Systems, methods, and devices for pressure wave eye therapy

Abstract

The present invention provides a device, system, and method for treating the eye using external pressure wave generation. The shock wave generator includes a housing containing a fluid-filled chamber and an eye-contacting surface or chamber configured to contact the surface of the eye. Coaxially aligned first and second electrodes disposed within the housing are configured to generate an electric arc across a gap between the electrode tips when energized, thereby generating shock waves in the fluid in the fluid-filled chamber. The shock wave generator couples the shock waves to the surface of the eye before focusing them at a predetermined location on or below the surface of the eye. Multiple shock wave generators may be disposed within the fluid-filled chamber of a contact lens, which may include a balloon.

Description

[Technical field]

[0001] The subject matter of this application is related to U.S. Provisional Patent Application No. 62 / 884333, entitled "Systems, Methods, and Apparatus for Pressure-Wave Ocular Therapy," filed on August 8, 2019 (Attorney Docket No. 56574-703.101), U.S. Provisional Patent Application No. 62 / 979097, entitled "Systems, Methods, and Apparatus for Pressure-Wave Ocular Therapy," filed on February 20, 2020 (Attorney Docket No. 56574-703.102), and U.S. Provisional Patent Application No. 63 / 043988, entitled "Systems, Methods, and Apparatus for Pressure-Wave Ocular Therapy," filed on June 25, 2020 (Attorney Docket No. 56574-703.103), the entire contents of which are incorporated herein by reference. [Background technology]

[0002] Existing methods and devices for treating glaucoma, presbyopia, age-related macular degeneration (AMD), dry eye disease, and other ophthalmic diseases can produce less than ideal results.

[0003] For example, many conventional methods for treating glaucoma focus on lowering the intraocular pressure (IOP) of the eye and may be more complicated and / or invasive than would be ideal. Current glaucoma interventions include, for example, collateral delivery of drugs (such as prostaglandins), stents (such as minimally invasive glaucoma surgery (MIGS) or canaloplasty), laser-type treatments (such as selective laser trabeculoplasty (SLT) or micropulse laser trabeculoplasty (MLT)), transscleral photocoagulation (TS-CPC), ultrasound CPC, trabeculoplasty or trabeculectomy. Complications from such treatments may include hypotension, hyphema, bleeding, high IOP spike rates, decreased vision, and cataract formation. For example, treatments such as trabeculectomy surgery or implantation of glaucoma drainage devices require invasive surgery and may have adverse safety risks in some cases. Additionally, other non-penetrating treatments often become less effective over time. Treatment of lowering intraocular pressure with medicinal eye drops may be less than ideal due to lack of patient compliance, possible side effects, and patient-to-patient variability that may lead to variability in the dosage and bioavailability of such drugs.In light of the above, there is a need for improved methods and devices for treating glaucoma.Ideally, such methods and devices will be less invasive than some conventional treatments and will successfully provide IOP reduction.

[0004] Conventional methods for treating presbyopia focus on improving accommodation width and / or replacing or restoring the patient's myopic function, and may be more complicated and / or invasive than would be ideal. Current presbyopia interventions include myopic wearables (such as glasses or contact lenses), lens or strut implants, medications for pupil constriction and lens dissociation, and incision techniques. Complications from such treatments may include invasiveness, drug side effects, and other complications in some cases. Furthermore, such therapies often target only one of many possible causes of accommodation loss, which may limit the overall effectiveness of such therapies as a singular treatment modality. In view of the above, improved methods and devices for treating presbyopia are needed. Ideally, such methods and devices would be less invasive than some of the prior treatments and successfully increase accommodation width.

[0005] Conventional methods for treating AMD focus on delaying the onset of dry AMD and / or sealing leaking blood vessels to limit degeneration in wet AMD, but may be less effective than desired and / or may fail to reverse degeneration that has already occurred. Current interventions include nutritional interventions such as high antioxidant diets for dry AMD, laser photocoagulation for wet AMD, and intraocular anti-vascular endothelial growth factor (VEGF) treatment for wet AMD. Complications from such treatments may include continued loss of vision, high recurrence rates of leakage in wet AMD cases, macular scarring, ocular infections, elevated intraocular pressure, retinal detachment, and possibly systemic vascular effects (bleeding, stroke, etc.). Furthermore, such treatments are rarely able to restore vision once lost. In light of the above, improved methods and devices for treating AMD are needed. Ideally, such methods and devices would be less risky than some conventional treatments and would successfully provide for the delay of degeneration and / or restoration of previously degenerated tissue.

[0006] Conventional methods for treating dry eye disease focus on improving, supplementing, and / or replacing natural tear formation and may be less effective than desired. Current interventions include over-the-counter eye drops (artificial tears), antibiotics, immunosuppressant eye drops, corticosteroid eye drops, ocular inserts, scleral lenses, phototherapy and eyelid massage, tear stimulating eye drops, lacrimal plugs, and lacrimal thermal cauterization. Complications from such treatments include continued dryness, increased irritation, sweating, corneal abrasion, and other drug side effects. Furthermore, such therapies often require prolonged use that is less than ideal due to lack of patient compliance, side effects in some instances, and patient-to-patient variability resulting in variable dosage and bioavailability of instilled medications. In light of the above, improved methods and devices for treating dry eye disease are needed. Ideally, such methods and devices would be more effective and provide a longer-lasting improvement in patients' ocular lubrication. Summary of the Invention [Problem to be solved by the invention]

[0007] It would therefore be desirable to provide improved methods and devices for treating glaucoma, presbyopia, age-related macular degeneration, dry eye disease, and other ophthalmic diseases. Not necessarily all such aspects or advantages are achieved by any particular embodiment. Thus, various embodiments may be practiced in a manner that achieves or optimizes one or more advantages taught herein without necessarily achieving other aspects or advantages that may be taught or suggested herein.

[0008] The present disclosure relates generally to medical devices and methods, and more particularly to methods and devices for treating the eye.

[0009] In a first aspect, a device for treating an eye is provided, the device comprising: a housing having a fluid-filled chamber and an eye-contacting surface configured to contact a surface of an eye, a first electrode disposed within the housing, and a second electrode disposed within the housing and coaxially aligned with the first electrode, the distal tip of the first electrode and the distal tip of the second electrode being separated by a gap, the first electrode and the second electrode configured to generate an electrical arc across the gap when energized to generate shock waves in a fluid in the fluid-filled chamber.

[0010] In some embodiments, the inner surface of the housing may be configured to focus the shock waves at a predetermined location on or below the surface of the eye.

[0011] In some embodiments, the device may further comprise a reflector disposed within the housing and configured to focus the shock waves to a predetermined location on or below the surface of the eye.

[0012] In some embodiments, the device may further comprise a fluid inlet and a fluid outlet in fluid communication with the fluid-filled chamber.

[0013] In some embodiments, the device may further comprise one or more wires coupled to the first electrode or the second electrode and configured to deliver energy thereto.

[0014] In some embodiments, the first and second electrodes may comprise a first tip of a first wire and a second tip of a second wire.

[0015] In some embodiments, the fluid may consist of saline or water.

[0016] In some embodiments, the first and second electrodes may be coated with graphene to reduce erosion due to shock wave generation during use.

[0017] In some embodiments, the housing may be an ellipsoid.

[0018] In some embodiments, the housing may further comprise a fluid-filled waveguide disposed between the fluid-filled chamber and the eye-contact surface, the fluid-filled waveguide configured to fluidly couple the fluid-filled chamber and the eye-contact surface.

[0019] In some embodiments, the device may further comprise an acoustic lens disposed within the housing, the acoustic lens being configured to focus the shock waves at one or more predetermined locations on or below the surface of the eye.

[0020] In some embodiments, the device may further comprise a conductivity sensor disposed at least partially within the fluid-filled chamber. The conductivity sensor may be configured to measure the conductivity of the fluid within the fluid-filled chamber. In some embodiments, the conductivity sensor may comprise a pair of platinum electrodes.

[0021] In some embodiments, the device may further comprise a light source disposed at least partially within the fluid-filled chamber and configured to emit light toward a surface of the eye, The light source may be configured to emit light having a wavelength sufficient to crosslink tissue.

[0022] In another aspect, a system for treating an eye is provided. The system includes any of the shock wave generators described herein and an energy source. The energy source may be operatively coupled to the first and second electrodes of an electrode-based device by one or more wires. The energy source may include a laser for a fiber optic-based device.

[0023] In some embodiments, the first electrode may be coupled to a positive terminal of the energy source and the second electrode may be coupled to a negative terminal of the energy source.

[0024] In some embodiments, the energy source may comprise a high voltage pulse generator.

[0025] In some embodiments, the system may further comprise a current sensor coupled to the first electrode or the second electrode and configured to determine a level of current flowing through the first electrode or the second electrode.

[0026] In some embodiments, the system may further comprise a conductivity sensor fluidly coupled to the fluid outlet and configured to measure the conductivity of the fluid exiting the fluid outlet.

[0027] In some embodiments, the system may further comprise a fluid recirculation system fluidly coupled to the fluid outlet and the fluid inlet and configured to recirculate fluid from the fluid-filled chamber and remove cavitation bubbles from the fluid.

[0028] In some embodiments, the system may further comprise a reservoir disposed on or under the eye-contacting surface. In some embodiments, the reservoir may include oxygen. Alternatively, or in combination, the reservoir may include riboflavin. Alternatively, or in combination, the reservoir may include a therapeutic agent or drug.

[0029] In another aspect, a device for treating an eye is provided, the device comprising: a housing having a fluid-filled chamber and an eye contacting surface configured to contact a surface of an eye, and an optical fiber disposed within the housing, the optical fiber configured to generate shock waves in a fluid in the fluid-filled chamber when light energy is emitted therefrom.

[0030] In some embodiments, the inner surface of the housing may be configured to focus the shock waves at a predetermined location on or below the surface of the eye.

[0031] In some embodiments, the device may further comprise a reflector disposed within the housing and configured to focus the shock waves to a predetermined location on or below the surface of the eye.

[0032] In some embodiments, the device may further comprise a fluid inlet and a fluid outlet in fluid communication with the fluid-filled chamber.

[0033] In some embodiments, the fluid may consist of saline or water.

[0034] In some embodiments, the fluid may include graphene to reduce light emission from the housing when a shock wave is generated.

[0035] In some embodiments, the housing may be an ellipsoid.

[0036] In some embodiments, the housing may further comprise a fluid-filled waveguide disposed between the fluid-filled chamber and the eye-contact surface, the fluid-filled waveguide configured to fluidly couple the fluid-filled chamber and the eye-contact surface.

[0037] In some embodiments, the device may further comprise an acoustic lens disposed within the housing, the acoustic lens being configured to focus the shock waves at one or more predetermined locations on or below the surface of the eye.

[0038] In another aspect, a system for treating an eye is provided that includes a plurality of shock wave generators and a contact lens disposed about the plurality of shock wave generators, the contact lens including a fluid-filled chamber and an eye-contacting surface configured to contact a surface of an eye.

[0039] In some embodiments, the contact lens may further comprise a suction mechanism configured to contact the surface of the eye and maintain contact between the surface of the eye and the eye-contacting surface.

[0040] In some embodiments, each of the multiple shock wave generators may comprise an optical fiber.

[0041] In some embodiments, each of the multiple shock wave generators may include a pair of coaxially arranged electrodes and a reflector.

[0042] In some embodiments, the contact lens may include an expandable outer housing that defines the eye-contacting surface.

[0043] In some embodiments, the contact lens may include an imaging port configured to receive an imaging device.

[0044] In some embodiments, the multiple shockwave generators may consist of multiple electrohydraulic, piezoelectric, laser, or magnetoelectric shockwave generators.

[0045] In another aspect, a method for treating an eye is provided that includes coupling an eye-contacting surface of a shockwave generator to a surface of the eye, generating shock waves with the shockwave generator, and focusing the shockwaves at a predetermined location on or below the surface of the eye.

[0046] In some embodiments, the method may further include inducing microporation, cavitation, vasodilation, neovascularization, dissection, and upregulated growth factor production at the predetermined locations with focused shock waves.

[0047] In some embodiments, the predetermined location may include one or more of the trabecular meshwork, Schlemm's canal, limbus, eyelid, meibomian gland, retina, and periorbital.

[0048] In some embodiments, the method may further include seeding the predetermined location with microbubbles prior to generating the shock waves.

[0049] In some embodiments, the shock wave generator may comprise an optical fiber. Generating the shock waves may include emitting optical energy from the optical fiber into a fluid surrounding the optical fiber.

[0050] In some embodiments, the shock wave generator may include a first electrode and a second electrode, and generating the shock waves may include energizing the first and second electrodes to form an electric arc across a gap between their tips.

[0051] In some embodiments, the method may further include coupling an eye-contacting surface of a second shockwave generator to a surface of the eye, generating second shockwaves with the second shockwave generator, and focusing the second shockwaves to a second predetermined location on or below the surface of the eye.

[0052] In some embodiments, the shock wave generator may be disposed within a fluid-filled chamber of the contact lens.

[0053] In some embodiments, the shockwave generator may be coupled to the trial frame.

[0054] In another aspect, a system for treating an eye is provided, the system comprising a shock wave generator configured to generate shock waves, and a fluid-filled waveguide fluidly coupled to the shock wave generator and configured to direct the shock waves to an eye contact surface configured to contact a surface of the eye.

[0055] In some embodiments, the director may be constructed from stainless steel tubing.

[0056] In some embodiments, the director may have a length of about 12 mm or greater.

[0057] In some embodiments, the director may have a diameter in the range of about 1 mm to about 8 mm. For example, the director may have a diameter of about 3 mm or about 8 mm.

[0058] In some embodiments, the system may further comprise a contact lens coupled to a distal end of the director, the contact lens comprising a fluid-filled chamber and an eye-contacting surface.

[0059] In some embodiments, at least a portion of the shockwave generator and director may be coupled to a trial frame.

[0060] These and other embodiments are described in further detail in the following description taken in conjunction with the accompanying drawings.

