Intraoperative visualization, measurement, and support for ophthalmic treatment

Abstract

A system for performing ophthalmic treatment includes a surgical microscope configured to capture surface images of the patient's eye, and an imaging device attached to the surgical microscope and configured to capture cross-sectional images of the patient's eye. A controller is coupled to the surgical microscope and the imaging device and is configured to receive surface and cross-sectional images and to provide feedback to facilitate the performance of ophthalmic treatment based on the cross-sectional and surface images. The feedback may relate to avoiding posterior capsule rupture during phacoemulsification, safely performing detachment of membranes formed on the retina, implanting IOLs, treating glaucoma, or performing other ophthalmic treatments.

Description

Technical Field

[0003] , , ,

[0005] , , , , ,

[0006] ,

[0004] , , , ,

[0001] Cross - reference to related applications This application claims the priority and benefit of U.S. Provisional Patent Application No. 63 / 578360, filed on August 23, 2023, which is incorporated herein by reference in its entirety.

[0002] This disclosure generally relates to the performance of ophthalmic surgery.

Background Art

[0003] The light received by the eye is focused by the cornea and lens of the eye onto the retina located behind the eye, which contains photoreceptor cells. The region between the cornea and the lens is known as the anterior segment of the eye. The portion between the lens and the retina inside the eye is known as the posterior segment of the eye and is filled with a transparent gel known as the vitreous humor. Many eye conditions can be treated by performing ophthalmic treatment inside or in the posterior segment of the eye.

[0004] Facilitating the performance of ophthalmic treatment would be an advancement in the art.

Summary of the Invention

Means for Solving the Problems

[0005] In certain embodiments, a system for performing ophthalmic treatment includes an operating microscope configured to capture a surface image of a patient's eye and an imaging device attached to the operating microscope and configured to capture a cross - sectional image of the patient's eye. A controller is coupled to the operating microscope and the imaging device, and the controller is configured to receive the surface image and the cross - sectional image and provide feedback that facilitates the performance of ophthalmic treatment based on the cross - sectional image and the surface image.

[0006] To allow for a more detailed understanding of the above-mentioned features of this disclosure, a more specific description of this disclosure, which has been briefly summarized above, can be provided by reference to embodiments, some of which are shown in the accompanying drawings. However, it should be noted that the accompanying drawings show only exemplary embodiments and are therefore not intended to limit the scope of the invention, as other equally effective embodiments are also possible. [Brief explanation of the drawing]

[0007] [Figure 1A] This shows a surgical microscope used by surgeons performing ophthalmic treatment. [Figure 1B] This shows a surgical microscope equipped with an auxiliary imaging device according to one embodiment of the present invention. [Figure 1C] This shows an auxiliary imaging device used in combination with a gonioscope according to a specific embodiment. [Figure 1D] This document describes an adjustable auxiliary imaging device for a surgical microscope, according to a specific embodiment. [Figure 2] This shows an eye undergoing treatment for glaucoma according to a specific embodiment. [Figure 3] This is a process flow diagram of a method for providing intraoperative support during glaucoma treatment according to a specific embodiment. [Figure 4A] Examples of visual aids displayed during glaucoma treatment according to a specific embodiment are shown. [Figure 4B] Examples of visual aids displayed during glaucoma treatment according to a specific embodiment are shown. [Figure 5] This image shows a retina undergoing treatment for internal limiting membrane detachment using displayed visual aids, according to a specific embodiment. [Figure 6A] This is a process flow diagram of a method for providing visual assistance during internal limiting membrane debridement therapy according to a specific embodiment. [Figure 6B] This is a process flow diagram of a method for providing visual assistance during internal limiting membrane debridement therapy according to a specific embodiment. [Figure 6C]This is a process flow diagram of a method for providing visual assistance during internal limiting membrane debridement therapy according to a specific embodiment. [Figure 7A] This describes cataract treatment including phacoemulsification and intraocular lens implantation. [Figure 7B] This describes cataract treatment including phacoemulsification and intraocular lens implantation. [Figure 8A] This is a process flow diagram of a method for providing support during cataract treatment according to a specific embodiment. [Figure 8B] This is a process flow diagram of a method for providing support during cataract treatment according to a specific embodiment. [Figure 8C] This is a process flow diagram of a method for providing support during cataract treatment according to a specific embodiment. [Figure 8D] This is a process flow diagram of a method for providing support during cataract treatment according to a specific embodiment. [Figure 8E] This is a process flow diagram of a method for providing support during cataract treatment according to a specific embodiment. [Figure 8F] This is a process flow diagram of a method for providing support during cataract treatment according to a specific embodiment. [Modes for carrying out the invention]

[0008] Referring to Figure 1A, the surgical environment 100 may be used for a surgeon 106 to perform ophthalmic treatment on the eye 102 of a patient 104. The surgical environment 100 may include a surgical microscope 108 suspended from a support 110 that facilitates the surgeon 106 positioning the surgical microscope 108 over the eye 102 at a desired height. For example, the surgical microscope 108 may be implemented as the NGENUITY 3D Visual System provided by Alcon of Fort Worth, Texas.

[0009] Referring to Figure 1B, the imaging device 112 is mounted on the surgical microscope 108 and provides imaging according to one or both of the following: (a) an imaging modality different from that of the surgical microscope 108, or (b) a different viewpoint or zoom level than that of the surgical microscope 108, such as a visible light camera with a wider field of view than that of the surgical microscope 108. To facilitate the performance of ophthalmic treatment, one or more additional auxiliary devices 114 may also be mounted on the surgical microscope 108. The auxiliary devices 114 may be other imaging devices that follow the same or different imaging modality as the imaging device 112. The auxiliary devices 114 may also be sensors other than imaging devices, such as intraocular pressure (IOP) sensors (e.g., contact or non-contact tonometer (NCT) IOP sensors) or other types of sensors. The auxiliary devices 114 may also be light sources for illuminating the eye 102. Examples of imaging modalities used to implement the surgical microscope 108, imaging device 112, and auxiliary device 114 include visible light cameras, infrared cameras, fundus autofluorescence (FAF) cameras, multispectral imaging (MSI), hyperspectral imaging (HSI) cameras, wide-angle field (WAV) cameras, optical coherence tomography (OCT) imaging devices, or scanning laser ophthalmoscopes (SLO). The auxiliary device 114 may be embodied as a laser or ultrasonic rangefinder or imaging device.

