wherein one or more of the fastener, the inserter housing, the treatment optical fiber housing, or the camera housing comprise an engagement structure for fixing the angular orientation, optionally wherein the structure comprises one or more of a flat engagement surface, a slot, a key, a groove, an opening, or a protrusion, optionally wherein the angular orientation comprises a fixed orientation, and wherein the fastener comprises the engagement structure. (Item 26) 26. The device of claim 25, wherein the fastener comprises one or more of a clip or an opening for engaging with one or more of the camera housing, the inserter housing, or the treatment optical fiber housing, and optionally the clip comprises the engagement structure sized and shaped to receive the one or more of the camera housing, the inserter housing, or the treatment optical fiber housing, and optionally the fastener comprises the opening, and the opening is sized and shaped to receive the one or more of the camera housing, the inserter housing, or the treatment optical fiber housing in the fixed orientation. (Item 27) 26. The device of claim 25, wherein the fastener is configured to allow the camera housing to slide relative to the inserter housing or the treatment optical fiber housing while fixing the orientation of the camera relative to the inserter housing or the treatment optical fiber housing, and optionally the engagement structure comprises one or more elongated engagement structures to maintain the angle when the camera housing is sliding relative to the inserter housing or the treatment optical fiber housing, and optionally the elongated engagement structures comprise one or more axially elongated grooves, one or more axially elongated flat surfaces, or one or more axially elongated protrusions. (Item 28) 26. The apparatus of claim 25, wherein the fastener is configured to fix a distance between the distal end of the probe and the array detector, and optionally the engagement structure comprises one or more of a stop, a pair of stops, a linking feature, a nesting feature, a circumferentially extending channel, a circumferentially extending protrusion, an annular protrusion, or an annular recess. (Item 29) the camera housing includes a maximum distance within a range of approximately 0.8 to 1.2 mm, the treatment optical fiber housing includes a maximum distance within a range of approximately 300 um to approximately 600 um, the fastener is sized and shaped to extend around at least a portion of the camera housing and a portion of the inserter housing or the treatment optical fiber housing, the fastener includes a first distance across the camera housing and the inserter housing or the treatment optical fiber housing, a second distance across the camera housing and the inserter housing or the treatment optical fiber housing, and a third distance along an elongated axis of the camera housing and the inserter housing or the treatment optical fiber housing, the second distance being smaller than the first distance, and the third distance being larger than the second distance and the first distance. The device described in item 25. (Item 30) Item 30. The device according to item 29, wherein the first distance is within a range of about 1.0 mm to about 2 mm, the second distance is within a range of about 0.8 to 1.5 mm, the third distance is within a range of about 2 mm to about 20 mm, the first distance is optionally within a range of about 1.3 to about 1.7 mm, the second distance is optionally within a range of about 1.0 to 1.3 mm, and the third distance is optionally within a range of about 2 mm to about 10 mm. (Item 31) 9. The device of claim 8, further comprising a housing for housing the treatment optical fiber, the housing comprising a beveled distal end. (Item 32) Item 32. The device of item 31, wherein the angled distal end of the housing extends circumferentially around at least a portion of the angled distal end of the treatment optical fiber. (Item 33) Item 32. The device of item 31, wherein the angled distal end of the housing and the angled distal end of the treatment optical fiber are angled at an angle within about 10 degrees of each other, and optionally the angled distal ends form a coplanar surface. (Item 34) Item 32. The device of item 31, wherein the detector array includes a flat-edged surface, and the treatment optical fiber extends along the flat-edged surface of the detector array. (Item 35) 10. The apparatus of claim 9, wherein the array detector includes a number of pixels along columns in the range of about 200 to about 500 pixels and a number of pixels along rows in the range of about 200 to about 500 pixels, and optionally, the number of pixels along the rows is in the range of about 200 to about 300 pixels and the number of pixels along the columns is in the range of about 200 to about 300 pixels. (Item 36) 37. The apparatus of claim 36, wherein the camera provides a spatial resolution of about 10 um to about 80 um for tissue adjacent to tissue contacting the beveled distal end of the probe, and optionally the resolution is about 20 um to