[0061] All publications, patents, and patent applications mentioned in this specification are herein incorporated by reference to the same extent as if each individual publication, patent, or patent application was specifically and individually indicated to be incorporated by reference. [Brief description of the drawings]

[0062] The novel features of the present disclosure are set forth with particularity in the appended claims. A better understanding of the features and advantages of the present disclosure will be obtained by reference to the following detailed description that sets forth illustrative embodiments, in which the principles of the disclosure are utilized, and the accompanying drawings of which: [Figure 1] 1 is a perspective view of a shock wave generating device according to an embodiment. FIG. [Diagram 2] FIG. 2 illustrates a side view of an exemplary shock wave generating device adjacent to an eye in an embodiment. [Diagram 3] FIG. 2 is a top view of an array of shockwave generators in an embodiment. [Figure 4] FIG. 1 is a top view of an array of shockwave generators arranged in multiple rows in an embodiment. [Diagram 5] FIG. 5 is a side view of the array of FIG. 4 in an embodiment. [Figure 6] FIG. 1 is a side cross-sectional view of an exemplary shockwave generator array system with a cone coupled to an eyeball in an embodiment. [Figure 7] FIG. 1 is a side cross-sectional view of an exemplary shockwave generator array system with a contact lens coupled to an eyeball, in an embodiment. [Figure 8] FIG. 2 is a perspective view of a shock wave generating device in an embodiment. [Figure 9] FIG. 13 is a side view of multiple shock wave generating devices coupled to an eye in an embodiment. [Figure 10] FIG. 13 is a side view of multiple shock wave generating devices coupled to an eyeball with a contact lens, in an embodiment. [Figure 11] FIG. 13 is a side cross-sectional view of multiple shock wave generating devices coupled to an eyeball with a contact balloon, in an embodiment. [Figure 12] FIG. 13 is a side cross-sectional view of multiple shock wave generating devices coupled to an eyeball with a contact balloon, in an embodiment. [Figure 13] FIG. 2 illustrates an exploded side view of an exemplary shock wave generating device adjacent to an eye in an embodiment. [Figure 14] FIG. 13 is an exploded side view of another exemplary shock wave generating device adjacent to an eye in an embodiment. [Figure 15] FIG. 13 is a side cross-sectional view of multiple shock wave generating devices coupled to an eye using a contact balloon, in an embodiment. [Figure 16] FIG. 16 is a perspective view of the system of FIG. 15 coupled to an eye, in an embodiment. [Figure 17] FIG. 16 is a perspective view of the system of FIG. 15 coupled to additional tubes and / or wires in an embodiment. [Figure 18]FIG. 18 is a side view of the system of FIG. 17 with tubes and / or wires coupled to a power source, in an embodiment. [Figure 19] FIG. 1 is a perspective view of a contact balloon with multiple shock wave generators embedded therein, in an embodiment. [Figure 20] FIG. 2 is a partial perspective view of a multiple stacked ring conductor shock wave generator according to an embodiment. [Figure 21] FIG. 21 is an exploded view of the ring conductor shock wave generator of FIG. [Figure 22] FIG. 1 illustrates an exemplary treatment pattern for glaucoma, in an embodiment. [Diagram 23] FIG. 1 illustrates an exemplary treatment pattern for presbyopia, in an embodiment. [Figure 24] FIG. 1 illustrates, in an embodiment, an exemplary treatment pattern for AMD. [Diagram 25] FIG. 1 is a top view of an exemplary treatment system for AMD, in an embodiment. [Figure 26] 26 is a side cross-sectional view of the system of FIG. 25 in an embodiment. [Figure 27] FIG. 1 illustrates another exemplary treatment system for AMD, in an embodiment. [Figure 28] FIG. 1 illustrates, in an embodiment, an exemplary treatment pattern for dry eye disease. [Figure 29] FIG. 1 illustrates, in an embodiment, an exemplary treatment system for dry eye disease. [Diagram 30] FIG. 1 illustrates, in an embodiment, an exemplary treatment system for dry eye disease. [Diagram 31] FIG. 1 illustrates, in an embodiment, an exemplary treatment system for dry eye disease. [Diagram 32] FIG. 1 illustrates, in an embodiment, an exemplary treatment system for dry eye disease. [Diagram 33] FIG. 1 illustrates, in an embodiment, a top view of an exemplary treatment system for lens softening. [Diagram 34]FIG. 34 is a side cross-sectional view of the system of FIG. 33 placed on an eye in an embodiment. [Diagram 35] 1 is a side cross-sectional view of an exemplary treatment system for presbyopia, in an embodiment; [Diagram 36] 1 is a side cross-sectional view of an exemplary treatment system for glaucoma, in an embodiment; [Figure 37] In an embodiment, a top view of the system of FIG. 36 is shown. [Figure 38] FIG. 2 is a side cross-sectional view of an exemplary array of shockwave generating devices, in an embodiment. [Figure 39] In an embodiment, a top view of the array of FIG. [Diagram 40] 1 is a side cross-sectional view of an exemplary treatment system for AMD, in an embodiment. [Diagram 41] 1 is a side cross-sectional view of an exemplary treatment system for dry eye disease, in an embodiment; [Diagram 42] 1 is a cross-sectional view of an exemplary laser-based shock wave generating device in an embodiment. [Diagram 43] FIG. 1 is a side cross-sectional view of an array of laser-based shock wave generators within a fluid-filled contact lens balloon, in an embodiment. [Diagram 44] FIG. 1 is a perspective view of an array of laser-based shock wave generators within an annular fluid-filled contact lens, in an embodiment. [Diagram 45] 45 is a side cross-sectional view of the system of FIG. 44 in an embodiment. [Figure 46] In an embodiment, a top view of the system of FIG. [Figure 47] FIG. 1 illustrates a top view of an array of laser-based shock wave generators within an annular fluid-filled contact lens, in an embodiment. [Figure 48] FIG. 48 is a side cross-sectional view of the system of FIG. 47 in an embodiment. [Figure 49] FIG. 1 is a side cross-sectional view of an array of shock wave generators arranged in a plurality of arrays and positioned on an eyeball, in an embodiment. [Figure 50]FIG. 1 illustrates an exemplary array of shock wave generators comprising a conductive wire disposed within an insulating sheath having multiple openings therein, in an embodiment. [Figure 51] FIG. 1 illustrates an exemplary array of shock wave generators comprising optical fibers disposed within a cladding having multiple openings therein, in an embodiment. [Figure 52] FIG. 1 is an exploded view of an embodiment of an array of electrode-based shockwave generators that include conductive wires disposed within an insulating sheath having multiple openings therein. [Figure 53] FIG. 1 is an exploded view of an array of laser-based shockwave generators including, in an embodiment, an optical fiber disposed within a cladding having multiple openings therein. [Figure 54] FIG. 1 illustrates, in an embodiment, a method for treating an eye. [Figure 55] FIG. 1 is a side cross-sectional view of an exemplary laser scanning shockwave generator system including a contact lens coupled to an eyeball, in an embodiment. [Figure 56] FIG. 1 is a side cross-sectional view of an exemplary multi-fiber laser shockwave generator array system with a contact lens, in an embodiment. [Figure 57] 2 is a side cross-sectional view of an exemplary shock wave director in an embodiment; [Figure 58] 2 is a side cross-sectional view of an exemplary shock wave director in an embodiment; [Figure 59] FIG. 2 is a schematic diagram of a wire frame tube of a shock wave director in an embodiment. [Figure 60] 2 is a side cross-sectional view of an exemplary shock wave director in an embodiment; [Figure 61] 2 is a side cross-sectional view of an exemplary shock wave director in an embodiment; [Figure 62] FIG. 2 is a side cross-sectional view of an exemplary parabolic shock wave director, in an embodiment. [Figure 63] FIG. 2 is a top view of an exemplary contact lens comprising an array of shock wave directors, in an embodiment. [Figure 64]FIG. 2 is a top view of an exemplary contact lens including an array for shockwave generators for meibomian gland treatment, in an embodiment. [Figure 65] FIG. 1 is a top view of an exemplary contact lens for treating dry eye disease, in an embodiment. [Figure 66] FIG. 1 illustrates a side view of an exemplary treatment system including an integrated imaging system in an embodiment. [Figure 67] FIG. 1 illustrates a side view of an exemplary treatment system including an integrated imaging system in an embodiment. [Figure 68] FIG. 1 illustrates a side view of an exemplary treatment system including an integrated imaging system in an embodiment. [Figure 69] FIG. 1 is a schematic diagram of an exemplary system for bubble extraction, in an embodiment. [Figure 70] FIG. 1 is a schematic diagram of an exemplary system for bubble extraction, in an embodiment. [Figure 71] FIG. 1 is a schematic diagram of an exemplary system for bubble extraction, in an embodiment. [Figure 72] FIG. 2 is an electrical schematic diagram of an exemplary treatment system, in an embodiment. [Figure 73] FIG. 2 is a side cross-sectional view of an exemplary variable focus treatment system, in an embodiment. [Figure 74] 1 is a side cross-sectional view of an exemplary treatment system for dry eye disease, in an embodiment; [Figure 75] 1 is a side cross-sectional view of an exemplary treatment system for percutaneous treatment, in an embodiment. [Figure 76] 1 is a side cross-sectional view of an exemplary treatment system for dry eye disease, in an embodiment; [Figure 77] FIG. 1 is a schematic diagram of an exemplary system for conductivity measurement, in an embodiment. [Figure 78] FIG. 2 is a side view of an exemplary shock wave director with an embedded conductivity sensor, in an embodiment. [Figure 79] FIG. 2 is a side view of an exemplary acoustically bridging shock wave director in an embodiment. [Figure 80] FIG. 2 is a side view of an exemplary acoustically bridging shock wave director in an embodiment. [Figure 81] 1 is a schematic diagram of an exemplary system for passive cavitation detection in an embodiment; [Figure 82] FIG. 1 illustrates an exemplary treatment system with passive cavitation detection in an embodiment. [Figure 83] FIG. 1 illustrates a side view of an exemplary treatment system including, in embodiments, a conductivity sensor, acoustic bridging, and / or passive cavitation detection. [Figure 84] FIG. 1 is a schematic diagram of an exemplary treatment system including acoustic bridging or passive cavitation detection in embodiments. [Fig. 85A] FIG. 1 illustrates, in an embodiment, exemplary treatment patterns for various indications. [Fig. 85B] FIG. 1 illustrates, in an embodiment, exemplary treatment patterns for various indications. [Fig. 85C] FIG. 1 illustrates, in an embodiment, exemplary treatment patterns for various indications. [Fig. 85D] FIG. 1 illustrates, in an embodiment, exemplary treatment patterns for various indications. [Fig. 85E] FIG. 1 illustrates, in an embodiment, exemplary treatment patterns for various indications. [Fig. 85F] FIG. 1 illustrates, in an embodiment, exemplary treatment patterns for various indications. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0063] In the following detailed description, reference is made to the accompanying drawings, which form a part hereof. In the drawings, like symbols indicate like components unless the context dictates otherwise. The exemplary embodiments described in the detailed description, drawings, and claims are not intended to be limiting. Other embodiments may be utilized and other changes may be made without departing from the scope of the subject matter presented herein. It is readily understood that the aspects of the present disclosure as generally described herein and shown in the drawings may be arranged, substituted, combined, separated, and designed in a wide variety of different configurations, all of which are expressly contemplated herein. Those skilled in the art will appreciate that the illustrations in the figures are not necessarily to scale, and that many elements may be enlarged or exaggerated for clarity and ease of understanding of the described embodiments.

[0064] Although specific embodiments and examples are disclosed below, the subject matter of the present invention extends beyond the specifically disclosed embodiments to other alternative embodiments and / or uses, as well as modifications and equivalents thereof. Thus, the scope of the claims appended hereto is not limited by any of the specific embodiments described below. For example, in any method or process disclosed herein, the acts or operations of the method or process may be performed in any suitable order and are not necessarily limited to the specific disclosed order. As a method that may aid in the understanding of certain embodiments, various operations may be described in sequence as multiple discrete operations, but the order of description should not be interpreted to imply that these operations are order dependent. Furthermore, the structures, systems, and / or devices described herein may be embodied as integrated or separate components.

[0065] For purposes of comparing various embodiments, certain aspects and advantages of those embodiments are described. Not necessarily all such aspects or advantages are achieved by any particular embodiment. Thus, for example, various embodiments may be implemented in a manner that achieves or optimizes one advantage or group of advantages taught herein, without necessarily achieving other aspects or advantages that may be taught or suggested by this specification.

[0066] The present disclosure will be described in the context of deploying systems, devices, or methods for the treatment of a patient's eye, however, those skilled in the art will appreciate that this is not intended to be limiting and that the devices and methods disclosed herein may be used in other anatomical regions and other surgical procedures.

[0067] The embodiments disclosed herein can be combined with one or more of a number of methods to provide improved methods and devices for treating the eye. The treated ocular tissues, membranes, or pathological modifications thereof may include the trabecular meshwork, sclera, vitreous body, retina, meibomian gland ducts, zonules (such as the posterior vitreous zonule (PVZ)), ciliary body, lens, and one or more of diseased areas thereof.

[0068] The embodiments disclosed herein provide improved methods and devices for the treatment of one or more of presbyopia, glaucoma, AMD, dry eye disease, other ophthalmic diseases, or combinations thereof. For example, the presbyopia treatments disclosed herein can have a beneficial effect on the patient's intraocular pressure (hereinafter, "IOP"). Alternatively, or in combination, the treatments can be directed to the treatment of, for example, glaucoma. The treatments and devices disclosed herein can be combined with many known treatment methods and devices. For example, the restoration of accommodative power described herein can be combined with, for example, one or more of many known accommodative intraocular lenses (IOLs). Alternatively, or in combination, the methods and devices as disclosed herein can be combined with one or more known glaucoma treatments. Although many embodiments are described with reference to the natural crystalline lens of the eye, the embodiments disclosed herein can be used to improve vision using intraocular lenses.

[0069] The term "shock wave" as used herein refers to an acoustic wave with high energy peaks, pressure jumps / step changes, fast rise times (e.g., on the order of 10 nanoseconds), high amplitudes, and non-periodicity / short duration (e.g., about 10 microseconds). Shock waves may also be referred to as pressure waves. Shock waves are different from ultrasound and high-intensity focused ultrasound, as they typically propagate at much higher speeds, with much higher intensities, and without the periodicity of ultrasound. Shock waves can be generated by electrohydraulic, piezoelectric, laser, or magnetoelectric means, as will be understood by those skilled in the art based on the description herein.

[0070] Extracorporeal shock wave therapy (ESWT) is a non-invasive method for the treatment of musculoskeletal disorders, primarily used to treat sports-related tendon overuse. ESWT has also been used to treat long bone fracture nonunion, femoral head vascular necrosis, chronic diabetic and non-diabetic ulcers, and ischemic heart disease. The shock waves used in ESWT have been shown to produce mechanical and cellular effects on the treated tissue. For example, shock wave therapy can produce an analgesic effect on the treated tissue. Shock wave therapy has also been shown to stimulate the production of growth factors such as endothelial nitric oxide synthase (eNOS), neuronal nitric oxide synthase (nNOS), and vascular endothelial growth factor (VEGF), which promote neovascularization and cell regeneration. Shock waves can also generate free radicals, promoting cell destruction.

[0071] 1 is a perspective view of a shockwave generator 100. The shockwave generator 100 may include a first electrode 110 and a second electrode 112 disposed within a housing 102. The housing 102 may include a fluid-filled chamber 106 and an eye-contacting surface 104. The eye-contacting surface 104 may be configured to couple to a surface of a patient's eye. The first and second electrodes 110, 112 may be coaxially aligned with one another such that a gap 114 is formed between the distal tips of the electrodes 110.

[0072] The shockwave generator 100 may be configured to generate one or more shock waves. The shockwave generator 100 may be configured to treat one or more tissues or structures on or below the surface of the eye with the shockwaves it generates. The treatment may be non-thermal. The shockwaves may be focused or unfocused at a predetermined location as described herein. The shockwaves may be used to locally fractionate, microporate, dilate, and / or sensorize desired ocular tissue. In some embodiments, the shockwaves may be used to produce biomechanical effects (vasodilation, microporation, softening, etc.) and / or biochemical effects (neovascularization, etc.) as described herein. In some embodiments, the shockwaves may be used for drug delivery to ocular tissue.

[0073] For example, application of shock waves to the eye can (i) enhance ischemic limb peri-scleral and meibomian gland fluid outflow via upregulation of VEGF and turbo green fluorescent protein 2 (TGFP2) (e.g., neovascularization) and / or eNOS and nNOS (e.g., vasodilation), (ii) induce stem cell differentiation (e.g., upregulation of Ca2+), (iii) improve visual acuity and accommodation amplitude by fractionating the vitreous break in the proximal pars plana, (iv) improve lens compliance by dissociation, and / or (v) deliver drugs (e.g., glaucoma, anti-VEGF, steroid drugs, etc., via ultrasound exposure (sonoporation) and / or sonophoresis). In some embodiments, shock wave therapy can reduce thermal tissue coagulation, perforation, lens or corneal dislocation, cataract induction, and / or other undesirable aberrations that may be the result of other treatment methods and systems.

[0074] The eye-contacting surface 104 (also referred to herein as the tissue interface) may be shaped to correspond to the surface of the eye to create a seal when placed on the eye. The eye-contacting surface 104 may be constructed from a flexible material configured to conform its shape to the surface of the eye when placed on the eye. The eye-contacting surface 104 may be constructed from nylon, polyethylene terephthalate (PET), biaxially oriented polyethylene terephthalate (BoPET), etc.

[0075] The eye-contacting surface 104 may have a thickness in the range of about 12 μm to about 100 μm.

[0076] The eye-contacting surface 104 may have a diameter in the range of about 1 mm to about 8 mm, for example, about 1 mm, about 2 mm, about 3 mm, about 5 mm, about 7 mm, or about 8 mm.