[0010] In the illustrated embodiment, the mounting ring 116 is fixed to the surgical microscope 108, for example, around the objective lens of the surgical microscope and / or the optical axis of the surgical microscope 108. The imaging device 112 and the auxiliary device 114 are fixed to the mounting ring 116 on both sides of the ring 116, for example, 180 degrees apart from each other around the center of the ring 116, or at any other position. The mounting ring may provide mounting points for detachably attaching either the imaging device 112 or the auxiliary device 114, which may include exchanging one imaging device and / or auxiliary device 114 for a different imaging device 112 and / or auxiliary device 114 during surgery.

[0011] Images received from the surgical microscope 108, the imaging device, and optionally the auxiliary device 114, or obtained from the received images, may be displayed on either (a) a display device (e.g., a stereoscopic display device) within the surgical microscope 108, or (b) an external display device 118 such as a monitor, projector, or other display device.

[0012] Referring to FIG. 1C, in some embodiments, the surgical microscope 108 may be used in combination with a gonioscope 120, such as in performing ophthalmic treatment of glaucoma. The gonioscope 120 may be implemented as a gonion prism or a gonion mirror. The portion of the image transmitted through the gonioscope 120 may be an inverted image. Thus, the portion of the image captured by the surgical microscope 108 that is received through the gonioscope 120 may be inverted to correspond to the actual orientation of the eye 102 using, for example, the techniques described in U.S. Patent No. 10,201,270, which is incorporated herein by reference in its entirety.

[0013] Referring to FIG. 1D, in some embodiments, one or both of the imaging device  112 and the auxiliary device 114 may be attached to the surgical microscope by an adjustable support 122. The adjustable support 122 may facilitate adjustment of the position of one or both of the imaging device 112 and the auxiliary device 114 to be substantially parallel (e.g., within 2 degrees) to the optical axis of the surgical microscope 108. The adjustable support 122 may also be adjustable in one or more other dimensions perpendicular to the optical axis of the surgical microscope 108. The control for adjusting the position of the imaging device 112 and / or the auxiliary device 114 may be manual or actuatable. When actuatable, the interface for adjusting the adjustable support 122 may include a physical button attached to the surgical microscope 108, voice commands, gesture control, a touch screen, or other interfaces.

[0014] Figures 2 and 3 illustrate the use of a surgical environment 100 for glaucoma treatment. Referring particularly to Figure 2, glaucoma treatment is often performed in the anterior segment 200 of the eye 102, which is behind the transparent, spherical cornea 202 through which light enters the eye 102. The iris 204 is an annular muscle that defines the pupil of the eye through which light passes. The lens 206 is behind the pupil and, together with the cornea 202, focuses light onto the photoreceptor cells of the retina 208. The retina 208 is formed on the opposite side of the anterior segment 200 inside the eyeball 210. The space between the lens 206 and the retina 208 within the eyeball 210 is filled with a transparent gel known as the vitreous humor 212.

[0015] The ciliary body 214 includes ligaments and muscles that connect the iris 204 and the lens 206 to the choroid 216 of the eye. The muscles of the ciliary body 214 serve to change the shape of the lens 206. The choroid 216 is a vascular layer on the back side of the eyeball 210.

[0016] The ciliary body 214 produces aqueous humor, a fluid that occupies the anterior segment 200. The aqueous humor lubricates the surfaces of the lens 206 and the iris 204 and flows around the anterior segment 200. The outer perimeter of the anterior segment includes structures that allow aqueous humor to be drained when functioning properly. These structures include the trabecular meshwork 218 and the Schlemm's canal 220. The trabecular meshwork 218 appears to function as a filter that restricts the over - outflow of aqueous humor and provides a back - pressure that is directly related to IOP. The Schlemm's canal 220 is located beyond the trabecular meshwork 218. The Schlemm's canal 220 is fluidly coupled to collector channels (not shown) to allow aqueous humor to flow out of the anterior segment 200.

[0017] Glaucoma can be treated, for example, by inserting the rod 222 shown in the figure into the anterior segment 200 through an incision in the limbus 224, which is the boundary between the cornea 202 and the sclera (white) of the eye. The rod 222 is then used to position the excision and, optionally, a stent, within one or more structures surrounding the anterior segment 200 to facilitate drainage of aqueous humor. For example, the incision or stent may be positioned in the trabecular meshwork 218 to facilitate drainage into Schlemm's canal 220. In another technique, the stent extends from the anterior segment into the suprachoroidal space between the choroid 216 and the eyeball 210.

[0018] Referring particularly to Figure 3, the method 300 shown in the figure may be performed using a surgical environment 100 to facilitate the administration of glaucoma treatment. The method 300 may be performed by a computing device that receives images from a surgical microscope 108 and an imaging device 112, as well as an auxiliary device 114, if used, and if there is output from the auxiliary device 114, it receives that output.

[0019] Method 300 includes taking one or more surface images of the eye 102 in step 302, and taking one or more cross-sectional images of the eye 102 in step 304. As used herein, “surface image” means an image capturing light reflected from the surface of the eye 102 and / or transmitted and reflected through one or more transparent structures of the eye, including the cornea 202 and the lens 206. The surface image may be a visible light image, a multispectral or hyperspectral image, an infrared image, or other type of image. The surface image may be one of two or more images that provide a stereoscopic view of the eye 102. As used herein, “cross-sectional image” means an image containing a cross-section of the tissue of the eye 102, including tissue at depths not visible in the surface image. In a cross-sectional image, the depth within the tissue of the eye, represented by pixels in the image, is known, whereas a surface image may flatten light reflected from various depths within the tissue of the eye 102 into a single image. The cross-sectional image may consist of a plurality of cross-sectional images forming a three-dimensional image. The cross-sectional image can be a three-dimensional image that can be viewed along various cross-sectional planes. In some embodiments, the cross-sectional image is an OCT image. The cross-sectional image taken in step 304 may constitute a three-dimensional image of at least a portion of the eye 102, such as the anterior segment 200. The surface image and the cross-sectional image may be aligned with respect to each other, that is, pixels representing anatomical structures in the surface image may be mapped to pixels (or voxels) in the three-dimensional image that correspond to the same anatomical structures.