about 40 um. 2. The device of claim 1, wherein the distal end of the probe extends beyond the distal-most lens of the camera by a distance in the range of about 2 mm to about 10 mm, optionally in the range of about 2.5 mm to about 5 mm. (Item 38) 10. The device of claim 1, wherein the distal end of the probe extends beyond the most distal lens of the camera by a distance in the range of about 2 mm to about 10 mm, optionally in the range of about 2.5 mm to about 5 mm, and optionally the distance is dimensioned to visualize a portion of the distal end of the probe in the image of the one or more of the ciliary body zonules or the scleral spurs or Schwalbe's lines. (Item 39) 2. The apparatus of claim 1, wherein the array detector is positioned at a distance from the distal end of the probe, the distance being within a range of about 2.5 mm to about 10.5 mm, optionally within a range of about 3 mm to about 6 mm. (Item 40) the angled end includes an angled surface for contacting the trabecular meshwork of the eye, the angled end includes a surface normal vector pointing in a direction away from the camera, one or more of the rows or columns are aligned within about 5 degrees of a transverse component of the surface normal vector, and optionally, the transverse component of the surface normal vector is aligned in a direction transverse to the treatment optical fiber. 2. The device according to claim 1, wherein the device extends in a direction parallel to the axis of the optical axis. (Item 41) The device of any one of the preceding items, wherein the treatment optical fiber includes an elongated shaft extending along a direction of light propagation along the treatment optical fiber, and the beveled distal end intersects the shaft at an angle within a range of about 45 degrees to about 65 degrees, optionally with the angle being within a range of about 50 degrees to about 60 degrees. (Item 42) 10. The apparatus of claim 9, further comprising a rotation angle between the distal end of the probe and one or more of the rows or columns of the detector array, wherein the processor is configured with instructions to determine an angle between the elongated insertion shaft or the angled end of the fiber and the one or more of the ciliary zonules or scleral spurs of the eye in response to the image and the rotation angle of one or more of the ciliary zonules or scleral spurs of the eye. (Item 43) 10. The device of claim 9, wherein the processor is configured with instructions to determine a rotational orientation angle between the elongated insertion shaft or the angled distal end of the treatment optical fiber and one or more of the rows or columns of the detector array. (Item 44) The device according to any one of the preceding items, wherein the treatment optical fiber comprises a core and a cladding, and the cladding comprises a diameter in the range of about 100 micrometers (um) to about 1000 um, optionally in the range of about 150 um to about 250 um. (Item 45) 10. The device of claim 1, wherein the treatment optical fiber comprises a plurality of treatment optical fibers, each treatment optical fiber having an angled distal end, the distal ends aligned to engage the eye tissue at similar angles within a range of about 10 degrees. (Item 46) 10. The device of claim 9, further comprising a microscope or camera system for observing an anterior portion of the eye from outside the eye, wherein the microscope has multiple eyepieces, thereby allowing a user to observe an optical image, or a camera, wherein an image of the anterior portion of the eye is formed by multiple lenses, and the microscope or camera system has a display for showing the image from the endoscope when the endoscope is positioned in the eye, thereby allowing the user to observe the anterior image of the eye through the microscope or camera system and simultaneously observe the image of the eye from the endoscope, and optionally the image from the endoscope includes one or more markers indicating the location of the one or more of the ciliary body zonules, the scleral spurs, Schwalbe's lines, or Schlemm's canal. (Item 47) 10. The device of claim 9, further comprising a microscope or camera system for observing a front portion of the eye from outside the eye, the microscope or camera system comprising a plurality of eyepieces whereby a user observes an optical image of the front portion of the eye formed by the plurality of lenses, the device further comprising a display for showing an image from the endoscope when the endoscope is placed in the eye and aligned with the image of the microscope or camera system, whereby the user observes the front image of the eye and simultaneously observes the image of the eye from the endoscope, both images being updated simultaneously with movement of elements in the images, and where, if necessary, the image from the endoscope on the display includes an image of an implant. (Item 48) a microscope or camera system for observing the anterior portion of the eye from outside the eye, the microscope or camera system comprising a plurality of eyepieces, whereby