[0077] The eye-contacting surface 104 may be made of any suitable material, including polytetrafluoroethylene (PTFE), ethylene tetrafluoroethylene (ETFE), fluorinated ethylene propylene (FEP), polyoxymethylene (POM, e.g., DELRIN® available from DuPont), polyether block esters, polyurethanes (e.g., Polyurethane 85A), polypropylene (PP), polyvinyl chloride (PVC), polyetheresters (e.g., ARNITEL® available from DSM Engineering Plastics), ether or ester based copolymers (e.g., butylene / poly(alkylene ether) phthalates and / or polyester elastomers such as HYTREL® available from DuPont), polyamides (e.g., DURETHAN® available from Bayer or CRISTA® available from Elf Atochem), or other suitable materials. D®, elastomeric polyamides, block polyamide / ethers, polyether block amides (PEBA, e.g., sold under the trade name PEBAX®), ethylene vinyl acetate copolymers (EVA), silicones, polyethylene (PE), Marlex high density polyethylene, Marlex low density polyethylene, linear low density polyethylene (e.g., REXELL®), polyester, polybutylene terephthalate (PBT), polyethylene terephthalate (PET), polytrimethylene terephthalate, polyethylene naphthalate (PEN), polyester ether ketone (PEEK), polyimide (PI), polyetherimide (PEI), polyphenylene sulfide (PPS), polyphenylene oxide (PPO), polyparaphenylene terephthalamide (e.g., KEVLAR®), polysulfone, nylon, nylon 2 (GRK available from EMS American Grillon Co., Ltd.Examples of suitable materials include AMID®, perfluoro(propyl vinyl ether) (PFA), ethylene vinyl alcohol, polyolefins, polystyrene, epoxies, polyvinylidene chloride (PVdC), poly(styrene A isobutylene A styrene) (e.g., SIBS and / or SIBS 50A), polycarbonates, ionomers, biocompatible polymers, other suitable materials or mixtures, combinations, copolymers, polymer / metal composites, and the like. In some embodiments, the eye-contacting surface 104 may be comprised of a mixture blended with a liquid crystal polymer (LCP) (e.g., up to about 6% LCP).

[0078] The fluid-filled chamber 106 may include a fluid disposed therein. The fluid may include a biocompatible liquid that is conductive (e.g., a conductivity of about 0.6 mS). The fluid may be comprised of water or saline. The fluid may be comprised of a suspension of graphene in saline. The fluid may be cooled (e.g., about 10° C.). In some embodiments, the shockwave generating device 100 may further include a fluid inlet 108 and a fluid outlet 109 in fluid communication with the fluid-filled chamber 106. The fluid may be used to couple the shockwaves generated in the gap 114 to the surface of the eye. The fluid may circulate within the fluid-filled chamber 106 via the fluid inlet 108 and the fluid outlet 109. The circulation of the fluid may allow for the continuous extraction of metal ions shed from the electrodes 110, 112 and cavitation bubbles generated during shockwave formation as the shockwave pulse delivery continues.

[0079] In some embodiments, the fluid exiting the fluid-filled chamber 106 via the fluid outlet 109 may be sampled periodically or continuously to determine the extent of electrode erosion. For example, the conductivity of the saline solution may be sampled (e.g., as a surrogate for measuring the distance of the gap 114 between the electrodes 110, 112 as the electrodes erode and metal ions are released into the saline solution), and the voltage delivered to the electrodes 110, 112 may be adjusted to account for the sensed change in conductivity.

[0080] The fluid-filled chamber 106 may be configured to act as a reflector to focus the shock waves toward a desired predetermined location. Alternatively, or in combination, one or more reflectors may be coupled to the inner surface of the fluid-filled chamber 106 to focus the shock waves. The inner wall of the fluid-filled chamber 106 or the reflector coupled to the inner surface of the fluid-filled chamber 106 may be an ellipsoid. It will be understood by those skilled in the art based on the disclosure herein that other exemplary shapes can be a blend between a sphere and an ellipsoid, may be an ellipsoid with offset standoffs, may include electrodes for radial wave transmission without a reflector, may include a coaxial wire with two insulated exposed electrodes, may be an ellipsoid with a flat-ended reflector of an asymmetric shape, an ellipsoid-toroid, a cone, an S-shape, a contact lens with multiple reflectors and electrodes, a meibomian gland coupled shape, a drug depot / reservoir coupled to a pressure wave generator, a suction ring function for stable intraoperative delivery, and the like.

[0081] The reflector may be constructed from sapphire, polymethylmethacrylate (PMMA), graphene coated polymers, shock wave reflective polymers, stainless steel, aluminum, or the like. Some examples of suitable metals and metal alloys include stainless steels, such as 304V, 304L, and 316LV stainless steels, mild steel, nickel-titanium alloys, such as linear elastic and / or superelastic Nitinol, other nickel alloys, such as nickel-chromium molybdenum alloys (e.g., UNS:N06625, such as INCONEL® 625, UNS:N06022, such as HASTELLOY® C-22®, HASTELLOY® C276®, and the like). nickel-copper alloys (e.g., UNS:N04400, such as MONEL® 400, NICKELVAC® 400, NICORROS® 400, etc.); nickel-cobalt-chromium-molybdenum alloys (e.g., UNS:R30035, such as MP35-N®); nickel-molybdenum alloys (e.g., UNS:N10276, such as HASTELLOY® alloys, etc.); Examples of suitable alloys include, but are not limited to, nickel-chromium alloys, cobalt-chromium-molybdenum alloys (e.g., UNS: N10665, such as ALLOY B2®), other nickel-chromium alloys, other nickel-molybdenum alloys, other nickel-cobalt alloys, other nickel-iron alloys, other nickel-copper alloys, other nickel-tungsten or tungsten alloys, cobalt-chromium alloys, cobalt-chromium-molybdenum alloys (e.g., UNS: R30003, such as ELGILOY®, PHYNOX®), platinum strengthened stainless steels, titanium, combinations thereof, and the like, or any other suitable material.

[0082] In some embodiments, an aluminum dome structure located near the shockwave generator may be used to direct the shockwave energy to a second focal point using an ellipsoidal dome, or into the tissue in a parallel direction using a parallel dome. The focal depth of the dome structure may be in the range of about 3 mm to about 3 cm past the shockwave generator at the first focal point.

[0083] It will be understood by those skilled in the art that the reflector (e.g., the shape of the fluid-filled chamber 106 and / or other reflectors coupled thereto) may be shaped to provide a desired focal position, shape of the shockwave pattern, etc.

[0084] The first and second electrodes 110, 112 may be operably coupled to a power source. In some embodiments, the first and second electrodes 110, 112 may be coupled to the power source by one or more wires 116. The one or more wires 116 may be insulated. In some embodiments, the first and second electrodes 110, 112 may comprise distal ends of one or more wires 116. In some embodiments, the first and second electrodes 110, 112 may include pins coupled to the wires 116. In some embodiments, the first and second electrodes 110, 112 may be constructed from platinum, tungsten titanium, aluminum, titanium alloy (Ti-3A1), stainless steel, silver, gold, copper, nickel-chromium alloy, iron, brass, copper-platinum, copper, or combinations thereof, or the like.

[0085] In some embodiments, the first and / or second electrodes 110, 112 may be coated with graphene, gold, or other materials to reduce erosion of the electrodes 110, 112 during use.

[0086] The first and second electrodes 110, 112 may have an outer diameter of about 0.5 mm. The first and second electrodes 110, 112 may have an outer diameter within a range of about 0.00785 mm to about 0.8118 mm. In some embodiments, the first and second electrodes 110, 112 may have an outer diameter within a range defined by any two of the following values: about 0.005 mm, about 0.01 mm, about 0.015 mm, about 0.02 mm, about 0.025 mm, about 0.03 mm, about 0.035 mm, about 0.04 mm, about 0.045 mm, about 0.05 mm, about 0.055 mm, about 0.065 mm, about 0.075 mm, about 0.085 mm, about 0.095 mm, about 0.105 mm, about 0.115 mm, about 0.125 mm, about 0.135 mm, about 0.145 mm, about 0.155 mm, about 0.165 mm, about 0.175 mm, about 0.185 mm, about 0.195 mm, about 0.205 mm, about 0.215 mm, about 0.225 mm, about 0.235 mm, about 0.245 mm, about 0.255 mm, about 0.265 mm, about 0.275 mm, about 0.285 mm, about 0.295 mm, about 0.305 mm, about 0.315 mm, about 0.325 mm, about 0.335 mm, about 0.345 mm, about 0.355 mm, about 0.365 mm, about 0.375 mm, about 0.385 mm, about 0.395 mm, about 0.3 mm, approximately 0.06mm, approximately 0.07mm, approximately 0.08mm, approximately 0.09mm, approximately 0.1mm, approximately 0.15mm, approximately 0.2mm, approximately 0.25mm, approximately 0.3mm, approximately 0.35mm, approximately 0 .4mm, 0.45mm, 0.5mm, 0.55mm, 0.6mm, 0.65mm, 0.7mm, 0.75mm, 0.8mm, 0.85mm and 0.9mm.

[0087] The first and second electrodes 110, 112 may have an outer diameter within a range of about 20 American Wire Gauge (AWG) to about 60 AWG. In some embodiments, the first and second electrodes 110, 112 may have an outer diameter within a range bounded by any two of the following values: about 20 AWG, about 25 AWG, about 30 AWG, about 35 AWG, about 40 AWG, about 45 AWG, about 50 AWG, about 55 AWG, and about 60 AWG.

[0088] In some embodiments, the first electrode 110 may be connected (e.g., via wire 116) to a positive terminal of a high-voltage pulse generator and the second electrode 112 may be connected to a negative terminal of the high-voltage pulse generator to generate shock waves in a gap 114 between the two electrodes.

[0089] In some embodiments, the polarity of the first and second electrodes 110, 112 may be reversible. Polarity reversal during treatment may help extend the life of the first and second electrodes 110, 112, resulting in improved reproducibility of treatment across patients and devices.

[0090] The gap 114 between the first and second electrodes 110, 112 may be defined by the distance between the tips of the first and second electrodes 110, 112. In some embodiments, the distance between the tips of the electrodes may be in the range of about 0.05 mm to about 0.5 mm, such as in the range of about 0.1 mm to about 0.15 mm. For example, the distance may be about 0.05 mm, about 0.06 mm, about 0.07 mm, about 0.08 mm, about 0.09 mm, about 0.1 mm, about 0.11 mm, about 0.12 mm, about 0.13 mm, about 0.14 mm, or about 0.15 mm, about 0.16 mm, about 0.17 mm, about 0.18 mm, about 0.19 mm, about 0.2 mm, about 0.25 mm, about 0.3 mm, about 0.35 mm, about 0.4 mm, about 0.45 mm, or about 0.5 mm.

[0091] The gap 114 between the first and second electrodes 110, 112 may be sufficient to generate shock waves using voltage pulses in the range of about 3 kilovolts (kV) to about 4 kV. These voltages may be stepped / compounded and / or pre-pulsed and may be in the range of about 0-500V, 0-1000V, 0-1500V, 0-2000V, 0-2500V, 0-3000V, 0-3500V, or 0-4000V. The system may be configured to alternate the polarity of the voltage to extend the life of the electrodes.

[0092] The gap 114 between the first and second electrodes 110, 112 may be sufficient to generate shock waves using a current of about 50 amps.

[0093] The system may include one or more sensors. For example, a sensor may be coupled to one or more electrodes to determine the current flowing through the electrode(s). Alternatively, or in combination, a sensor may be provided to measure the conductivity of the saline solution exiting the fluid outlet, as described herein. Temperature, sonic cavitation (i.e., bubble formation) efficiency, and / or fluid pressure sensors may be located in the shockwave generation flow chamber (also referred to herein as the fluid-filled chamber) and may be used for intraoperative shockwave amplitude and focus adjustment. One or more sensors may be used to provide a uniform and stable delivery of shockwaves during treatment.

[0094] In some embodiments, the one or more sensors may be configured to perform elastography measurements of various ocular tissues (e.g., the cornea, lens, and / or retina) based on the pressure waves generated by the shock wave generator(s) 100.

[0095] In some embodiments, the system may include one or more pressure sensors configured to provide pressure feedback to the shockwave generator(s) 100.

[0096] In some embodiments, the housing 102 may be formed by molding, 3D printing, or the like.

[0097] In some embodiments, the shockwave generator 100 may be located at the distal end of a handheld probe.

[0098] FIG. 2 is a side view of an exemplary shockwave generator 100 adjacent to an eye 200. The shockwave generator 100 may be substantially similar to the shockwave generator 100 shown in FIG. 1. The shockwave generator 100 may include a first electrode 110 and a second electrode 112 disposed within a housing 102. The electrodes 110, 112 may be configured, for example, by gold-plated pins coupled to one or more insulated wires 116, as described herein. The housing 102 may be ellipsoidal, for example, to facilitate focusing of the shockwaves 204 in a desired direction and to a desired location on or below the surface of the eye. The housing 102 may include a fluid-filled chamber 106 and an eye-contacting surface 104 (also referred to herein as a tissue interface). The fluid-filled chamber 106 may be filled with a fluid, such as, for example, saline 206. The eye-contacting surface 104 may be configured to be coupled to a surface of a patient's eye. The first and second electrodes 110, 112 may be coaxially aligned with one another with a gap therebetween, as described herein.

[0099] The shock wave generator 100 may be configured to focus shock waves at a predetermined location on or under the surface of the eye. The shock wave generator 100 may be configured to focus shock waves at a predetermined location in the ocular tissue 200 in a transscleral, translimbal, or transcorneal manner. The predetermined location may be, for example, one or more of the following: circumferential (i.e., 360°) trabecular meshwork, Schlemm's canal, ciliary body (e.g., selected portions such as ciliary processes, muscles, anterior / posterior / middle ciliary body), pars plana, ciliary folds, cornea, sclera, lens, retina, orbit, periorbital, intermediate vitreous zonule (IVZ), posterior vitreous zonule (PVZ), vitreous, eyelid, and / or meibomian gland.

[0100] In some embodiments, the predetermined location may be on the surface of the eye, hi some embodiments, the predetermined location may be at a tissue depth within a range of up to about 30 mm below the surface of the eye (e.g., about 0.1 mm below the surface).

[0101] In some embodiments, the shock waves may generate pressures within the eye at the predetermined location at a magnitude up to about 100 MPa, for example, within a range of about 0.1 MPa to about 100 MPa. In some embodiments, the shock waves may generate pressures within the eye at the predetermined location at a magnitude within a range of about 0.05 MPa to about 5 MPa.

[0102] In some embodiments, a coupling fluid or gel 202 may be disposed on the eye-contacting surface 104 to facilitate contact between the eye-contacting surface 104 and the surface of the eye and / or to facilitate transmission of shock waves from the shockwave generator to the eye. The coupling fluid or gel 202 may help prevent misdirection of energy due to unwanted reflections caused by an air gap between the shockwave generator 100 and the surface of the eye. In some embodiments, the coupling fluid or gel 202 may include one or more therapeutic substances.

[0103] In some embodiments, the shockwave generator 100 has a shockwave output of approximately 0.1 mJ / mm 2 to about 10 mJ / mm 2 For example, the shockwave generator 100 may be configured to deliver energy to the eye within a range bounded by any two of the following values: 0.1 mJ / mm 2 , 0.2mJ / mm 2 , 0.3mJ / mm 2 , 0.4mJ / mm 2 , 0.5mJ / mm 2 , 0.6mJ / mm 2 , 0.7mJ / mm 2 , 0.8mJ / mm 2 , 0.9mJ / mm 2 , 1mJ / mm 2 , 1.5mJ / mm 2 , 2mJ / mm 2 , 2.5mJ / mm 2 , 3mJ / mm 2 , 3.5mJ / mm 2 , 4mJ / mm 2, 4.5mJ / mm 2 , 5mJ / mm 2 , 5.5mJ / mm 2 , 6mJ / mm 2 , 6.5mJ / mm 2 , 7mJ / mm 2 , 7.5mJ / mm 2 , 8mJ / mm 2 , 8.5mJ / mm 2 , 9mJ / mm 2 , 9.5mJ / mm 2 or 10 mJ / mm 2 .

[0104] In some embodiments, the shockwave generator 100 may be configured to deliver shockwaves having an energy rise time within a range of about 10 nanoseconds to about 100 microseconds. In some embodiments, the shockwave generator 100 may be configured to deliver shockwaves having an energy rise time within a range bounded by any two of the following values: 10 nanoseconds, 50 nanoseconds, 100 nanoseconds, 200 nanoseconds, 300 nanoseconds, 400 nanoseconds, 500 nanoseconds, 600 nanoseconds, 700 nanoseconds, 800 nanoseconds, 900 nanoseconds, 1 microsecond, 10 microseconds, 20 microseconds, 30 microseconds, 40 microseconds, 50 microseconds, 60 microseconds, 70 microseconds, 80 microseconds, 90 microseconds, or 100 microseconds.