[0020] If a gonioscope 120 is used, method 300 may include inverting the image received through the gonioscope 120 and then reversing the inversion caused by the gonioscope 120, such as the image received from the surgical microscope 108, in step 306. If a gonioscope 120 is not used, step 306 may be omitted.

[0021] Method 300 includes identifying anatomical structures in a three-dimensional image and one or more surface images in step 308. Identifying anatomical structures may include processing one or both of the three-dimensional image and one or more surface images using a machine learning model. For example, for each item of an eye anatomical structure to be identified, a training data entry may be created that includes a three-dimensional image and one or more surface images, and labels indicating the part of the anatomical structure corresponding to that item in the three-dimensional image and one or more surface images. Then, in step 308, a machine learning model may be trained using the training data entry to identify its anatomical items. There may be multiple machine learning models, each trained to identify one or more different items of anatomical structures.

[0022] Method 300 may include in step 310 identifying one or more sites for incisions or stents depending on the anatomical structure. For example, this site may be selected to position an incision or stent that passes into Schlemm's canal 220. Thus, the site selected in step 310 can be positioned in the trabecular meshwork 218 that covers Schlemm's canal 220. The drainage channel guides fluid out of Schlemm's canal. Thus, the insertion site may also be selected to be adjacent, for example, within 0.5 mm of the drainage channel. Identifying one or more sites may include identifying sites having a number and distribution specified in the treatment plan, for example, sites having the minimum spacing between them. Sites may be identified in the trabecular meshwork 218, the filtration bleb, or other locations on the eye 102. Step 310 may further include identifying a vector for each insertion site. The vector may specify the direction in which an incision should be made or a stent should be inserted at a site, for example, to extend into Schlemm's canal or to have a desired relationship with other anatomical structures of the eye 102.

[0023] The method may include, in step 312, superimposing one or more representations of one or more parts onto an image, such as a surface image from step 302, a cross-sectional plane from step 304, a rendering of a three-dimensional image, or any other image. Step 312 may further include superimposing a representation of each vector identified in step 310 onto the image. The image with the superimposed representations of parts and / or vectors may then be displayed in step 314 on a display device 118, a display of a surgical microscope 108 (e.g., a stereoscopic display), or elsewhere.

[0024] For example, referring to Figure 4A, the illustrated image may be marked with a site marker 400 representing the site identified in step 310 and a vector marker 402 representing the vector identified in step 310. Other items of anatomical structure may be marked, such as a marker 404a marking the stained trabecular meshwork, which is often the site of incision or selected for stent placement. One or more markers 404b may mark the location of drainage pipes.

[0025] Referring again to Figure 3, method 300 may further include detecting the formation of an incision or the placement of a stent in step 316. Step 316 may include detecting the movement of the rod 222, detecting changes in the trabecular meshwork in three-dimensional and / or surface images taken after the formation of the incision or the placement of a stent, detecting a marker or otherwise detecting the stent in the three-dimensional image, or any other method.

[0026] Method 300 may include detecting fluid flow through the incision or stent in step 318. Step 318 may additionally or alternatively include detecting IOP in the eye 102. Detecting fluid flow may be done using an auxiliary imaging device 112. For example, the velocity of fluid flow through the incision and / or stent may be obtained by detecting the red / blue shift of reflected light using any technique known in the art. The velocity of fluid flow may be measured in a specific area, such as the area of ​​the incision or stent. A dye may be injected into the anterior segment of the eye to facilitate visualization of the fluid flow. Fluid flow may be inferred by detecting a change or rate of change in IOP sensed after the formation of the incision, such as when the auxiliary device 114 is an IOP sensor.

[0027] Method 300 may include, in step 320, detecting the degree of dilation of Schlemm's canal 220. For example, Schlemm's canal 220 may be identified in a first three-dimensional image taken before the formation of the incision and / or the placement of the stent. Schlemm's canal 220 may then be identified in one or more second three-dimensional images taken after the formation of the incision and / or the placement of the stent. The size of the representation of Schlemm's canal 220 in the first three-dimensional image and one or more second three-dimensional images, for example, the number of voxels identified as part of the representation of Schlemm's canal, can then be calculated. Thus, the degree of dilation can be calculated as the ratio of the number of voxels representing Schlemm's canal 220 in the first three-dimensional image to the number of voxels representing Schlemm's canal 220 in one of the second three-dimensional images.

[0028] Method 300 may include, in step 322, superimposing drainage targets onto an image of the eye 102, such as a surface image of the eye 102 taken before or after the formation of the incision or the placement of the stent. For example, as shown in Figure 4B, drainage targets may include symbols such as the arrow 406 in the figure. The attributes of the symbols may indicate the degree of drainage, such as size (e.g., larger indicates greater drainage) or color (green = sufficient improvement in drainage, yellow = insufficient improvement in drainage, red = no significant improvement in drainage). The attributes of the drainage targets may be a function of some or all of the amount of fluid flow detected in step 318 and the degree of expansion of the Schlemm tube 220 detected in step 320. Step 322 may also include superimposing a representation 408 of the incision and / or stent onto the image at a position corresponding to that detected in step 316, with or without site markers indicating the desired position for positioning the incision and / or stent.