a user observes an optical image of the anterior portion of the eye formed by the plurality of lenses; The device of any one of the preceding items, further comprising a display for showing an image from the endoscope when the endoscope is placed in the eye and aligned with the image of the microscope or camera system, whereby the user observes the forward image of the eye and simultaneously observes the image of the eye from the endoscope, both images being updated simultaneously with movement of elements within the images, and where, if necessary, the image from the endoscope on the display includes an image of a treatment element. (Item 49) The device of any one of the preceding items, wherein the camera includes an optical axis, the optical axis of the camera is aligned within about 5 degrees with a tissue engagement structure on the probe, and the tissue engagement structure comprises one or more of: a distal end of the probe shaped to contact the trabecular meshwork, a beveled distal end of the probe shaped to contact the trabecular meshwork, a stylet sized and shaped to penetrate the trabecular meshwork, the stylet tip, an implant on the distal end of the probe, or a sharp end of an implant on the distal end of the probe. (Item 50) Item 13. The device of item 11 or 12, further comprising a treatment optical fiber housing that houses the treatment optical fiber and an endoscope housing that houses the endoscope with a fixed rotational orientation between the endoscope and the treatment optical fiber. (Item 51) Item 51. The device described in item 50, wherein the treatment optical fiber comprises a beveled distal end, the endoscope comprises a lens and one or more optical fibers for generating an image, and the treatment optical fiber housing is coupled to the endoscope housing so as to maintain a fixed rotational orientation between the treatment optical fiber housing and the endoscope housing. (Item 52) Item 52. The apparatus of item 51, wherein the one or more optical fibers comprise an optical fiber array comprising an ordered arrangement of bundles of fibers. (Item 53) Item 53. The apparatus of item 52, wherein the ordered arrangement of the fiber bundles remains consistent at a distal end of the fiber bundle and a proximal end of the fiber bundle. (Item 54) inserting a probe into the patient's eye; capturing one or more images of the interior of the eye; determining the location of one or more of Schlemm's canal or the trabecular meshwork, wherein the one or more images are updated simultaneously with movement of the probe. method. (Item 55) 55. The method of claim 54, further comprising delivering an implant to Schlemm's canal with the probe. (Item 56) Item 55. The method of item 54, wherein determining the location of Schlemm's canal is performed by a processor configured with instructions to determine the location of Schlemm's canal, and the image is updated simultaneously with movement of the probe. (Item 57) 57. The method of claim 56, further comprising determining, by the processor, an angular orientation of the probe in response to an image of one or more of a ciliary body zonules or scleral spurs or Schwalbe's lines of the eye. (Item 58) and displaying a boundary of the scleral spur on a display, optionally the boundary of the scleral spur being indicated by displaying a plurality of markers located along a curve. Item 55. The method according to item 54. (Item 59) 55. The method of claim 54, further comprising displaying a boundary of the Schwalbe line on a display, optionally wherein the boundary of the Schwalbe line is indicated by displaying a plurality of markers located along the line. (Item 60) 55. The method of claim 54, further comprising delivering laser energy by a laser through a treatment optical fiber carried by the probe. (Item 61) Item 55. The method of item 54, further comprising overlaying a marker on the one or more images of the interior of the eye. (Item 62) 55. The method of claim 54, further comprising contacting the trabecular meshwork of the eye with an end of the probe. (Item 63) Item 55. The method of item 54, wherein the one or more images of the interior of the eye are captured by a camera coupled to the probe. (Item 64) Item 55. The method of item 54, wherein the one or more images of the interior of the eye are captured by an endoscope coupled to the probe. (Item 65) 1. A device for treating an eye, comprising: a probe sized for insertion into the eye, the probe comprising a camera with a lens and an array detector, the array detector comprising a plurality of rows and columns; an implant located near the distal end of the probe, the implant having a distal portion sized and shaped for insertion into Schlemm's canal; a processor coupled to the array detector, the processor configured with instructions to determine a location of Schlemm's canal in response to an image of one or more of a ciliary body zonules or scleral spurs or Schwalbe's lines of the eye. (Item 66) 1. A device for treating an eye, comprising: a probe sized for insertion into the eye, the probe comprising a camera with