[0105] In some embodiments, the shockwave generator 100 may have a pulse duration in the range of about 10 nanoseconds to about 10 microseconds. In some embodiments, the shockwave generator 100 may have a pulse duration in the range bounded by any two of the following values: 10 nanoseconds, 50 nanoseconds, 100 nanoseconds, 200 nanoseconds, 300 nanoseconds, 400 nanoseconds, 500 nanoseconds, 600 nanoseconds, 700 nanoseconds, 800 nanoseconds, 900 nanoseconds, 1 microsecond, 10 microseconds, 20 microseconds, 30 microseconds, 40 microseconds, 50 microseconds, 60 microseconds, 70 microseconds, 80 microseconds, 90 microseconds, or 100 microseconds.

[0106] In some embodiments, the shockwave generator 100 may deliver shockwaves at a repetition rate within a range of about 1 Hz to about 50 kHz, for example, within a range of about 1 Hz to about 1 kHz, for example, within a range of about 1 Hz to about 5 Hz. The shockwaves may be generated at a frequency of about 10 kHz. In some embodiments, the shockwave generator 100 may deliver shockwaves at a repetition rate within a range bounded by any two of the following values: 1 Hz, 5 Hz, 10 Hz, 50 Hz, 100 Hz, 200 Hz, 300 Hz, 400 Hz, 500 Hz, 600 Hz, 700 Hz, 800 Hz, 900 Hz, 1 kHz, 10 kHz, 20 kHz, 30 kHz, 40 kHz, or 50 kHz.

[0107] In some embodiments, the number of shock waves delivered by the shockwave generator 100 may be in the range of about 1 to about 10,000. It will be understood by one skilled in the art that the number of shock waves delivered may depend on the desired tissue transformation outcome of the treatment.

[0108] In some embodiments, the total time for treatment of the target tissue at a given location may be within a range of about 30 seconds to about 30 minutes, such as within a range of about 2 minutes to about 5 minutes. In some embodiments, the total time for treatment of the target tissue at a given location may be within a range bounded by any two of the following values: 30 seconds, 1 minute, 2 minutes, 3 minutes, 4 minutes, 5 minutes, 6 minutes, 7 minutes, 8 minutes, 9 minutes, 10 minutes, 11 minutes, 12 minutes, 13 minutes, 14 minutes, 15 minutes, 16 minutes, 17 minutes, 18 minutes, 19 minutes, 20 minutes, 21 minutes, 22 minutes, 23 minutes, 24 minutes, 25 minutes, 26 minutes, 27 minutes, 28 minutes, 29 minutes, or 30 minutes.

[0109] In some embodiments, the RF frequency of the electrodes 110, 112 may be in the range of approximately 3 Hz to 30 Hz, and 300 GHz to 3 THz. Lower power pre-pulses may be incorporated for tissue seeding.

[0110] The shock waves may be focused or unfocused. In some embodiments, focused shock waves are preferred for the delivery of a greater amount of energy to the target tissue to produce a biomechanical effect in the tissue. In some embodiments, unfocused shock waves may be preferred for the delivery of a lower level of energy to the target tissue to provide a gentle biochemical stimulation of the tissue.

[0111] In some embodiments, the shock waves may be focused at a predetermined location on or below the surface of the eye. The propagation of the focused waves may be non-linear and may undergo steepening. The shock waves have a rise time of about 0.01 microseconds, a compression of about 0.3 microseconds, a positive peak pressure in the range of about 0 to about 100 MPa, and a force of about 0 to about 3 mJ / mm. 2 The energy flux density at a given location may be

[0112] In some embodiments, the shock waves may be delivered to a location on or below the surface of the eye without focusing. Unfocused waves may be diverging, converging, or plane waves. The propagation of unfocused waves may be linear and may not experience steepening. Shock waves have a rise time of about 50 nanoseconds, a compression of about 200 nanoseconds to about 10 microseconds, a positive peak pressure in the range of about 0 to about 10 MPa, and a force of about 0 to about 0.3 mJ / mm. 2 The energy flux density at a given location may be

[0113] 3 is a top view of an array 300 of shockwave generators 100. In some embodiments, the array 300 may consist of eight shockwave generators 100 spaced equally in a ring of about 10 mm to about 15 mm diameter around the limbus 302 for limbal guided glaucoma treatment. The limbal guided glaucoma treatment may be focused toward the trabecular meshwork and / or Schlemm's canal as described herein. Focusing shockwaves at multiple locations along the trabecular meshwork and / or Schlemm's canal may improve the expansion and fluid outflow of the treated tissue, lowering intraocular pressure in glaucomatous eyes.

[0114] An array of shockwave generators may be comprised of two or more shockwave generators 100. For example, an array may be comprised of 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50 or more shockwave generators. An array of shockwave generators may be comprised of any desired number of shockwave generators.

[0115] The shock wave generating devices 100 may be connected in parallel or in series.

[0116] The shockwave generators 100 may be configured to be energized independently of each other or simultaneously. In some embodiments, all of the shockwave generators 100 may be activated simultaneously. In some embodiments, none of the shockwave generators may be activated simultaneously. In some embodiments, at least two shockwave generators 100 may be activated simultaneously. In some embodiments, each shockwave generator may be controlled independently.

[0117] In some embodiments, each shockwave generator 100 may be configured to be energized circumferentially sequentially. In at least some embodiments, it may be preferable to fire the shockwaves one at a time to avoid the formation of unintended constructive shockwaves within the eye that may result in undesirable tissue effects at or outside of the predetermined target location.

[0118] Figure 4 is a top view of an array 400 of shockwave generators 100 arranged in multiple rows. Figure 5 is a side view of the array 400 arranged on the surface 500 of the eye 200. The array 400 may be composed of at least two rows of shockwave generators 100. For example, the array 400 may be composed of a first row 402, a second row 404, and a third row 406. Each row may be arranged such that the shockwaves generated by each row are targeted to a different location on or under the surface of the eye.

[0119] For example, a first row 402 may be positioned around the limbus to treat and dilate the trabecular meshwork and / or Schlemm's canal, as shown in Figure 3, a second row 404 may be positioned radially outward from the first row 402 and over the ciliary body folds to treat the scleral tissue and / or ciliary body underneath, and a third row 406 may be positioned radially outward from the second row 404 and over the pars plana to treat the scleral tissue and / or ciliary body underneath, for example, to increase porosity. Increased porosity in the pars plana and / or nearby intermediate stroma over the ciliary folds can, for example, improve fluid conductivity / transport of the suprachoroid, ciliary body, and / or lymphatic outflow pathways of the eye, lowering IOP for treating glaucoma.

[0120] It will be understood by those skilled in the art based on the teachings herein that the number of rows, the spacing between the shockwave generators, and the location of the rows may be configured to treat one or more desired indications. In some embodiments, the rows may be equally spaced apart from one another. In some embodiments, the rows may be spaced apart at different distances from one another. In some embodiments, each shockwave generator in a row may be spaced apart the same distance (i.e., equidistant) from one another. In some embodiments, one or more shockwave generators may be unequally spaced apart from one or more other shockwave generators. In some embodiments, the array of shockwave generators may include 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, or more rows as desired. The number of rows may or may not correspond to the number of ophthalmic disorders to be treated in the eye.

[0121] FIG. 6 is a side cross-sectional view of an exemplary shockwave generator array system 600 with a cone coupled to an eye. The system 600 may include an array of shockwave generators that may be substantially similar to any of the shockwave generator arrays described herein. For example, the system 600 may include an array of shockwave generators 100 arranged in an annular arrangement of three spaced rows as described in FIGS. 4 and 5. The shockwave generators 100 may be coupled to a surface 500 of the eye 200, for example, to the sclera or limbus of the eye. In some embodiments, the shockwave generators 100 may comprise individual housings that define a fluid-filled chamber, as shown in FIG. 1. Alternatively, one or more shockwave generators 100 may share a fluid-filled chamber or housing. For example, instead of individual housings, the shockwave generators 100 may be disposed within a housing configured to form a water channel 602 for immersing the shockwave generators 100 in a fluid. The walls of the water channel 602 may be constructed from PET. The system 600 may further include a cone 604 disposed about the walls of the flume 602 and may include a speculum and a suction ring.

[0122] FIG. 7 is a side cross-sectional view of an exemplary shockwave generator array system 700 comprising a contact lens 702 coupled to a surface 500 of the eye 200. The system may include one or more shockwave generators 100, which may be substantially similar to any of the shockwave generators described herein. For example, the shockwave generator 100 may comprise a pair of electrodes 110, 112 as described herein. The shockwave generator 100 may be disposed beneath the contact lens 702. A film 704 may be disposed across the bottom of the contact lens 702 to form a fluid-filled chamber 106 around the shockwave generator 100. The film 704 may comprise an eye-contacting surface configured to be coupled to the surface of the eye, which may be substantially similar to any of the eye-contacting surfaces described herein. The fluid-filled chamber 106 may be filled with saline 206 as described herein. In some embodiments, the shockwave generating device 100 may further comprise a fluid inlet and a fluid outlet in fluid communication with the fluid-filled chamber 106, as described herein.

[0123] In some embodiments, the contact lens 702 may be configured to act as a reflector to focus the shock waves toward a desired predetermined location. Alternatively, or in combination, one or more reflectors may be coupled to an inner surface of the fluid-filled chamber 106 to focus the shock waves. The reflectors coupled to the inner wall of the fluid-filled chamber 106 or to the inner surface of the fluid-filled chamber 106 may be ellipsoidal.

[0124] In some embodiments, the system 700 may comprise an array of shockwave generators 100. For example, the system 700 may include eight shockwave generators 100 spaced at 45° intervals along a circular pattern on the surface of the eye.

[0125] In some embodiments, the system 700 may be securely coupled to the eye using suction (eg, via suction rings) on the inner and outer edges of the annular contact lens 702 .

[0126] In some embodiments, the film may be constructed from PET.

[0127] The film may be composed of nylon, polyethylene terephthalate (PET), biaxially oriented polyethylene terephthalate (BoPET), etc. The film may be composed of polytetrafluoroethylene (PTFE), ethylene tetrafluoroethylene (ETFE), fluorinated ethylene propylene (FEP), polyoxymethylene (POM, e.g., DELRIN® available from DuPont), polyether block esters, polyurethanes (e.g., Polyurethane 85A), polypropylene (PP), polyvinyl chloride (PVC), polyetheresters (e.g., ARNITEL® available from DSM Engineering Plastics), ether or ester based copolymers (e.g., butylene / poly(alkylene ether) phthalates and / or polyester elastomers such as HYTREL® available from DuPont), polyamides (e.g., DURETHAN® available from Bayer or CRISTA® available from Elf Atochem), or other polymers such as ethylene glycol, propylene glycol, propylene glycol terephthalate ... D®), elastomeric polyamides, block polyamide / ethers, polyether block amides (PEBA, sold, for example, under the trade name PEBAX®), ethylene vinyl acetate copolymers (EVA), silicones, polyethylene (PE), Marlex high density polyethylene, Marlex low density polyethylene, linear low density polyethylene (for example, REXELL®), polyester, polybutylene terephthalate (PBT), polyethylene terephthalate (PET), polytrimethylene terephthalate, polyethylene naphthalate (PEN), polyester ether ketone (PEEK), polyimide (PI), polyetherimide (PEI), polyphenylene sulfide (PPS), polyphenylene oxide (PPO), polyparaphenylene terephthalamide (for example, KEVLAR®), polysulfone, nylon, nylon 2 (for example, GRK available from EMS American Grillon, Inc.AMID®), perfluoro(propyl vinyl ether) (PFA), ethylene vinyl alcohol, polyolefins, polystyrene, epoxies, polyvinylidene chloride (PVdC), poly(styrene A isobutylene A styrene) (e.g., SIBS and / or SIBS 50A), polycarbonates, ionomers, biocompatible polymers, other suitable materials or mixtures, combinations, copolymers, polymer / metal composites, and the like. In some embodiments, the film may be comprised of a mixture blended with a liquid crystal polymer (LCP) (e.g., up to about 6% LCP).

[0128] FIG. 8 is a perspective view of a shockwave generator 800. The shockwave generator 800 may be substantially similar to the shockwave generator 100 described herein, except that the housing 102 may include an internally disposed reflector 802 instead of having an inner wall of the housing 102 acting as a reflector. The shockwave generator 100 may include a pair of electrodes 110, 112 disposed within the housing 102 as described herein. The housing 102 may include a fluid-filled chamber 106 and an eye-contacting surface 104. The eye-contacting surface 104 may be configured to be coupled to a surface of a patient's eye. The first and second electrodes 110, 112 may be coaxially aligned with one another such that a gap 114 is formed between the distal tips of the electrodes 110. The fluid-filled chamber 106 may be filled with saline 206 as described herein. In some embodiments, the shockwave generating device 100 may further comprise a fluid inlet and a fluid outlet in fluid communication with the fluid filled chamber 106, as described herein. The reflector 802 may be configured to help focus the shockwaves towards a predetermined location on or below the surface 500 of the eye 200, as described herein.

[0129] 9 is a side view of multiple shockwave generators 800 coupled to the surface 500 of the eye 200. In some embodiments, multiple shockwave generators 800 may be positioned on the surface 500 of the eye simultaneously. For example, the multiple shockwave generators 800 may consist of multiple individual shockwave generators or an array of shockwave generators. In some embodiments, the multiple shockwave generators 800 may comprise multiple shockwave generators positioned at the distal end of a handheld probe.

[0130] FIG. 10 is a side view of a plurality of shockwave generators 800 coupled to an ocular surface 500 having a contact lens 702. The shockwave generators 800 may be disposed beneath the contact lens 702. A film 704 may be disposed across the bottom surface of the contact lens 702 to form a fluid-filled chamber 106 around the shockwave generators 800. The film 704 may include an eye-contacting surface configured to be coupled to the ocular surface, which may be substantially similar to any of the eye-contacting surfaces described herein. The fluid-filled chamber 106 may be filled with saline 206 as described herein. In some embodiments, the shockwave generators 800 may further comprise a fluid inlet and a fluid outlet in fluid communication with the fluid-filled chamber 106 as described herein. Alternatively, or in combination, one or more of the plurality of shockwave generators 800 may constitute their own fluid-filled chamber, independent of one or more of the other shockwave generators 800. The film 704 may be placed across the bottom of the contact lens 702 to form individual fluid-filled chambers 106 of the shockwave generators 800, each of which may have a dedicated fluid inlet and outlet.

[0131] 11 is a side cross-sectional view of multiple shockwave generators 100 coupled to a surface 500 of the eye 200 using a contact balloon (also referred to herein as a fluid cushion) 1100. The contact balloon 1100 may comprise an inflatable outer housing 1102 within which multiple shockwave generators 100 are embedded. The outer housing 1102 may define an inner chamber 1106 that may be filled with a liquid, such as saline 206, to inflate the outer housing 1102 before, during, or after placement of the contact balloon 1100 on the surface 500 of the eye 200 (e.g., adjacent the limbus, sclera, eyelid, etc., as described herein). Each shockwave generator 100 may comprise a pair of coaxially aligned electrodes 110, 112 and a reflector 802, as described herein. The electrodes 110, 112 may be coupled to a voltage pulse generator, as described herein. The reflector 802 may be configured to help focus the shock waves towards a predetermined location on or below the surface 500 of the eye 200, as described herein. In some embodiments, the shock wave generators 100 may be arranged in multiple annular rows, as described herein, to target multiple locations on the eye. For example, a first row of shock wave generators may be arranged adjacent to the limbus and configured to focus shock waves on the trabecular meshwork and Schlemm's canal. A second row of shock wave generators may be arranged adjacent to and radially outward from the ciliary fold, and a third row of shock wave generators may be arranged adjacent to and radially outward from the second row. The second and / or third rows of shock wave generators may be configured to focus shock waves on, for example, the sclera, the ciliary fold, the ciliary body plana, the ciliary body, the IVZ, and / or the PVZ.