[0029] Referring to Figure 5, the surgical environment 100 may be used to facilitate the detachment of a membrane, such as the internal limiting membrane (ILM) or epiretinal membrane (ERM), from the retina 208. The membrane may be detached using an instrument 500 having forceps 502 that are inserted into the eye and extended from the instrument 500 and actuated to grasp the membrane. The detachment treatment may include detaching the membrane within the boundary 504, such as over the macula of the eye 102. The detachment treatment may include detaching all of the membrane within the boundary 504 in one step, or it may be performed in sections. For example, a detachment area 506 may be detached in a first grasping and detachment step, and the remainder may be detached in one or more other grasping and detachment steps.

[0030] Figures 6A, 6B, and 6C show methods that may be performed using the surgical environment 100 to facilitate dissection. When performing dissection, the auxiliary device 114 may be implemented as a light source. The light source may be controllable with respect to several parameters, such as color and intensity. The light source may be a multispectral or hyperspectral light source, thereby the multiple parameters include the intensity of light within each of three, four, five, or more wavelength bands.

[0031] Referring particularly to Figure 6A, method 600a may include taking one or more surface images of the retina 208 in step 602 and taking one or more cross-sectional images of the retina 208 in step 604. One or more surface images may be taken by illuminating the retina 208 with only the light source of the surgical microscope 108, or by having an auxiliary device 114 provide light according to initial values ​​of several parameters.

[0032] Method 600a may include, in step 606, evaluating the characteristics of the membrane representation in one or both of one or more surface images and one or more cross-sectional images. The characteristics of the membrane representation may include image quality metrics corresponding to whether the operator can clearly see the membrane during dissection surgery. Image quality metrics may include values ​​such as sharpness, contrast, saturation, or other image quality metrics. The characteristics of the membrane representation may be the output of a machine learning model. For example, each of multiple training data entries may include one or more images taken during past dissection procedures as input, and one or more human-assigned metrics of the quality of the membrane representation in one or more images. The machine learning model may then be trained with the multiple training data entries to output one or more metrics of the image quality of the membrane representation in a given input image. Alternatively, a machine vision algorithm may be configured to output one or more metrics of image quality.

[0033] Method 600a may include in step 608 selecting values ​​for a plurality of parameters based on the evaluation in step 606. The values ​​for the plurality of parameters may be selected based on one or more image quality metrics acquired in step 606. The selection of values ​​for the plurality of parameters may include applying a predefined algorithm that converts one or more metrics to corresponding values ​​for the plurality of parameters, the predefined algorithm configured to select values ​​for the plurality of parameters that improve one or more metrics, i.e., that subsequent surface images better visualize the retina 208 and the membrane to be removed. Alternatively or additionally, step 608 may include a search algorithm that illuminates the retina 208 with light generated according to a set of values ​​for the plurality of parameters, takes a surface image of the retina 208, and calculates one or more quality metrics for the surface image. In this way, multiple sets of values ​​in the search space may be tested, and then a set of values ​​that achieves the best one or more image quality metrics may be selected.

[0034] Figure 6B shows method 600b for identifying a membrane-covered area of ​​the retina 208. Method 600b is particularly suitable for identifying pathological membranes, such as ELMs, which may have irregular shapes and locations. The area of ​​ILM to be removed from the retina 208 can be easily identified based on the anatomical structure of the retina, i.e., a circle of known radius centered on the fovea of ​​the retina 208, which can be identified by higher pigment deposition and the absence of neovascularization. However, in some embodiments, method 600b may also be used to identify ILMs.

[0035] Method 600b may include taking one or more surface images and one or more cross-sectional images in steps 610 and 612, as described above. Method 600b may include evaluating the reflectance of different areas of the retina in one or more surface images and optionally one or more cross-sectional images in step 614. Step 614 may include evaluating the variation in reflectance within individual wavelength bands.

[0036] Method 600b may include, in step 616, identifying a representation of the film in one or more surface images and optionally one or more cross-sectional images. Step 616 may include identifying the film based on the change in reflectivity evaluated in step 614, for example, the change in reflectivity indicating the boundaries of the film.

[0037] Method 600b may include, in step 618, superimposing a membrane index onto an image, such as one or more surface images. For example, as shown in Figure 5, the membrane boundary 504 may be indicated as a line, a shaded area, or other visual index. Method 600b may be repeated during the dissection procedure so that dissected areas 506 without membrane are also represented in the image, for example, by the absence of a membrane index or being outside a line indicating the current boundary 504 of the membrane. In some embodiments, numerical values, text, or other indexes indicate the amount of membrane that has already been dissected and / or remains dissected. The image with the membrane index superimposed thereon may be displayed to the operator on a display device 118, on the internal display of a surgical microscope 108, or on any other display device.

[0038] Referring to Figure 6C, the surgical environment 100 may be used to perform Method 600c shown in the figure to provide feedback during the dissection procedure. Method 600c may include taking one or more surface images in step 620, taking one or more cross-sectional images in step 622, and identifying anatomical structures in step 624. Steps 620, 622, and 624 may be performed with respect to any of the aforementioned methods.

[0039] Method 600c may further include in step 626 identifying the position and, optionally, the orientation of surgical instruments such as instrument 500 and forceps 502 in one or both of one or more surface images and one or more cross-sectional images. For example, the position and orientation of the surgical instruments may be identified in three dimensions from a three-dimensional image formed by one or more cross-sectional images.

[0040] Method 600c may further include evaluating the reflectivity of the film in step 628. In particular, variations in the reflectivity of the film may be evaluated in a surface image and within the portion of the surface image corresponding to the film. For example, variations in reflectivity in the region around the position of the forceps 502. When the film deforms, variations in reflectivity occur. Therefore, in step 630, the variations in reflectivity can be used to characterize the deformation of the film. Step 630 may include applying a predefined function, algorithm, or machine learning model to translate the variations in reflectivity into deformation characterization. The deformation may be translated into the force applied by the forceps 502, or the reflectivity may be directly translated into an estimate of the force applied by the forceps 502.