a lens and an array detector, the array detector comprising a plurality of rows and columns; an implant located near the distal end of the probe, the implant comprising a distal portion sized and shaped for insertion into Schlemm's canal of the eye, the distal portion extending along an elongated insertion axis, the distal end coupled to the camera in a fixed rotational orientation relative to the angled distal end of the fiber; a processor coupled to the array detector, the processor configured with instructions to determine an angular orientation of the elongated insertion shaft in response to an image of one or more of a ciliary body zonules or scleral spurs or Schwalbe lines of the eye. (Item 67) 1. A device for treating an eye, comprising: a probe sized for insertion into the eye, the probe comprising a treatment optical fiber and a camera, the camera comprising a lens and an array detector, the array detector comprising a plurality of rows and columns; a processor coupled to the array detector, the processor configured with instructions to determine a location of Schlemm's canal in response to an image of one or more of a ciliary body zonules or scleral spurs or Schwalbe's lines of the eye. (Item 68) 1. A device for treating an eye, comprising: A laser, a probe comprising a camera and a treatment optical fiber, the camera comprising a lens and an array detector, the array detector comprising a plurality of rows and columns, the treatment optical fiber coupled to the laser, the treatment optical fiber having angled distal and proximal ends, the distal end coupled to the camera in a fixed rotational orientation relative to the angled distal end of the fiber; a processor coupled to the array detector, the processor configured with instructions to determine an angular orientation of the angled distal end of the fiber in response to an image of one or more of a ciliary body zonules or scleral spurs or Schwalbe lines of the eye. (Item 69) 1. A device for treating an eye, comprising: a probe sized for insertion into the eye, the probe comprising an endoscope, the endoscope comprising a lens and a fiber optic array coupled to the lens to transmit images to an array detector, the array detector including a plurality of rows and columns; an implant located near the distal end of the probe, the implant having a distal portion sized and shaped for insertion into Schlemm's canal; a processor coupled to the array detector, the processor configured with instructions to determine a location of Schlemm's canal in response to an image of one or more of a ciliary body zonules or scleral spurs or Schwalbe's lines of the eye. (Item 70) 1. A device for treating an eye, comprising: A laser, a probe comprising an endoscope and a treatment optical fiber, the endoscope comprising a lens and an array of optical fibers coupled to the lens to transmit images to an array detector, the array detector including a plurality of rows and columns, the treatment optical fiber coupled to the laser, the treatment optical fiber having angled distal and proximal ends, the distal end coupled to the array of optical fibers in a fixed rotational orientation relative to the angled distal ends of the fibers; a processor coupled to the array detector, the processor configured with instructions to determine an angular orientation of the angled distal end of the fiber in response to an image of one or more of a ciliary body zonules or scleral spurs or Schwalbe lines of the eye. (Item 71) 1. A device for treating an eye, comprising: a probe sized for insertion into the eye, the probe including a treatment optical fiber and an endoscope, the endoscope including a lens and an optical fiber array for transmitting images to an array detector, the array detector including a plurality of rows and columns; a processor coupled to the array detector, the processor configured with instructions to determine a location of Schlemm's canal in response to an image of one or more of a ciliary body zonules or scleral spurs or Schwalbe's lines of the eye. (Item 72) 1. A device for treating an eye, comprising: a probe sized for insertion into the eye, the probe comprising an endoscope, the endoscope comprising a lens, one or more optical fibers for generating images, and one or more detectors for generating an image of the interior of the eye; a processor coupled to the detector and configured with instructions to determine a location of Schlemm's canal in response to images of one or more of the ciliary body zonules, scleral spurs, or Schwalbe's lines of the eye, the images being updated concurrently with movement of the probe, and to provide information regarding the relative positions of the probe and one or more of Schlemm's canal or trabecular meshwork. and a processor. (Item 73) 10. The apparatus of claim 1, wherein the imaging system is configured to display images of the anatomical structures within the eye and a probe positioned within the eye, and is further configured to provide updated images concurrently with movement of the probe.

Claims

[Claim 1] The invention described herein.

Images