[0132] In some embodiments, the fluid filling the inner chamber 1106 of the contact balloon 1100 may be a cooled or temperature controlled liquid.

[0133] The outer housing 1102 may be constructed from a compliant material. Alternatively, or in combination, at least a portion of the outer housing 1102 may be constructed from a non-compliant material.

[0134] The outer housing 1102 may be constructed from any biocompatible plastic known to those of skill in the art.

[0135] In some embodiments, a coupling fluid or gel may be present on the eye-contacting surface of the outer housing to facilitate contact between the eye-contacting surface and the surface of the eye and / or to facilitate transmission of shock waves from the shock wave generating device to the eye.

[0136] In some embodiments, a therapeutic substance may be disposed between the eye-contacting surface and the surface of the eye. The therapeutic substance may be provided, for example, in a layer bonded to the eye-contacting surface. In some embodiments, the therapeutic substance may include microcapsules formed from polymers, starch, and / or glucose. Delivery of shock waves from a shockwave generator within the housing to a predetermined location on the eye can facilitate delivery of the therapeutic substance to the eye.

[0137] In some embodiments, any of the shock wave generators described herein may be configured to facilitate the delivery of small molecular weight molecules, such as methylene blue, riboflavin, or small therapeutic molecules.

[0138] FIG. 12 is a side cross-sectional view of multiple shockwave generators coupled to the eye by a contact balloon 1200. The contact balloon 1200 may be substantially similar to the contact balloon 1100, except that the contact balloon 1200 may be comprised of multiple non-homologous shockwave generators 100. For example, the contact balloon 1200 may comprise one or more shockwave generators 100a configured to generate focused shockwaves and one or more shockwave generators 100b configured to generate unfocused shockwaves. Providing multiple shockwave generators 100 with different focal points may allow a single array of shockwave generators to treat multiple predetermined locations and / or induce multiple bioeffects within the same predetermined location. The contact balloon 1200 may be coupled to the eye with suction rings 1202 on the inner and outer edges of the annular contact balloon 1200.

[0139] FIG. 13 is an exploded side view of an exemplary shockwave generator 100 adjacent to the eye. The shockwave generator 100 may be embedded within a fluid-filled contact balloon 1300 as described herein. The shockwave generator 100 may include a pair of electrodes 110, 112 having a gap 114 between their tips configured to generate an electrical arc therebetween. The contact balloon 1300 may be filled with a fluid, such as saline 206, and the resulting shockwaves may propagate through the fluid 206 (which may act as an acoustic window) as described herein. An acoustic reflector or lens 1302 may be positioned above the electrodes 110, 112 to focus the shockwaves toward a predetermined location on or below the surface 500 of the eye 200 as described herein. The reflector 1302 may have a convex shape, for example. The eye-contacting surface 1304 of the contact balloon 1300 may be coupled directly or indirectly (e.g., with a gel or saline interface 202 therebetween) to a surface 500 of the eye 200. The ocular surface 500 may comprise, for example, the conjunctiva or cornea of ​​the eye 200.

[0140] 14 is an exploded side view of another exemplary shockwave generator 100 adjacent to the eye 200. The shockwave generator 100 may be embedded within a contact balloon 1400 as described herein. The shockwave generator 100 may be substantially similar to the shockwave generator shown in FIG. 13, except that the reflector 1402 may have a concave shape. The eye-contacting surface 1404 of the contact balloon 1400 may be coupled directly or indirectly (e.g., with a gel or saline interface 202 therebetween) to the surface 500 of the eye 200.

[0141] FIG. 15 is a side cross-sectional view of multiple shockwave generators 100 coupled to the eye 200 by a contact balloon 1500, and FIG. 16 is a perspective view of the system of FIG. 15 coupled to the eye 200. The contact balloon 1500 may comprise an inflatable outer housing 1502 having multiple shockwave generators 100 embedded therein. The outer housing 1502 may define an inner chamber 1506 that may be filled with a fluid 206, such as saline, to inflate the outer housing 1502 before, during, or after placement of the contact balloon 1500 on the surface 500 of the eye 200 (e.g., adjacent the limbus, sclera, eyelid, etc., as described herein). Each shockwave generator 100 may comprise a pair of coaxially aligned electrodes and a reflector, as described herein. The reflector may be configured to help focus the shockwaves toward a predetermined location on or below the surface of the eye, as described herein. In some embodiments, the shockwave generators 100 may be arranged in a ring shape in multiple rows connected by wires to target multiple locations on the eye. For example, a first row of shockwave generators may be arranged adjacent to the limbus and configured to focus shockwaves on the trabecular meshwork and Schlemm's canal. A second row of shockwave generators may be arranged adjacent to and radially outward from the ciliary folds, and a third row of shockwave generators may be arranged adjacent to and radially outward from the second row. The second and / or third rows of shockwave generators may be configured to focus shockwaves on, for example, the sclera, the ciliary folds, the ciliary body plana, the ciliary body, the IVZ, and / or the PVZ.

[0142] In some embodiments, the fluid 206 filling the inner chamber of the contact balloon 1500 may be a chilled or temperature-controlled liquid.

[0143] The outer housing 1502 may be constructed of a compliant material. Alternatively, or in combination, at least a portion of the outer housing may be constructed of a non-compliant material.

[0144] The outer housing 1502 may be constructed from a biocompatible plastic as known to those skilled in the art. For example, the outer housing may be constructed from PMMA or other shaped biocompatible materials.

[0145] In some embodiments, the eye-contacting surface 1504 of the outer housing may be configured to conform to the surface of the eye in a manner similar to a conventional soft contact lens.

[0146] In some embodiments, a coupling fluid or gel may be present on the eye-contacting surface of the outer housing to facilitate contact between the eye-contacting surface and the surface of the eye and / or to facilitate transmission of shock waves from the shock wave generating device to the eye.

[0147] 17 is a perspective view of the system 1500 of FIG. 15 coupled to additional tubes and / or wires 1700. In some embodiments, the additional tubes and / or wires 1700 may be comprised of a cable including an inner conductor and an outer conductive shield insulated from the inner conductor. A first portion of the coaxially arranged electrodes may be formed at least in part by the central conductor of the cable, and a second portion of the coaxially arranged electrodes may be formed at least in part by the outer conductive shield of the cable.

[0148] Figure 18 is a side view of a system 1800 comprising the system 1500 of Figure 17 with tubes and / or wires 1700 coupled to a power source 1802. The tubes and / or wires 1700 may be coupled to a fluid source for inflation of the contact balloon and / or fluid circulation for conductivity sampling, as described herein.

[0149] The power supply 1802 may comprise a high voltage pulse generator. In some embodiments, the power supply 1802 may comprise a high voltage capacitor charging power supply. A gated high voltage electronic driver may be coupled to the shockwave generator(s) 100 and may be adapted to control the drive voltage of the electrodes in response to safety feedback mechanisms such as maximum current (e.g., as sensed by a current sensor as described herein), dwell time before current onset, temperature rise (e.g., of the electrode, fluid, or ocular surface), peak pressure, and / or elasticity changes.

[0150] The power supply 1802 may be on the order of about 1 kV to about 10 kV.

[0151] Any of the systems described herein may include a processor (e.g., processor 7002 shown in FIG. 70) having a tangible medium (e.g., RAM). The processor may be configured to include one or more instructions for performing any one of the steps and substeps of the methods and / or treatments described herein. The processor may include a memory having instructions for performing the method, and the processor may include, for example, a processor system configured to perform the method. In many embodiments, the processor is comprised of array logic, such as, for example, a programmable array logic (PAL), configured to perform one or more steps of any of the methods or treatments described herein.

[0152] The processor may be configured with one or more instructions of a treatment program embodied in a tangible medium, such as a computer memory or a gate array, to perform one or more steps of the treatment methods disclosed herein. The processor may include instructions for treating a patient according to the embodiments described herein.

[0153] The processor may be operatively coupled to the energy source and configured with instructions to provide energy to the shockwave generator(s) with treatment parameters as described herein. For example, the processor may be configured with instructions to provide multiple shockwaves to predetermined locations on or below the surface of the eye according to a desired treatment pattern and parameters. In embodiments in which more than one shockwave generator is coupled to the eye at one time, the processor may be configured with instructions to sequentially or simultaneously provide energy to the multiple shockwave generators based on a predetermined treatment pattern input by a user or generated by the processor based on user input (e.g., an image or a desired treatment effect).

[0154] Any of the systems described herein may include an imaging system, such as, for example, an ultrasound biomicroscopy (UBM), ultrasound (US) imaging, and / or optical coherence tomography (OCT) device or system. The imaging system may be used to capture one or more images of the eye before, during, or after treatment as described herein. A processor or controller may be coupled to the energy source and the imaging system and configured with instructions to provide energy to the shockwave generator and image the tissue during treatment. The system may also include a display coupled to the processor and allowing the user to visualize the tissue before, during, or after treatment. The display may display images that allow the user to see the tissue being treated and plan the treatment. The images shown on the display may be provided in real time and can be used pre-treatment (e.g., dislocating ocular structures relative to one another when undesired) to allow the user to align the tissue and / or monitor tissue effects of the treatment (e.g., cavitation) to ensure that unintended effects of the treatment are not occurring.

[0155] For example, one or more shockwave generators may include a central opening configured to allow for incorporation of an OCT or wavefront imaging system or sensor therein. In some embodiments, multiple shockwave generators may be arranged in an annular ring around a central imaging system to allow for passive cavitation monitoring. Those skilled in the art will appreciate that many configurations of shockwave generators and imaging devices can be created based on the description herein.

[0156] FIG. 19 is a perspective view of a contact balloon 1900 including multiple shockwave generators 100 embedded therein. The contact balloon 1900 may be substantially similar to any of the contact balloons described herein. The multiple shockwave generators 100 may be substantially similar to any of the shockwave generators described herein. The shockwave generators 100 may constitute an array of shockwave generators as described herein. For example, the array of shockwave generators may be coupled to a power source via intervening wires 116 in series or parallel as described herein. The array of shockwave generators may be disposed within a fluid-filled chamber 1906 of the contact balloon 1900 as described herein. The fluid-filled chamber 1906 may comprise a fluid, such as saline, as described herein. The contact balloon 1900 may comprise an inflatable fluid-filled chamber 1906 configured to expand when a fluid is introduced therein as described herein. The contact balloon 1900 may comprise a fluid inlet 108 and a fluid outlet 109 as described herein. The contact balloon 1900 may be secured to the eye using a suction portion 1202 (eg, having one or more suction rings) as described herein.

[0157] FIG. 20 is a partial perspective view of a multiple stacked ring conductor shock wave generator 2000. FIG. 21 is an exploded view of the ring conductor shock wave generator 2000 of FIG. 20. The stacked ring conductor shock wave generator 2000 may be comprised of multiple ring conductors "stacked" around each other such that adjacent rings are within a predetermined distance of each other. The ring conductor may comprise an insulated conductor 2100 wound around an insulated structural ring 2102. The insulated ring conductor 2102 may comprise one or more openings 2104 spaced a predetermined distance from another opening in the insulator of the same or adjacent ring conductor to form a gap through which shock waves can form in a manner substantially similar to that described herein with respect to the concentric electrode embodiment. The exposed conductor openings 2104 may be used to generate shock waves as described herein. In some embodiments, the insulated conductors 2100 and exposed or uninsulated conductors 2106 may be wound around the insulated structural ring 2102 such that each loop goes from exposed to insulated and back to exposed. The openings 2104 of the insulated conductors 2100 may be spaced a predetermined distance from the exposed conductors 2106 of the same or adjacent ring conductors to form gaps through which shock waves can be generated as described herein. The stacked ring conductor shock wave generator 2000 may be placed in a fluid (e.g., saline) environment such as a contact lens or balloon contact lens as described herein.

[0158] FIG. 22 illustrates an exemplary treatment pattern for glaucoma. One or more shockwave generators, e.g., an array 2200 of shockwave generators 100, may be placed on the surface 500 of the eye 200 as described herein. The shockwave generator(s) 100 may be substantially similar to any of the shockwave generators described herein. The shockwave generators may be configured to target one or more tissue locations of the eye 200 to reduce intraocular pressure. For example, multiple shockwave generators may be placed above the limbus 302 of the eye as described herein, and shockwaves may be focused toward the trabecular meshwork and / or Schlemm's canal 2202 to cause its dilation and improve fluid outflow from the eye. Alternatively, or in combination, multiple shockwave generators may be placed above the pars plana as described herein, and shockwaves may be focused on the sclera 2204 and / or ciliary body 2210 to generate microperforations therein to facilitate uveal outflow. Alternatively, or in combination, one or more shockwave generators may be placed on the cornea 2206 and shockwaves may be focused on the retina 2208 to provide low energy acoustic stimulation there for vasodilation and neovascularization, and to enhance neurotrophic delay in retinal ganglion cell (RGC) and / or retinal pigment epithelium (RPE) cell degeneration. Retinal targeting may also stimulate RPE cells to reset the homeostatic intraocular pressure set point (and subsequently lower intraocular pressure) to inhibit aqueous humor production.

[0159] FIG. 23 illustrates an exemplary treatment pattern for presbyopia. One or more shockwave generators, e.g., an array 2300 of shockwave generators 100, may be disposed on the surface 500 of the eye 200 as described herein. The shockwave generator(s) 100 may be substantially similar to any of the shockwave generators described herein. The shockwave generators may be configured to target one or more tissue locations of the eye 200 to improve the accommodation amplitude of the eye. For example, multiple shockwave generators may be disposed on the sclera 2204 of the eye, and shockwaves may be focused towards the IVZ 2304 and / or PVZ 2306 to cause its dissection and improve its movement. Alternatively, or in combination, multiple shockwave generators may be disposed above the pars plana, and shockwaves may be focused on the sclera 2204 to generate micro-perforations therein and improve compliance and anterior and centripetal movement of the ciliary tip thereof. Alternatively, or in combination, one or more shockwave generators may be placed on the cornea 2206 and shockwaves may be focused on the crystalline lens 2302 (natural or intraocular lens (IOL)) to cause de-agglomeration and softening of the lens and initiate lens epithelial cell (LEC) apoptosis. Different effects and treatment locations can be targeted by varying the focal depth (e.g., by the ellipsoid of the reflective element), adjusting the amount of energy delivered per shockwave (e.g., by adjusting the voltage or power of the laser delivered to the electrodes), adjusting the repetition rate of the treatment, etc.

[0160] FIG. 24 illustrates an exemplary treatment pattern for AMD. A shockwave generator 2400, which may be substantially similar to any of the shockwave generators described herein, may be placed on the surface of the eye. The shockwave generator 2400 may be configured to focus shockwaves on the retina 2208. In some embodiments, multiple shockwave generators 2400 may be placed on the surface 500 of the eye 200 and configured to direct shockwaves to multiple locations on the retina. For example, shockwaves may be directed to the pan-macular, to the foveal periphery, and / or to the central retina (e.g., shockwaves may be directed to a central 6 mm diameter portion of the retina). Shockwaves may be directed transcorneal toward the retina 2208 without heating or damaging any tissue in between. Shockwave treatment of the central retina may stimulate angiogenesis and vasodilation while treating retinal ganglion cells (RGCs) and / or retinal vascular plexus for neural and / or endothelial protection to reduce or reverse the progression of AMD.

[0161] FIG. 25 is a top view of an exemplary treatment system 2600 for AMD. FIG. 26 is a side cross-sectional view of the system 2600 of FIG. 25. An array of large (e.g., 5 mm outer diameter) shockwave generators 2500 may be arranged in an annular pattern adjacent to the limbus 302 of the eye 200 (e.g., an annular shape with a diameter of about 11 mm). By using large shockwave generators 2500, the system 2600 can deliver biologically relevant shockwave energy to a greater focal depth within the eye than is possible with smaller shockwave generators. The array may, for example, comprise four shockwave generators 2500. The shockwave generators 2500 may be substantially similar to any of the shockwave generators described herein. The array of shockwave generators 2500 may be arranged on the surface 500 of the eye 200, for example, on the sclera 2204. In some cases, it may be beneficial to direct the shockwaves transscleral without passing through the cornea 2206. The array of shockwave generators 2500 may be configured to treat one or more predetermined locations on the retina 2208, for example, the periorbital area (e.g., an annular treatment pattern of about 6 mm diameter and about 23 mm depth within the eyeball), to stimulate angiogenesis and vasodilation in the retina to reduce or reverse the progression of AMD. Vascular effects can be stimulated, for example, by directing low-energy broadband shockwaves to the orbit in an annular area of ​​5.5 mm diameter over the center of the retina for pan-macular irradiation. Treating the periorbital area may result in greater recruitment of RPE cells and their stimulation to generate vasodilation and choroidal neovascularization compared to treating the orbit. Shockwaves can be applied to the retina without damaging the optic nerve.