[0041] Method 600c may include, in step 632, providing the surgeon with feedback regarding the force applied to the retina 208 by the surgeon. For example, the feedback may be a color-coded indicator output to the display device 118, an internal display of the surgical microscope, an auditory signal, tactile feedback, or other feedback. For example, visual feedback may be a red symbol or overlay if the force is excessive, a green symbol or overlay if the force is within a range suitable for grasping the membrane, and a yellow symbol or overlay if the force is too weak for grasping the membrane.

[0042] Other forms of feedback may also be provided. For example, the orientation of a surgical instrument with respect to the retina 208 may be compared to an acceptable range of relative orientations for grasping the membrane, and feedback may be provided accordingly. The feedback may be visual, auditory, or text message indicating the necessary change in orientation. The feedback may be in the form of an overlay superimposed on a surface image, or a rendering based on a three-dimensional image showing the correct orientation of the surgical instrument.

[0043] In some embodiments, the feedback is distance feedback. For example, it may be undesirable for the forceps 502 to come into contact with an anatomical structure that should not be detached, such as an area of ​​the retina 208 not covered by the membrane to be detached, or with other anatomical structures of the eye 102. Therefore, feedback may be provided if the position of the forceps 502 is within a threshold distance of an anatomical structure that should not be detached. The feedback may be visual, auditory, or text message indicating that the operator is instructed to stop moving the forceps 502 along its current trajectory. The distance feedback may be a displayed numerical value or other indicator, for example, a distance in micrometers or other units indicating the distance of the forceps from the retina 208, which may include the distance to the area of ​​the retina 208 to be detached to assist the operator in bringing the forceps into contact with the membrane.

[0044] Referring to Figures 7A and 7B, during cataract surgery, the lens 206 is removed by phacoemulsification. The lens 206 is located within the lens capsule 700, which is connected to the ciliary body 214 by fibers known as the ciliary zonules 702. Subsequently, an intraocular lens (IOL) 704 is placed within the lens capsule 700, replacing the lens 206. The success of cataract surgery depends on the condition of the lens capsule 700 and the ciliary zonules 702. If the lens capsule 700 ruptures or the ciliary zonules 702 rupture, a different type of IOL and a different placement will be required. The success of cataract surgery also depends on the correct selection and placement of the IOL 704 in relation to the retina 208 and cornea 202 to reduce postoperative refractive errors of the eye 102.

[0045] Cataract surgery is typically performed by inserting an instrument 706 through an incision located at the limbus 224 of the cornea. Using the instrument 706, an opening 708 is created within the lens capsule 700 (anterior capsulotomy), from which the lens 206 is removed and the IOL 704 is inserted.

[0046] Figures 8A–8F illustrate methods that may be performed using the surgical environment 100 to facilitate cataract surgery. Figure 8A shows a method 800a that may be performed preoperatively. Method 800a may include some or all of taking one or more surface images of the eye 102 in step 802 and taking one or more cross-sectional images of the eye 102, in particular the lens 206, ciliary body 214, lens capsule 700, and ciliary zonule 702 in step 804. Since method 800a is performed preoperatively, the one or more surface images and one or more cross-sectional images may be acquired using imaging devices that are not attached to or otherwise associated with the surgical microscope 108.

[0047] Method 800a may include, in step 806, identifying anatomical structures represented in one or more cross-sectional images and one or more surface images. In particular, the representations of the lens 206, ciliary body 214, lens capsule 700, and ciliary zonules 702 may be identified according to any of the methods described herein. Subsequently, in step 808, the lens capsule 700 and ciliary zonules 702 may be characterized. Characterization of the lens capsule 700 may include the average thickness of the lens capsule 700, the minimum thickness of the lens capsule 700, the location of regions of the lens capsule 700 below a thickness threshold, or other characterizations. Characterization of the ciliary zonules 702 may include the number or average density of ciliary zonules (e.g., per unit area of ​​the surface of the lens capsule), the average diameter of the ciliary zonules 702 (average diameter at the thinnest point of all ciliary zonules 702), the minimum diameter of the ciliary zonules 702, or other characterizations.

[0048] Referring to Figure 8B, method 800b may be performed in the surgical environment 100 using preoperative characterization of the lens capsule 700 and ciliary zonule 702 in accordance with method 800a. Method 800b includes some or all of taking one or more surface images of the eye 102 in step 810, taking one or more cross-sectional images of the eye 102 in step 812, and identifying the anatomical structures of the eye in step 814. Steps 810, 812, and 814 may be performed in accordance with any of the methods described above.

[0049] Method 800b includes, in step 816, characterizing one or both of the lens capsule 700 and the ciliary zonule 702 according to one or more surface images and one or more cross-sectional images. Step 816 may be performed in the same manner as in step 808 described above. Method 800b may include, in step 818, comparing the characterization of the lens capsule 700 and the ciliary zonule 702 with the preoperative characterization of the lens capsule 700 and the ciliary zonule 702 according to Method 800a.

[0050] If, in step 820, one or more differences between the characterization in step 818 and the preoperative characterization are found to exceed a corresponding threshold, the method may include outputting feedback to the operator in step 822. The feedback may be visual or textual information conveying the differences between the preoperative characterization and the characterization in step 818. For example, the feedback may be a marking superimposed on a rendering from a surface image or a 3D image, where the marking indicates a portion of the lens capsule 700 that is thinner or looser than indicated in the preoperative data, or a region of the ciliary zonule 702 that is thinner, looser, or missing with respect to the preoperative characterization. Thus, the operator can determine whether the proposed cataract treatment is still viable or whether modifications should be made, for example, whether the IOP should be reduced to reduce pressure on the lens capsule 700.

[0051] Figure 8C shows a method 800c that provides feedback to the surgeon to help avoid rupture of the lens capsule 700 during cataract surgery. Method 800c may include some or all of the following: taking one or more surface images in step 810; taking one or more cross-sectional images in step 812; and identifying anatomical structures as described above in step 814.

[0052] Method 800c may include defining an instrument envelope in step 824. The instrument envelope may include a circular path for performing an anterior capsulotomy, i.e., for cutting an opening in the lens capsule 700 from which the lens 206 can be removed. The circular path may be defined with respect to the detected inner surface of the iris 204, which is, for example, a path offset inward by a predetermined margin from the iris 204. The instrument envelope may be defined with respect to the inside of the lens capsule 700 for ultrasonic phacoemulsification. For example, the instrument envelope may include a volume within the lens capsule 700, which is, for example, a volume offset by a certain margin from the inner surface of the lens capsule, such as 0.01 to 0.1 mm.

[0053] Method 800c may include, in step 826, identifying a representation of an instrument, such as a phaco-vitrectomy tool, in a three-dimensional image composed of one or more cross-sectional images. If, in step 828, it is determined that the instrument, for example, its distal end, is within the threshold distance of the instrument envelope, Method 800c may include, in step 830, outputting feedback to the operator. The feedback may simply indicate a potential collision with the instrument envelope. The feedback may also indicate a direction to move the instrument to avoid a collision with the instrument envelope. The feedback may include a visual alert output on the display device 118 or on a display device inside the surgical microscope 108. The alert may be an auditory alert output through a speaker. The alert may be tactile feedback output on or through a tactile device attached to the handpiece to which the instrument is mounted. Method 800c may be repeated throughout the entire phacoemulsification procedure, as shown in Figure 8C.

[0054] Figure 8D shows a method 800d that can be performed using the surgical environment 100 to facilitate early detection of lens capsule rupture. When the lens 206 is removed, the lens capsule 700 holds the vitreous humor 212 within the posterior segment. If the lens capsule 700 ruptures, the vitreous humor 212 may begin to leak out of the posterior segment. However, because the vitreous humor 212 and lens capsule 700 are transparent, it can be difficult for the surgeon to detect posterior capsule rupture. Using the surgical environment 100, it is possible to detect the different refractive indices of the vitreous humor 212, lens capsule 700, and the perfusion fluid used to fill the posterior segment during ultrasonic phacoemulsification.

[0055] Method 800d may include some or all of the following: taking one or more surface images in step 810; taking one or more cross-sectional images in step 812; and identifying anatomical structures as described above in step 814.

[0056] Method 800d may include identifying a vitreous boundary in step 832. Step 832 may include detecting a blob of pixels (or voxels) within the posterior segment and detecting the boundary of this blob. For example, assuming that the center of the posterior segment (or any point closer to the retina 208) is reliably occupied by the vitreous humor, step 832 may include examining outward from such a point to detect a boundary where the refractive index changes or any other anatomical boundary reaching the retina and / or choroid, etc.

[0057] Method 800d may include, in step 834, evaluating whether a posterior capsule rupture has occurred. For example, if the vitreous representation identified in step 832 is found to extend into the lens capsule, or beyond the iris, or to another part of the anterior segment 200, it may be determined that the lens capsule has ruptured. If so, feedback may be output in step 836. The feedback may be in the form of a visual message, such as text or other symbols, output to the display device 118 or a display device inside the surgical microscope 108. The feedback may also be in the form of an auditory message output by a speaker, tactile feedback via a handpiece, or other types of feedback.

[0058] Figure 8E shows a method 800e that may be performed using the surgical environment 100 to facilitate the placement of the IOL 704. Once the lens 206 is removed, the IOL 704 can be placed within the lens capsule 700. Correct placement of the IOL may be facilitated using the surgical environment 100 to avoid rupture of the lens capsule 700 and reduce postoperative refractive errors.

[0059] Method 800e may include some or all of the following: taking one or more surface images in step 810; taking one or more cross-sectional images in step 812; and identifying anatomical structures as described above in step 814.

[0060] Method 800d may include, in step 838, identifying a desired IOL location with respect to the anatomical structure identified in step 814. For example, a treatment plan for cataract surgery may specify a desired location (e.g., along the optical axis of the eye 102) and optionally an orientation (e.g., an angular position around the optical axis of the eye 102) of the IOL 704. The desired location may be defined with respect to an anatomical structure such as the lens capsule 700, the iris 204, the ciliary body 214, or other items of anatomical structure. Thus, identifying a desired IOL location may include identifying the location of the IOL with respect to the anatomical structure identified in step 814, corresponding to the relative location of the IOL with respect to the anatomical structure in the treatment plan.

[0061] Method 800d may include, in step 840, determining the actual location of the IOL. Step 840 may include identifying the voxel corresponding to the IOL in a three-dimensional image composed of one or more cross-sectional images. Method 800d may include, in step 842, determining whether the difference between the actual IOL location and the desired IOL location exceeds a threshold amount, for example, a first threshold distance along the optical axis, a first threshold angle around the optical axis, and / or a second threshold angle in a plane parallel to the optical axis, i.e., determining the inclination.

[0062] If it is found that the difference between the actual IOL position and the desired IOL position exceeds one or more thresholds, method 800e may include, in step 844, outputting feedback to the operator. The feedback may be in the form of text or auditory output conveying the translation or rotation of the IOL necessary to achieve the desired IOL position. The feedback may also be in the form of an overlay superimposed on a surface image or a rendering of a three-dimensional image, the overlay indicating the desired IOL position. The overlay may further emphasize the representation of the IOL 704 to more clearly show the difference between the actual IOL position and the desired IOL position.

[0063] Figure 8F shows a method 800f for selecting IOL 704, i.e., the power or other characteristics of IOL 704. Method 800f includes some or all of the following: taking one or more surface images of eye 102 in step 810; taking one or more cross-sectional images of eye 102 in step 812; and identifying the anatomical structure of eye 102 in step 814. Steps 810, 812, and 814 may be performed according to any of the methods described above.

[0064] Method 800f may include estimating the refractive error of the eye 102 in step 846. Estimating the refractive error may include estimating the focal point of the eye by performing ray tracing or other algorithms to take into account the refraction of the cornea 202, lens 206, lens capsule 700, aqueous humor (fluid filling the anterior segment 200), and vitreous humor 212.