[0162] The array 2600 may be disposed within a contact lens 2602, as described herein. In some embodiments, the contact lens 2602 may include an imaging port 2604 configured to receive an imaging device therein, such as an OCT transducer. The treatment may be monitored by the imaging device, as described herein.

[0163] FIG. 27 illustrates another exemplary treatment system 2700 for AMD. The system 2700 may include a large aperture shock wave generator 2500 configured to deliver shock waves onto the retina 2208. The shock wave generator 2500 may be substantially similar to any of the shock wave generators described herein. For example, the shock wave generator 2500 may include a first electrode 110 and a second electrode 112 disposed within a housing 102. The housing 102 may include a fluid-filled chamber 106 and an eye-contacting surface 104. The fluid-filled chamber 106 may be configured to act as a reflector to focus the shock waves toward a desired predetermined location. Alternatively, or in combination, one or more reflectors may be coupled to an inner surface of the fluid-filled chamber 106 to focus the shock waves. The inner wall of the fluid-filled chamber 106 or a reflector coupled to an inner surface of the fluid-filled chamber 106 may be ellipsoidal. The conjugate points of the ellipse 2702 may be configured such that the shock waves pass through the lens 2302 of the eye and are focused, and then refract the shock waves onto the retina 2208 of the eye. The shockwave generator 2500 may have an ellipsoidal footprint on the sclera 2204 with an aperture of around 12 mm. Due to the large size of the shockwave generator 2500, the predetermined location on the retina 2208 may be relatively large (e.g., 6 mm in diameter) compared to smaller shockwave generators that may facilitate rapid treatment of the retina 2208. The eye contact surface 104 may be configured to be coupled to the surface 500 of the patient's eye 200. A coupling fluid or gel, such as, for example, a water column 2704, may be disposed on or under the eye contact surface 104 to facilitate contact between the eye contact surface 104 and the surface 500 of the eye and / or to facilitate transmission of the shock waves from the shockwave generator 2500 to the eye 200. The first and second electrodes 110, 112 may be coaxially aligned with one another such that a gap 114 is formed between the distal tips of the electrodes 110, 112. The shockwave generating device 2500 may be configured to generate one or more shock waves.

[0164] FIG. 28 illustrates an exemplary treatment pattern for dry eye disease. In some patients, dry eye disease may be caused or exacerbated by meibomian gland dysfunction (MGD). Blockage of the meibomian glands 2800, which produce an oily substance that prevents evaporation of the eye's tear film, called meibum, may lead to evaporation of tears and dry eyes. One or more shockwave generators substantially similar to any of the shockwave generators described herein may be coupled to the eyelid 2802 adjacent to the meibomian glands, and low energy shockwaves may be directed at the meibomian glands 2800 to cause their expansion and promote secretion of meibum therefrom. Alternatively, or in combination, one or more high energy shock waves may be directed at the blockage in the meibomian gland to break up or destroy the blockage. In at least some instances, shock wave therapy may be more comfortable and / or more effective than current treatments for unblocking the meibomian gland, which include thermopulsing, punctal plugs, and drug therapy.

[0165] 29-32 show an exemplary treatment system 2900 for dry eye disease. FIG. 29 shows an array 2900 of shockwave generators 100 placed on the inner surface of the eyelid 2802 (i.e., lid placement) across multiple meibomian glands 2800. FIG. 30 shows an enlarged view of the array 2900 of shockwave generators that can be used to treat the meibomian glands 2800. The array 2900 of shockwave generators 100 may be substantially similar to any of the shockwave generators described herein. For example, the array 2900 of shockwave generators 100 may be constructed of coaxial conductors 110, 112 exposed to fluid as described herein to maintain a thin profile for patient comfort and ease of use. FIG. 31 shows multiple radial unfocused shockwaves 204 that can be generated by the shockwave generator array 2900 to treat the meibomian glands 2800. 32 is a cross-sectional view of an eye 200 in which an array 2900 of shockwave generators 100 are arranged in a ring around the limbus 302 to treat the meibomian glands 2800 of the eye 100 as described herein. The array 2900 of shockwave generators 100 may be disposed within a fluid-filled chamber 106 of a housing 102 having a fluid inlet 108 and a fluid outlet 109 as described herein.

[0166] FIG. 33 is a flattened top view of an exemplary treatment system 3300 for lens softening. FIG. 34 is a side cross-sectional view of the system 3300 of FIG. 33 disposed on an eye. One or more shockwave generators, for example an annular array of shockwave generators 100, may be disposed on the surface 500 of the eye 200 as described herein. The shockwave generator(s) 100 may be substantially similar to any of the shockwave generators described herein. The shockwave generators 100 may be configured to target the lens 2302 (natural or IOL) of the eye 200 to soften the lens 2302 (e.g., to improve the eye's accommodation amplitude). For example, multiple shockwave generators 100 may be disposed on the sclera 2204 of the eye, and shockwaves may be focused towards the lens 2302 to cause deagglomeration and softening of the lens and initiate LEC apoptosis.

[0167] 35 is a side cross-sectional view of an exemplary treatment system 3500 for presbyopia. One or more shockwave generators, for example, an array of shockwave generators 100, may be disposed on the surface 500 of the eye 200 as described herein. The shockwave generator(s) 100 may be substantially similar to any of the shockwave generators described herein. The shockwave generators 100 may be configured to target one or more tissue locations of the eye 200 to improve the accommodation amplitude of the eye. For example, multiple shockwave generators 100 may be disposed on the sclera 2204 of the eye, and shockwaves may be focused toward the IVZ 2304 and / or the PVZ 2306 to cause its dissociation and improve its movement. For example, a first annular row of shock wave generators may be configured to focus shock waves toward the IVZ 2304, and a second annular row of shock wave generators disposed radially outward from the first annular row may be configured to focus shock waves toward the PVZ 2306. Alternatively, or in combination, multiple shock wave generators 3506 may be positioned above the pars plana and shock waves may be focused at the sclera 2204 to create micro-perforations therein and enhance compliance and anterior and centripetal movement of the ciliary tip.

[0168] FIG. 36 is a side cross-sectional view of an exemplary treatment system 3600 for glaucoma. FIG. 37 is a top view of the system of FIG. 36. One or more shockwave generators, for example, an array of shockwave generators 100, may be disposed on the surface 500 of the eye 200 as described herein. The shockwave generator(s) 100 may be substantially similar to any of the shockwave generators described herein. The shockwave generators 100 may be configured to target one or more tissue locations of the eye 200 to reduce intraocular pressure. For example, multiple shockwave generators 100 may be disposed on the limbus 302 of the eye 200 as described herein, and shockwaves may be focused toward the trabecular meshwork and / or Schlemm's canal 2202 to cause its dilation and improve fluid outflow from the eye. The shockwave generators disposed on the limbus 302 may be configured as a first annular row 3602 of shockwave generators. Alternatively, or in combination, multiple shockwave generators 100 may be positioned above the pars plana as described herein, and shockwaves may be focused on the sclera 2204 and / or ciliary body 2210 to generate micro-perforations therein to facilitate uveal outflow. The shockwave generators 100 positioned above the pars plana may be configured as a second annular row 3604 of shockwave generators positioned radially outward from the first annular row.

[0169] FIG. 38 is a side cross-sectional view of an exemplary array 3800 of shockwave generators 100. FIG. 39 is a top view of the array of FIG. 38. The system 3800 may include one or more shockwave generators 100, which may be substantially similar to any of the shockwave generators described herein. For example, the shockwave generator 100 may include a pair of electrodes or optical fibers as described herein. The shockwave generator 100 may be disposed beneath a contact lens 3802. The contact lens 3802 may be substantially similar to any of the contact lenses described herein. A film 3804 may be disposed across a bottom surface of the contact lens 3802 to form a fluid-filled chamber 3806 around the shockwave generator. The film 3804 may include an eye-contacting surface configured to be coupled to a surface of an eye, which may be substantially similar to any of the eye-contacting surfaces described herein. The fluid-filled chamber 3806 may be filled with saline and / or graphene, as described herein. In some embodiments, the shockwave generator array 3800 may further comprise a fluid inlet 108 and a fluid outlet 109 in fluid communication with the fluid-filled chamber 3806, as described herein.

[0170] In some embodiments, the contact lens 3802 may be configured to act as a reflector to focus the shock waves toward a desired location. For example, the inner surface of the contact lens may have one or more ellipsoid shapes or structures embedded therein. Alternatively, or in combination, one or more reflectors may be coupled to the inner surface of the fluid-filled chamber to focus the shock waves. The reflectors coupled to the inner wall of the fluid-filled chamber 3806 or the inner surface of the fluid-filled chamber 3806 may be ellipsoids.

[0171] In some embodiments, the contact lens 3802 may be configured to a thickness of about 2.0 mm, about 1.5 mm, about 1.0 mm, or about 0.5 mm.

[0172] In some embodiments, the outer housing of the contact lens 3802 may be positioned approximately 1.5 mm above the surface of the eye when the film is placed thereon.

[0173] In some embodiments, the system 3800 may include an array of shockwave generators 100. For example, the system may include eight shockwave generators spaced at 45° intervals along a circular pattern on the surface of the eye, as shown in FIG. For example, an annular pattern having a diameter of 11 mm may have each shockwave generator spaced 4 mm from its nearest neighbour.

[0174] In some embodiments, the system 3800 may include an array comprising a plurality of shockwave annular rings as described herein. In some embodiments, when treating glaucoma, the first ring 3808 may have a diameter of about 11 mm to be positioned above the edge of the eye when the contact lens is placed thereon, the second ring 3810 may have a diameter of about 14 mm, and the third ring 3812 may have a diameter of about 17 mm. In some embodiments, when treating presbyopia, the pars plana and structures adjacent thereto may be treated with the first ring 3808 having a diameter of about 13 mm, the second ring 3810 having a diameter of about 16 mm, and the third ring 3812 having a diameter of about 19 mm. In some embodiments, the lens may be targeted with the first ring 3808 having a diameter of about 3 mm, the second ring 3810 having a diameter of about 6 mm, and the third ring 3812 having a diameter of about 9 mm.

[0175] In some embodiments, the system 3800 may be securely coupled to the eye by suction (eg, by suction ring 1202) on the inner and outer edges of the annular contact lens 3802.

[0176] FIG. 40 is a side cross-sectional view of an exemplary treatment system for AMD. The system may include a large diameter shock wave generator 4000 configured to deliver shock waves onto the retina 2208. The shock wave generator 4000 may be substantially similar to any of the shock wave generators described herein. For example, the shock wave generator 4000 may include a first electrode 110 and a second electrode 112 disposed within a housing 102. The housing 102 may include a fluid-filled chamber 106 and an eye-contacting surface 104. The fluid-filled chamber 106 may be configured to function as a reflector to focus the shock waves toward a desired predetermined location. Alternatively, or in combination, one or more reflectors may be coupled to an inner surface of the fluid-filled chamber 106 to focus the shock waves. The one or more reflectors may include, for example, an electronically variable acoustic lens 4002, which can variably focus the shock waves onto the macula of the retina 2208. The inner wall of the fluid-filled chamber 106 may be an ellipsoid. The conjugate points of the ellipsoid may be configured such that the shock waves are focused through the lens 2302 of the eye, which then refracts the shock waves onto the retina 2208 of the eye. The eye-contact surface 104 may be configured to be coupled to a surface 500 of the patient's eye. A coupling fluid or gel, such as, for example, a water column, may be disposed on or under the eye-contact surface to facilitate contact between the eye-contact surface 104 and the surface 500 of the eye and / or to facilitate transmission of the shock waves from the shockwave generator to the eye. A suction ring 1202 may be disposed on the outer edge of the shockwave generator 4000 to couple the shockwave generator 4000 to the cornea or sclera of the eye. The first and second electrodes 110, 112 may be coaxially aligned with one another such that a gap 114 is formed between the distal tips of the electrodes 110, 112. The shockwave generating device 4000 may be configured to generate one or more shockwaves.

[0177] FIG. 41 is a side cross-sectional view of an exemplary treatment system 4100 for dry eye disease. The system 4100 may include a large diameter shock wave generator 4102 configured to deliver shock waves onto a heat-diffusing contact lens 4104 disposed on the cornea 2206 of the eye. The shock wave generator 4102 may be substantially similar to any of the shock wave generators described herein. For example, the shock wave generator 4102 may include a first electrode 110 and a second electrode 112 disposed within a housing 102. The housing 102 may include a fluid-filled chamber 106 and an eye-contacting surface 104. The fluid-filled chamber 106 may be configured to function as a reflector to focus the shock waves toward a desired predetermined location. Alternatively, or in combination, one or more reflectors may be coupled to an inner surface of the fluid-filled chamber 106 to focus the shock waves. The inner wall of the fluid-filled chamber 106 or a reflector coupled to the inner surface of the fluid-filled chamber 106 may be ellipsoidal. The eye contact surface 104 may be configured to be coupled to the patient's eyelid 2802 (e.g., when the patient's eye is closed). A thermal diffusion contact lens 4104 may be positioned on the patient's cornea 2206 under the eyelid 2802 to facilitate the transfer of shock waves from the shock wave generator to the eye 200. The thermal diffusion contact lens 4104 may be configured to act as an acoustic reflector and direct shock waves toward one or more meibomian glands to treat dry eye as described herein. A suction ring 1202 may be positioned on an outer edge of the shock wave generator 4102 to couple the shock wave generator 4102 to the eyelid 2802. The first and second electrodes 110, 112 may be coaxially aligned with one another such that a gap 114 is formed between the distal tips of the electrodes 110, 112. The shock wave generator 4102 may be configured to generate one or more shock waves.

[0178] FIG. 42 is a cross-sectional view of an exemplary laser-based shockwave generator 4200. The shockwave generator 4200 may include a fiber optic cable 4202 disposed within a housing 102. The housing 102 may include a fluid-filled chamber 106 and an eye-contacting surface 104 as described herein. The eye-contacting surface 104 may be configured to be coupled to a surface 500 of a patient's eye as described herein. The optical fiber 4202 may be configured to generate one or more shockwaves within the fluid 206 of the fluid-filled chamber 106 upon emission of optical energy therefrom. A laser, for example a pulsed laser, may be coupled to the optical fiber 4202 to provide optical energy thereto. The shockwave generator system may include one or more sensors as described herein.

[0179] The shockwave generator 4200 may be configured to generate one or more shockwaves via the optical fiber 4202. The shockwave generator 4200 may be configured to treat one or more tissues or structures on or below the surface 500 of the eye with the shockwaves it generates. The treatment may be non-thermal. The shockwaves may be focused or unfocused at a predetermined location as described herein. The shockwaves may be used to locally fractionate, microporate, dilate, and / or sensorize desired ocular tissue. In some embodiments, the shockwaves may be used to produce biomechanical effects (vasodilation, microporation, softening, etc.) and / or biochemical effects (neovascularization, etc.) as described herein. In some embodiments, the shockwaves may be used for drug delivery to ocular tissue.

[0180] The fluid-filled chamber 106 may comprise a fluid 206 disposed therein. The fluid may comprise a biocompatible liquid that is electrically conductive (e.g., a conductivity of about 0.6 mS). The fluid may be water or saline. The fluid may be comprised of a suspension of graphene in saline. In some embodiments, the fluid may include a suspension of graphene in saline that can absorb light sufficiently to prevent or reduce the light emitted by the shockwave generator 4200. The fluid may be cooled (e.g., to about 10° C.). In some embodiments, the shockwave generator 4200 may further comprise a fluid inlet and a fluid outlet in fluid communication with the fluid-filled chamber 106. The fluid 206 may be used to couple the shockwaves generated by the optical fiber 4202 to the surface 500 of the eye. The fluid may circulate within the fluid-filled chamber 106 via the fluid inlet and the fluid outlet. The fluid circulation may allow for continuous extraction of heat accumulation, cavitation bubbles, and ions generated during shockwave formation while continuing the pulsed application of the shockwaves. In some embodiments, the fluid 206 exiting the fluid-filled chamber 106 via the fluid outlet may be sampled periodically or continuously as described herein.