[0065] Method 800f may further include, in step 848, identifying the location of the IOL in accordance with the anatomical structure identified in step 814. For example, based on the dimensions of the lens capsule 700 and known dimensions of the IOL, the location in which the IOL will fit within the lens capsule 700 may be identified. The IOL may be selected from a set of available IOLs and housed within the volume provided by the lens capsule 700.

[0066] Method 800f includes, in step 850, selecting a power for an IOL placed at the location selected in step 848, based on the refractive error calculated in step 846. The power may be the power of the refractive components of a multifocal IOL. Method 800f may include, in step 852, estimating the refractive error of an IOL having the selected power when implanted at the location identified in step 848. Step 852 may include performing ray tracing or other modeling techniques to estimate the focal location of the eye 102-IOL complex. In step 854, if it is found that the refractive error estimated in step 852 meets a threshold, Method 800f proceeds. Otherwise, Method 800f may continue from step 850. Method 800f may further include, in step 856, outputting feedback such as a report of the refractive error estimated in step 852.

[0067] Additional matters The above description is provided so that those skilled in the art can implement the various embodiments described herein. Various modifications to these embodiments will be readily apparent to those skilled in the art, and the general principles defined herein may also apply to other embodiments. For example, changes may be made to the function and arrangement of the elements described above without departing from the scope of this disclosure. Various procedures or components may be omitted, replaced or added as appropriate in various examples. Also, features described in some examples may be combined with any of the other examples. For example, an apparatus may be implemented or a method may be carried out using any number of embodiments described herein. Furthermore, the scope of this disclosure is intended to cover such apparatus or method carried out using, in addition to or other structures, functions, or structures and functions in addition to, the various embodiments of this disclosure described herein. It should be understood that any aspect of the disclosure disclosed herein can be realized by one or more elements described in the claims.

[0068] As used herein, the phrase “at least one of” the list of items means any combination of those items that includes a single element. For example, “at least one of a, b, or c” shall encompass a, b, c, ab, ac, bc, and abc, as well as any combination of multiple identical elements (e.g., aa, aaa, aab, aac, abb, acc, bb, bbb, bbc, cc, and ccc, or any other sequence of a, b, and c).

[0069] As used herein, the term “identify” encompasses a wide range of actions. For example, “identify” may include calculating, calculating, processing, deriving, investigating, searching (e.g., searching in a table, database, or other data structure), confirming, etc. It may also include receiving (e.g., receiving information), accessing (e.g., accessing data in memory), etc. It may also include resolving, selecting, choosing, confirming, etc.

[0070] The methods disclosed herein include one or more steps or operations for implementing the method. The steps and / or operations of the method may be interchangeable with one another without departing from the claims. In other words, unless a specific order of steps or operations is specified, the specific order and / or use of the steps and / or operations may be modified without departing from the claims. Furthermore, the various operations of the method described above may also be performed by any suitable means capable of performing the corresponding function. These means may include, but are not limited to, various hardware and / or software components and / or modules, including circuits, application-specific integrated circuits (ASICs) or processors. Generally, where operations are shown in the drawings, these operations may have corresponding means-plus-function elements with similar numbering.

[0071] The various exemplary logic blocks, modules, and circuits described in connection with this disclosure may be implemented or run by a general-purpose processor, a digital signal processor (DSP), an application-specific integrated circuit (ASIC), a field-programmable gate array (FPGA) or other programmable logic element (PLD), discrete gate or transistor logic, discrete hardware components, or any combination thereof designed to perform the functions described herein. The general-purpose processor may be a microprocessor, but alternatively, the processor may be any commercially available processor, controller, microcontroller or state machine coupled to the components of the operating circuit. The processor may also be implemented as a combination of computing devices, such as a DSP and a microprocessor, multiple microprocessors, a combination of a DSP core and one or more microprocessors working together, or any other such configuration.

[0072] The processing system may be implemented using a bus architecture. The bus may include any number of interconnection buses and bridges, depending on the specific application and overall design constraints of the processing system. The bus may interconnect various circuits, including, among others, processors, machine-readable media, and input / output devices. User interfaces (e.g., keypads, displays, mice, joysticks, etc.) may also be connected to the bus. The bus may also connect various other circuits, such as timing sources, peripherals, voltage regulators, and power management circuits, which are well known in the art and will not be described further. The processor may be implemented using one or more general-purpose and / or dedicated processors. Examples include microprocessors, microcontrollers, DSP processors, and other software-executable circuits. Those skilled in the art will understand how to optimally implement the described functions of the processing system, depending on the specific application and the overall design constraints imposed on the system as a whole.

[0073] When implemented in software, these functions may be stored or transmitted as one or more instructions or codes in a computer-readable medium. Software, regardless of the term used—software, firmware, middleware, microcode, hardware description language, or otherwise—is broadly interpreted to mean instructions, data, or any combination thereof. Computer-readable medium includes both computer storage media and communication media, such as any medium that facilitates the transfer of computer programs from one location to another. A processor may be responsible for managing buses and general operations, including the execution of software modules stored in computer-readable storage media. Computer-readable storage media may be coupled to a processor so that the processor can read information from and write information to the storage media. Alternatively, the storage media may be integrated into the processor. For example, computer-readable medium may include computer-readable storage media in which instructions are stored separately from transmission lines, data-modulated carriers, and / or wireless nodes, all of which may be accessed by the processor via a bus interface. Alternatively, or additionally, computer-readable media or any part thereof may be integrated into the processor, such as with caches and / or general register files. Examples of machine-readable storage media include, for example, RAM (random access memory), flash memory, ROM (read-only memory), PROM (programmable read-only memory), EPROM (erasable programmable read-only memory), EEPROM (electrically erasable programmable read-only memory), registers, magnetic disks, optical disks, hard drives, or any other suitable storage media or any combination thereof. Machine-readable media can be embodied in computer program products.

[0074] A software module may contain a single instruction or a number of instructions and may be distributed across several different code segments, different programs, and multiple storage media. A computer-readable medium may contain many software modules. When executed by a device such as a processor, a software module contains instructions that cause the processing system to perform various functions. A software module may include transmit modules and receive modules. Each software module may reside in a single storage device or be distributed across multiple storage devices. For example, when a trigger event occurs, a software module may be loaded from the hard drive into RAM. While a software module is executing, the processor may load some of the instructions into a cache to increase access speed. Thus, one or more cache lines may be loaded into a general-purpose register file to be executed by the processor. When referring to the functionality of a software module, it should be understood that such functionality is realized by the processor when executing instructions from that software module.

[0075] The following claims are not limited to the embodiments shown herein and shall be consistent with the entire scope of the claims as consistent with the language of the claims. Where an element is referred to in the singular in a claim, unless otherwise specifically stated, it shall mean "one or more" and not "only one". Unless otherwise specifically stated, the term "several" refers to one or more. No element of a claim shall be construed under Section 112(f) of the U.S. Patent Act unless the element is expressly described using the phrase "means for..." or, in the case of a method claim, using the phrase "steps for...". All structural and functional equivalents of elements of various forms described throughout this disclosure, which are known to those skilled in the art or which will be known thereafter, are expressly incorporated by reference herein and are incorporated into the claims. Furthermore, nothing disclosed herein, whether such disclosure is expressly stated in the claims or not, is made available to the public.

Claims

1. A system for performing ophthalmic treatment, A surgical microscope configured to take images of the surface of the patient's eye, An imaging device attached to the surgical microscope and configured to capture cross-sectional images of the patient's eye, A controller coupled to the surgical microscope and the imaging device, configured to receive the surface image and the cross-sectional image, and to provide feedback based on the cross-sectional image and the surface image to facilitate the performance of the ophthalmic treatment, A system that includes this.

2. The system according to claim 1, wherein the imaging device is an optical coherence tomography (OCT) apparatus.

3. The system according to claim 1, wherein the imaging device is attached to the surgical microscope by an adjustable support.

4. The system according to claim 1, wherein the imaging device is attached to a ring fixed to the surgical microscope.

5. The system according to claim 1, further comprising an auxiliary device fixed to the surgical microscope, wherein the auxiliary device includes at least one of a sensor or a light source.

6. The system according to claim 5, wherein the auxiliary device is an intraocular pressure sensor.

7. The system according to claim 1, wherein the ophthalmic treatment includes treatment for glaucoma, the feedback includes a feedback image derived from at least one of the surface image and the cross-sectional image, and the feedback image includes markings indicating a site for at least one of creating an incision or implanting a stent.

8. The system according to claim 1, wherein the ophthalmic treatment includes treatment for glaucoma, the feedback includes a feedback image derived from at least one of the surface image and the cross-sectional image, and the feedback image includes markings representing drainage from the anterior segment of the patient's eye.

9. The system according to claim 1, wherein the ophthalmic treatment includes treatment for detachment of a membrane formed on the retina, and the feedback includes a feedback image derived from at least one of the surface image and the cross-sectional image, the feedback image includes an overlay marking superimposed on the representation of the membrane in the feedback image.

10. The system according to claim 1, wherein the ophthalmic treatment includes treatment for detachment of a membrane formed on the retina, and the feedback includes feedback regarding the angle of the surgical instrument.

11. The system according to claim 1, wherein the ophthalmic treatment includes treatment for detachment of a membrane formed on the retina, and the feedback includes feedback regarding the force applied by the surgical instrument.

12. The system according to claim 11, wherein the controller is configured to estimate the applied force based on the reflectivity of a film formed on the retina.

13. The system according to claim 1, wherein the ophthalmic treatment includes phacoemulsification, and the feedback includes feedback regarding the condition of the lens capsule and ciliary zonules of the patient's eye.

14. The system according to claim 1, wherein the ophthalmic treatment includes the implantation of an intraocular lens (IOL), and the feedback includes feedback regarding the position of the IOL.

15. The system according to claim 1, wherein the controller is configured to detect the representation of the instrument in one or both of the surface image and the cross-sectional image, and the controller is further configured to output feedback regarding the proximity of the instrument to the anatomical structure of the patient's eye.

16. In the method of performing ophthalmic surgical procedures, This involves taking images of the surface of the patient's eye using a surgical microscope configured to capture such images, The imaging device attached to the surgical microscope captures a cross-sectional image of the patient's eye, The surface image and the cross-sectional image are received by a controller coupled to the surgical microscope and the imaging device. The controller provides feedback to facilitate the performance of the ophthalmic treatment according to the surface image and the cross-sectional image, A method that includes this.

17. The method according to claim 16, wherein the imaging device is an optical coherence tomography (OCT) apparatus.

18. The aforementioned ophthalmic treatment is for glaucoma. The controller generates a first feedback image derived from at least one of the surface image and the cross-sectional image, wherein the first feedback image includes markings indicating a site for at least one of creating an incision or placing a stent. The controller outputs the first feedback image to the display device, The controller estimates the discharge from the anterior segment of the patient's eye based on the cross-sectional image, The controller generates a second feedback image derived from at least one of the surface image and the cross-sectional image, wherein the second feedback image includes a marking representing the discharge of the patient's eye from the anterior segment. The controller outputs the second feedback image to the display device, The method according to claim 16, including the method described in claim 16.

19. The aforementioned ophthalmic treatment is the treatment of detachment of a membrane formed on the retina. The controller is used to evaluate the reflectivity of the film formed on the retina, The controller calculates the estimated force applied to the membrane formed on the retina according to the reflectivity, The controller outputs the feedback based on the estimated force, The method according to claim 16, including the method described in claim 16.

20. The controller detects the representation of the device in one or both of the surface image and the cross-sectional image, The controller outputs the feedback, the feedback corresponding to the proximity of the instrument to the anatomical structure of the patient's eye. The method according to claim 16, further comprising:

Images