[0181] The fluid-filled chamber 106 may be configured to act as a reflector to focus the shock waves toward a desired predetermined location. Alternatively, or in combination, one or more reflectors substantially similar to any of the reflectors described herein may be coupled to an inner surface of the fluid-filled chamber to focus the shock waves. The inner wall of the fluid-filled chamber 106 or the reflector coupled to the inner surface of the fluid-filled chamber 106 may be an ellipsoid as described herein.

[0182] In some embodiments, the optical fiber 4202 may be configured to emit a collimated beam of optical energy into the fluid in the fluid-filled chamber 106 .

[0183] The optical fiber 4202 may be coupled to a source of optical energy, for example, a laser. The laser may be a pulsed laser. The laser may be configured to emit light at a wavelength that is highly absorbed by water. The laser may be configured to emit light at a wavelength in the mid-infrared range, for example, 1.44 μm, 1.475 μm, 1.55 μm, 1.948 μm, or 6 μm. The laser may be, for example, a Nd:Yag laser or a Th:Ho laser, etc.

[0184] In some embodiments, the light energy pulses from the pulsed laser may be from about 1 Hz to about 25 Hz.

[0185] In some embodiments, the pulses of optical energy from a pulsed laser may be on the order of nanoseconds to microseconds in length.

[0186] In some embodiments, the laser may be a free-space scanning laser, or fiber-coupled delivery may be utilized depending on the access to the target tissue. For example, the scanning laser may be cone-coupled to the eye. The cone may position the scanning laser at a known working distance above the eye. A contact lens balloon filled with saline may be placed above the eye within the cone. The outer housing of the contact lens balloon may be transparent to the laser light (e.g., infrared-transparent if an infrared laser is used). The laser may be scanned on the contact lens balloon, and when the laser light reaches the fluid in the contact lens balloon, shock waves may be generated in a manner substantially similar to that described herein.

[0187] In some embodiments, the shockwave generator may be located at the distal end of a handheld probe.

[0188] In some embodiments, the laser shock wave generator 4200 may be positioned adjacent to the limbus 302 and configured to focus shock waves on the trabecular meshwork 4206 and Schlemm's canal 2202 and / or open the iridocornea 4204 for the treatment of glaucoma.

[0189] FIG. 43 is a side cross-sectional view of an array 4300 of laser-based shock wave generators 4200 within a fluid-filled contact lens 4302. The fluid-filled contact lens balloon 4302 may be substantially similar to any of the contact lenses described herein. For example, the contact balloon 4302 may be comprised of an inflatable outer housing 4304 having a plurality of ellipsoidal reflectors 4306 embedded therein. The outer housing 4304 may define an inner chamber 4308 that may be filled with a liquid, such as saline or graphene-enriched saline, to inflate the outer housing 4304 before, during, or after placement of the contact balloon 4302 on the surface of the eye (e.g., adjacent the limbus, sclera, eyelid, etc., as described herein). One or more optical fibers 4202 may be disposed within the fluid-filled chamber 4308 and configured to generate shock waves therefrom as described herein. The ellipsoidal reflectors 4306 embedded along the inner surface of the fluid filled chamber 4308 may be configured to help focus the shock waves towards a predetermined location on or below the surface of the eye, as described herein. In some embodiments, the reflectors 4306 may be arranged in multiple annular rows, as described herein, to target multiple locations on the eye. For example, a first row of reflectors may be arranged adjacent to the limbus and configured to focus the shock waves on the trabecular meshwork and Schlemm's canal. A second row of reflectors may be arranged radially outward therefrom adjacent to the ciliary folds, and a third row of shock wave generators may be arranged radially outward from the second row adjacent to the pars plana. The second and / or third row of reflectors may be configured to focus the shock waves on the sclera, ciliary folds, pars plana, ciliary body, IVZ, and / or PVZ, for example. As described herein, one or more suction rings may be positioned along one or more edges of the contact lens balloon 4302 to secure the contact lens balloon to the surface of the eye.

[0190] In some embodiments, the fluid filling the inner chamber 4308 of the contact balloon 4302 may be a chilled or temperature controlled liquid.

[0191] The outer housing 4304 may be constructed from a compliant material. Alternatively, or in combination, at least a portion of the outer housing 4304 may be constructed from a non-compliant material. In some embodiments, the outer housing may be constructed from polymethylmethacrylate (PMMA).

[0192] In some embodiments, a coupling fluid or gel 202 may be disposed on the eye-contacting surface 4310 of the outer housing 4304 to facilitate contact between the eye-contacting surface 4310 and the surface of the eye and / or to facilitate transmission of shock waves from the shock wave generator / reflector to the eye.

[0193] In some embodiments, an imaging device, such as, for example, a camera, OCT, or wavefront device, may be placed within the contact lens (e.g., at the center of the cornea) to increase intraoperative accuracy of pressure wave delivery as described herein.

[0194] FIG. 44 is a perspective view of an array 4400 of laser-based shock wave generators 4200 in an annular fluid-filled contact lens 4402. FIG. 45 is a side cross-sectional view of the system 4400 of FIG. 44. FIG. 46 is a top view of the system 4400 of FIG. 44. The system 4400 may include one or more shock wave generators 4200, which may be substantially similar to any of the shock wave generators described herein. For example, the shock wave generator 4200 may include one or more optical fibers 4202 as described herein. The shock wave generator 4200 may be disposed under the contact lens or within the contact lens balloon 4402 as described herein. A film 4404 may be disposed across the bottom surface of the contact lens 4402 to form a fluid-filled chamber 4406 around the shock wave generator 4200. The film 4404 may comprise an eye-contacting surface configured to be coupled to an ocular surface 500, which may be substantially similar to any of the eye-contacting surfaces described herein. The fluid-filled chamber 4406 may be filled with saline and graphene, as described herein. In some embodiments, the system 4400 may further comprise a fluid inlet 108 and a fluid outlet 109 in fluid communication with the fluid-filled chamber 4406, as described herein.

[0195] In some embodiments, the contact lens 4402 may be configured to act as a reflector to focus the shock waves toward a desired predetermined location. For example, the inner surface of the contact lens may be comprised of one or more ellipsoid shapes or structures embedded therein. Alternatively, or in combination, one or more reflectors may be coupled to the inner surface of the fluid-filled chamber to focus the shock waves. The reflector coupled to the inner wall of the fluid-filled chamber or the inner surface of the fluid-filled chamber may be an ellipsoid.

[0196] In some embodiments, the distal end of the optical fiber 4202 may be located approximately 1.5 mm above the surface of the eye when the film 4404 is placed thereon.

[0197] In some embodiments, the system 4400 may include an array of shockwave generators 4200. For example, the system 4400 may include multiple shockwave generators 4200 arranged in a circular pattern. Multiple optical fibers 4202 may be coupled to the contact lens 4402 and disposed within the fluid-filled chamber 4406 to generate multiple shockwaves, as described herein.

[0198] In some embodiments, the system 4400 may be securely coupled to the eye using suction (eg, suction ring 1202) on the inner and outer edges of the annular contact lens 4402.

[0199] FIG. 47 is a top view of an array 4700 of laser-based shockwave generators 4200 within an annular contact lens 4702. FIG. 48 is a side cross-sectional view of the system 4700 of FIG. 47. A plurality of shockwave generators 4200, substantially similar to any of the shockwave generators described herein, may be disposed within the contact lens 4702. For example, the plurality of shockwave generators 4200 may comprise a housing 102 and an eye-contacting surface 104 defining a fluid-filled chamber 106 therein. The housing 102 may be coupled to or may form a structure disposed within the annular contact lens 4702. For example, the housing 102 may be constructed from a 3D printed material and surrounded by a contact lens material such as PMMA to form an annular contact lens structure 4702 that encloses the shockwave generators 4200. The annular contact lens 4702 may be securely coupled to the eye using suction (e.g., suction ring 1202) on its inner and outer edges. The multiple shockwave generator 4200 may comprise a pair of electrodes or optical fibers configured to generate shockwave(s) within a fluid-filled chamber as described herein. The shockwaves may be focused at one or more locations on or below the surface of the eye as described herein.

[0200] In some embodiments, the annular contact lens 4702 may include multiple shock wave generators, for example, 8 or 16 shock wave generators arranged around a peripheral diameter of about 11 mm.

[0201] In some embodiments, the diameter of each shockwave generator 4200 may be approximately 3 mm.

[0202] In some embodiments, the outer diameter of the annular contact lens 4702 may be approximately 19 mm.

[0203] FIG. 49 is a side cross-sectional view of an array 4900 of shock wave generators arranged in a plurality of arrays and placed on the eye. The array of shock wave generators may comprise conductive wires arranged in an insulating sheath having a plurality of openings therein (e.g., as shown in FIGS. 50 and 52) or optical fibers arranged in a cladding having a plurality of openings therein (e.g., as shown in FIGS. 51 and 53). One or more shock wave generating wires or fibers may be disposed in a fluid-filled contact lens as described herein. A portion of one or more shock wave generating wires or fibers disposed adjacent to the eye may be formed into an annular shape as described herein. In some embodiments, the fluid-filled contact lens may comprise three annular shock wave generating wires or fibers disposed in its fluid-filled chamber. For example, a first wire or fiber 4902 may be positioned within the contact lens above the limbus, as described herein, a second wire or fiber 4904 may be positioned within the contact lens above the ciliary fold, and a third wire or fiber 4906 may be positioned within the contact lens above the pars plana.

[0204] The openings of the shock wave generating wire or fiber may be configured to direct shock waves to one or more locations on or below the surface of the eye, as described herein.

[0205] The contact lens may include one or more reflective surfaces (e.g., the inner ellipsoid wall and / or the reflector of the fluid-filled chamber) as described herein to facilitate focusing of the shock waves.

[0206] In some embodiments, the opening may be located within the contact lens approximately 1 mm above the surface of the eye.

[0207] Suction may be used to secure the contact lens on the eye. For example, a first suction ring may be placed on the inner edge (e.g., about 9 mm) of the annular contact lens and a second suction ring may be placed on the outer edge (e.g., about 19 mm).

[0208] The fluid may be circulated within the fluid-filled chamber as described herein.

[0209] FIG. 50 illustrates an exemplary array 5000 of shockwave generators including conductive wires 5002 disposed within an insulating sheath having multiple openings 5004 therein. The conductive wires may be disposed within an insulating sheath or coating configured to prevent electrical energy from emitting therethrough. The conductive wires may be disposed adjacent to the eye, for example, within a low-profile fluid-filled contact lens coupled to the surface of the eye as described herein. The fluid-filled contact lens may be configured to focus shockwaves generated by the conductive wires at one or more predetermined locations on or below the surface of the eye. The conductive wires may be disposed in an annular ring within the fluid-filled contact lens. In some embodiments, the fluid-filled contact lens may include multiple annular wires of multiple radial diameters disposed therein as described herein. One or more holes or openings may be provided in the insulation at predetermined locations to allow the conductive wires to function as electrodes and generate shockwaves when energized as described herein. For example, eight side-firing openings may be disposed within the cladding to form eight shockwave generators along the length of the wire. A single wire may be used to transfer energy from an electric arc of an electrode exposed at the opening to the surrounding fluid, thereby generating shock waves as described herein.

[0210] One skilled in the art will appreciate that the number of side firing apertures disposed within the insulator may be any number desired based on the intended treatment location(s) and pattern(s).

[0211] In some embodiments, the conductive wire or cable may have an outer diameter of about 100 μm.

[0212] FIG. 51 illustrates an exemplary array 5100 of shockwave generators comprising optical fibers 5102 disposed within a cladding having a plurality of openings 5104 therein. The optical fibers may be disposed within a cladding configured to prevent light from being emitted therethrough. The optical fibers may be disposed adjacent to the eye, for example, embedded within a fluid-filled annular (e.g., scleral) contact lens bonded to the surface of the eye as described herein. The fluid-filled contact lens may be configured to focus shockwaves generated by the optical fibers at one or more predetermined locations on or below the surface of the eye. The optical fibers may be disposed in an annular ring within the fluid-filled contact lens. One or more holes or openings (i.e., selective non-cladding) may be provided in the cladding at predetermined locations to allow the optical fibers to pass therethrough and emit light. For example, nine side-firing openings may be disposed within the cladding to form nine shockwave generators along the length of the fiber. Since a single optical fiber can be used to deliver light energy through the openings to the surrounding fluid to generate shock waves as described herein, the power of the shock waves generated at each opening can be the same. Shock waves can be generated simultaneously at each of the openings. A mirror can be disposed at the distal end of the optical fiber.

[0213] It will be appreciated by those skilled in the art that the number of side firing apertures disposed within the cladding may be any number desired based on the intended treatment location(s) and pattern(s).

[0214] In some embodiments, the optical fiber may have a Polymicro™ 50 μm core (for an outer diameter of 80 μm) with a 30 μm cladding around it.

[0215] In some embodiments, the optical fiber may be constructed with an outer diameter of about 100 μm.

[0216] FIG. 52 is an exploded view of a shockwave generator array 5200 comprising conductive wires 5206 disposed within an insulating sheath 5202 having a number of openings 5204 therein. The conductive wires 5206 may be disposed within an insulating sheath or coating 5202 configured to prevent electrical energy from being emitted therethrough. The conductive wires 5206 may be disposed adjacent to the eye, for example, within a fluid-filled contact lens coupled to the surface of the eye as described herein. The fluid-filled contact lens may be configured to focus shockwaves generated by the conductive wires at one or more predetermined locations on or below the surface of the eye. The conductive wires 5206 may be disposed in an annular ring within the fluid-filled contact lens. In some embodiments, the fluid-filled contact lens may comprise a number of annular wires disposed therein at multiple radial diameters as described herein. One or more holes or openings 5204 may be provided within the insulator 5202 at predetermined locations to allow the conductive wires 5206 to function as electrodes and generate shockwaves when energized as described herein. For example, nine side firing apertures 5204 may be positioned within the cladding 5202 to form nine shockwave generators along the length of the wire. A single wire 5206 may be used to transfer energy from an electric arc of an electrode exposed at the aperture to the surrounding fluid, thereby generating shockwaves as described herein. Shockwaves may be generated simultaneously at each of the apertures 5204.

[0217] In some embodiments, the openings 5204 may be evenly spaced along the length of the conductive wire 5206 adjacent the eye. For example, each of the nine openings 5204 may be spaced 4 mm from its immediate neighbors. In some embodiments, the openings 5204 may not be evenly spaced along the length of the wire 5206 adjacent the eye.

[0218] It will be appreciated by those skilled in the art that the number of side firing apertures 5204 disposed within the insulator 5202 may be any number desired based on the intended treatment location(s) and pattern(s).

[0219] In some embodiments, the insulator 5202 may be constructed from polyamide insulator.

[0220] In some embodiments, the opening 5204 may be about 0.5 mm in diameter.

[0221] FIG. 53 is an exploded view of a shockwave generator array 5300 comprising optical fibers 5302 disposed within a cladding 5304 having a number of openings 5306 therein. The optical fibers 5302 may be disposed within a cladding 5304 configured to prevent light from radiating therethrough. The optical fibers 5302 may be disposed adjacent to the eye, for example, within a fluid-filled contact lens bonded to the surface of the eye as described herein. The fluid-filled contact lens may be configured to focus shockwaves generated by the optical fibers to one or more predetermined locations on or below the surface of the eye. The optical fibers 5302 may be disposed in an annular ring within the fluid-filled contact lens. One or more holes or openings 5306 (i.e., optional non-cladding) may be provided within the cladding 5304 at predetermined locations to allow the optical fibers 5302 to radiate light therethrough. For example, nine side-firing openings 5306 may be disposed within the cladding 5304 to form nine shockwave generators along the length of the fiber 5302. A single optical fiber 5302 may be used to deliver light energy through the openings 5306 to the surrounding fluid, thereby generating shock waves as described herein, so that the power of the shock waves generated at each opening 5306 may be the same. A mirror 5308 may be disposed at the distal end of the optical fiber 5302.

[0222] In some embodiments, the apertures 5306 may be evenly spaced along the length of the optical fiber 5302 adjacent to the eye. For example, each of the nine apertures 5306 may be spaced 4 mm from its immediate neighbors. In some embodiments, the apertures 5306 may not be evenly spaced along the length of the optical fiber adjacent to the eye.

[0223] It will be appreciated by those skilled in the art that the number of side firing apertures 5306 disposed within the cladding may be any number desired based on the intended treatment location(s) and pattern(s).

[0224] In some embodiments, the optical fiber 5302 may comprise a Polymicro™ 50 μm core (for an outer diameter of 80 μm) with a 30 μm cladding around it.

[0225] FIG. 54 illustrates a method 5400 for treating an eye.

[0226] In step 5401, one or more shockwave generators may be coupled to the surface of the eye. The shockwave generator(s) may comprise any of the shockwave generators described herein. For example, a single shockwave generator may be coupled to the eye as described herein. Alternatively, an array of shockwave generators may be coupled to the eye as described herein, such as with a contact lens or contact balloon.

[0227] In step 5402, one or more of the shockwave generators may be energized to generate one or more shockwaves as described herein. In cases where more than one shockwave generator is used, the shockwave generators may be energized independently of each other (e.g., sequentially) or in cooperation with one or more other shockwave generators (e.g., at least two simultaneous firing generators). It will be understood by those skilled in the art that any combination of shockwave generators may be energized together or independently of each other.

[0228] In step 5403, the shock wave(s) may be focused at a predetermined location on or under the surface of the eye. One skilled in the art will appreciate that the predetermined location may be selected based on the ocular condition or condition to be treated. For example, in the case of treating a glaucoma eye, the predetermined location may include the trabecular meshwork, Schlemm's canal, the sclera, and / or the retina. In the case of presbyopia, the predetermined location may include the sclera, the IVZ, the PVZ, and / or the lens. In the case of an AMD eye, the predetermined location may include the pan-macular retina, e.g., the fovea or perifoveal area of ​​the retina. In the case of an eye with dry eye disease, the predetermined location may include the meibomian gland. One skilled in the art will appreciate that multiple conditions may be treated in the same eye, and the predetermined locations treated in the eye may correspond to the conditions to be treated. For example, an eye being treated for both glaucoma and presbyopia may focus shock waves on the sclera to generate microperforations in the sclera, improving fluid outflow (which may then reduce IOP for glaucoma treatment) and scleral compliance (which may improve its range of motion during accommodation).

[0229] In step 5404, steps 5401 through 5403 may be repeated as necessary to treat the eye for the target condition.

[0230] The shockwave generators described herein are generally based on electrohydraulic shockwave generation, although one of ordinary skill in the art would understand based on the teachings herein that other methods of shockwave generation may be utilized, including piezoelectric, laser, magnetoelectric shockwave generator(s) as described herein. For example, a moving coil or permanent magnet coupled to the eye can also function as a shockwave generator.

[0231] The shock wave therapy described herein may be enhanced by application of nanoparticles. Nanoparticles can mediate the initiation of shock waves at a lower cavitation threshold than without nanoparticles. Acoustic sensitive nanoparticles may be added to the fluid of the fluid-filled chamber of any of the shock wave generating devices described herein to lower the threshold for cavitation bubbles and shock wave formation. In some embodiments, nanoparticles can be injected (e.g., pre-operatively) into the tissue to be treated to enhance the extravasation and / or penetration of nanoparticles. Alternatively, or in combination, pre-injection of nanoparticles into the tissue can accelerate and / or prolong inertial cavitation and / or reduce associated side effects.

[0232] Without being limited to a particular theory, nanoparticle-mediated acoustic cavitation can produce cytotoxic effects through one or both of two main pathways hypothesized in the art. 1. The collapse of the bubbles directly damages cells through shock waves, shear stress, and the formation of reactive oxygen species; and / or 2. Activation of nanoparticles by cavitation (depending on the nanoparticle formulation and the desired effect) can lead to chemical cytotoxicity.

[0233] In some embodiments, the nanoparticles may include nanodroplets, nanocones, polymer cups, etc. For example, the nanoparticles may be comprised of perfluorohexane nanocones, mesoporous silica nanoparticles, solid gas-trapping nanoparticles, microbubbles, acoustically vaporizable droplets, polymer cups, etc.

[0234] In any of the embodiments described herein, the housing and / or one or more reflectors coupled to an inner surface of the housing may be constructed from plastic or metal. In at least some examples, a metal housing or metal reflector may reflect shock waves more efficiently than a plastic housing or plastic reflector due to the lower acoustic impedance of metal compared to plastic. This may reduce the input power required to generate the shock waves.

[0235] In some embodiments, the shockwave generator array may be comprised of multiple electrodes shaped like a wheel and spokes, such that each electrode is electrically coupled to every other electrode and driven by the same power source to fire simultaneously. The multiple electrodes may be formed from metal foil (e.g., brass, stainless steel, etc.).

[0236] FIG. 55 is a side cross-sectional view of an exemplary laser scanning shockwave generator system 5500 comprising a contact lens 5502 coupled to a surface 500 of the eye 200. The contact lens 5502 may be substantially similar to any of the fluid-filled contact lenses described herein. The contact lens may comprise a film or membrane 5504 disposed across a bottom of the contact lens 5502 to form a fluid-filled chamber 5506 between the eye and the contact lens. The membrane 5504 may comprise an eye-contacting surface configured to be coupled to the surface of the eye, which may be substantially similar to any of the eye-contacting surfaces described herein. The fluid-filled chamber 5506 may be filled with a fluid, such as saline as described herein. The fluid 206 may be comprised of a suspension of graphene in saline. In some embodiments, the fluid 206 may include a suspension of graphene in saline that can absorb light sufficiently to prevent or reduce light emitted by the scanning laser 5508. In some embodiments, the contact lens 5502 may further comprise a fluid inlet 108 and a fluid outlet 109 in fluid communication with the fluid filled chamber 106 as described herein. The fluid 206 may be circulated within the fluid filled chamber 5506 via the fluid inlet 108 and the fluid outlet 109. The front surface 5510 of the contact lens may define a transparent meniscus window through which optical energy may pass. For example, the transparent meniscus window 5510 may be transparent to laser light (e.g., infrared transmissive in the case of using an infrared laser). The system 5500 may further include a free space scanning laser 5508. The scanning laser 5508 may be a pulsed laser. In some embodiments, the scanning laser 5508 may be cone coupled to the eye. The cone may position the scanning laser 5508 at a known working distance above the eye. The contact lens 5502 may be placed above the eye within the cone.The laser 5508 may be scanned over the contact lens balloon 5502 and when the laser light reaches the contact lens fluid, shock waves may be generated in a manner substantially similar to that described herein. The use of a scanning laser 5508 can provide increased flexibility in time and space of treatment location compared to fixed shock wave generating devices.

[0237] In some embodiments, the system 5500 can be securely coupled to the eye using suction on the outer edge of the contact lens (eg, via a suction ring 1202).

[0238] In some embodiments, film 5504 may be constructed from a PET and / or PTFE membrane, as described herein. Film 5504 may be constructed from any of the materials described herein.

[0239] The laser 5508 may be configured to emit light at a wavelength that is highly absorbed by water. The laser may be configured to emit light at a wavelength in the mid-infrared range, for example, 1.44 μm, 1.475 μm, 1.55 μm, 1.948 μm, 3 μm, or 6 μm. The laser may be, for example, a Nd:Yag laser or a Th:Ho laser. In some embodiments, the laser may be configured to emit light at a wavelength in the near-infrared range. In some embodiments, the laser may be configured to emit light at a long wavelength infrared range, for example, 10 μm. In some embodiments, the laser may be configured to emit light at a wavelength in the far-infrared range, for example, at a frequency of several terahertz (THz).

[0240] In some embodiments, the light energy pulses from the pulsed laser may be from about 1 Hz to about 25 Hz.

[0241] In some embodiments, the pulses of optical energy from a pulsed laser may be on the order of nanoseconds to microseconds in length.

[0242] FIG. 56 is a side cross-sectional view of an exemplary multi-fiber laser shockwave generator array system 5600 including a contact lens 5602. The contact lens 5602 may be substantially similar to any of the fluid-filled contact lenses described herein. The contact lens 5602 may include a film or membrane 5604 disposed across a bottom of the contact lens 5602 to form a fluid-filled chamber 5606 between the contact lens 5602 and the eye. The film 5604 may include an eye-contacting surface configured to be coupled to a surface of the eye, which may be substantially similar to any of the eye-contacting surfaces described herein. The fluid-filled chamber 5606 may be filled with a fluid, such as saline, as described herein. The fluid may be comprised of a suspension of graphene in saline. In some embodiments, the fluid may include a suspension of graphene in saline that can absorb light sufficiently to prevent or reduce the light emitted by the scanning laser. In some embodiments, the contact lens 5602 may further comprise a fluid inlet and a fluid outlet in fluid communication with the fluid filled chamber 5606, as described herein. Fluid may be circulated within the fluid filled chamber 5606 via the fluid inlet and fluid outlet. The system 5600 may further comprise one or more fiber optic cables 4202 coupled to the contact lens. The one or more optical fibers 4202 may be configured to generate one or more shock waves within the fluid of the fluid filled chamber 5606 upon emission of light energy therefrom. The shock waves may be generated in a manner substantially similar to that described herein when laser light reaches the fluid of the contact lens balloon 5602.

[0243] A laser, e.g., a pulsed laser, may be coupled to the optical fiber 4202 to provide optical energy thereto. In some embodiments, the one or more optical fibers 4202 may comprise a fiber bundle or multi-fiber array 5608. Two or more optical fibers 4202 may be bundled into a fiber bundle 5608, which may be split into an array of fibers 4202 adjacent the contact lens 5602 so that they can be individually coupled to the contact lens 5602 at predetermined locations as described herein.

[0244] In some embodiments, the front surface 5608 of the contact lens 5602 may define a transparent meniscus window through which optical energy can pass as described herein. The optical fiber 4202 may be coupled to the front surface 5608 of the contact lens 5602 such that optical energy passes from the optical fiber 4202, through the front surface 5608 of the contact lens 5602, and into the contact lens fluid. Alternatively, or in combination, the optical fiber 4202 may pass through the front surface 5608 of the contact lens 5602 such that optical energy passes directly from the optical fiber 4202 into the contact lens fluid.

[0245] In some embodiments, the contact lens 5602 may be configured to act as a reflector (or reflector array) to focus the shock waves toward a desired predetermined location(s). Alternatively, or in combination, one or more reflectors may be coupled to an inner surface of the fluid-filled chamber 5606 to focus the shock waves.

[0246] In some embodiments, the optical fiber 4202 may be configured to emit a collimated beam of optical energy into the fluid in the fluid-filled chamber.

[0247] FIG. 57 is a side cross-sectional view of an exemplary shockwave generator 5700 including a director 5702. The shockwave generator 5700 may be substantially similar to any of the shockwave generators described herein. For example, the shockwave generator 5700 may include a first electrode 110 and a second electrode 112 disposed within a housing 102. The housing may include a fluid-filled chamber 106 and an eye-contacting surface 104. In some embodiments, the shockwave generator 5700 may further include a fluid inlet 108 and a fluid outlet 109 in fluid communication with the fluid-filled chamber 106, as described herein. Fluid may be circulated within the fluid-filled chamber 106 via the fluid inlet 108 and the fluid outlet 109. In some embodiments, the shockwave generating elements (e.g., electrodes, laser fibers, etc.) and the fluid-filled chamber 106 may be spaced from the eye-contacting surface 104 by the director 5702. The director 5702 may be disposed between the fluid-filled chamber 106 and the eye-contact surface 104. The fluid-filled chamber 106 may be configured to act as a reflector to focus the shock waves via the director 5702 towards a desired pre-determined location. Alternatively, or in combination, one or more reflectors may be coupled to an inner surface of the fluid-filled chamber 106 to focus the shock waves. The inner wall of the fluid-filled chamber 106 may be an ellipsoid. Alternatively, or in combination, the end of the director 5702 that constitutes the eye-contact surface 104 may be configured to focus the shock waves at a pre-determined location on or below the surface of the eye. The eye-contact surface 104 may be configured to be coupled to the surface of the patient's eye. A coupling fluid or gel, e.g., a water column, may be present on or below the eye-contact surface to facilitate contact between the eye-contact surface and the surface of the eye and / or to facilitate transmission of the shock waves from the shockwave generating device to the eye as described herein. The first and second electrodes 110, 112 may be coaxially aligned with one another such that a gap 114 is formed between the distal tips of the electrodes 110, 112. The shockwave generating device 5700 may be configured to generate one or more shock waves.The director 5702 may be configured to transmit shock waves from the fluid-filled chamber 106 of the shock wave generating device to the eye contact surface 104.

[0248] In some embodiments, the director 5702 can improve the safety of the shock wave system by increasing the spacing between the electrodes in the fluid of the shock wave generating device 5700 and the plane of the eye contact surface 104. The director 5702 can also increase the fluid volume and length for fluid circulation and bubble removal. In some embodiments, the director 5702 can have a length in the range of about 1 cm to about 2 cm. In some embodiments, the director 5702 can have a length of about 12 mm or more. For example, the director 5702 can have a length in the range of about 12 mm to about 80 mm.

[0249] In some embodiments, the director can reduce the need to miniaturize the system components to fit compactly into a space directly adjacent to the eye (such as within a contact lens balloon).

[0250] In some embodiments, the shockwave generator 5700 with the director 5702 may be attached to a trial frame, such as adjustable goggles, for stress-free packaging in a shockwave delivery accessory. The trial frame goggles may be configured to stabilize the fluid, electronic, and / or shockwave director and apply gentle contact to the eye or eyelid. The trial frame may be configured to have an adjustable apex distance between the frame and the cornea. In some embodiments, the apex distance may be adjusted to position the shockwave generator about 12 mm or more above the eye. One or more shockwave directors may extend from the trial frame to the surface of the eye.

[0251] In some embodiments, the shock wave director 5702 may be constructed from a tubular director. In some embodiments, the shock wave director 5702 may be constructed from a solid rod. One skilled in the art will appreciate that the director 5702 may be constructed from any desired shape to transmit the shock waves generated by the shock wave generating device to the eye.

[0252] In some embodiments, the shockwave director 5702 may be constructed from a material having a reflectivity of about 40% or greater. For example, in some embodiments, the shockwave director 5702 may be constructed from stainless steel, titanium alloys, aluminum alloys, graphene polymers, metallized ceramics, or the like, or any combination thereof.

[0253] The shock wave director 5702 may be constructed from a stainless steel tube having an outer diameter in the range of about 1 mm to about 8 mm.

[0254] FIG. 58 is a side cross-sectional view of an exemplary shockwave generator 5800 including a director 5802. The shockwave generator 5800 may be substantially similar to any of the shockwave generators described herein. For example, the shockwave generator 5800 may include a first electrode 110 and a second electrode 112 disposed within a housing 102. The housing 102 may include a fluid-filled chamber 106 and an eye-contacting surface 104. The housing 102 may be substantially tubular, with the electrodes 110, 112 disposed near a proximal end of the fluid-filled chamber 106 and the eye-contacting surface 104 disposed at a distal end of the fluid-filled chamber 106 having an elongated central portion that provides a director 5802 between the fluid-filled chamber 106 and the eye. The proximal end of the fluid-filled chamber 106 may be configured to act as a reflector to focus the shockwaves toward a desired predetermined location via the director. Alternatively, or in combination, one or more reflectors may be coupled to the inner surface of the fluid-filled chamber 106 to focus the shock waves. The inner wall of the fluid-filled chamber 106 may be ellipsoidal. Alternatively, or in combination, the distal portion of the director 5802 may be configured to focus the shock waves at a predetermined location on or below the surface of the eye. The eye contact surface 104 may be configured to be coupled to the surface of the patient's eye. A coupling fluid or gel, such as, for example, a water column, may be disposed on or below the eye contact surface 104 to facilitate contact between the eye contact surface 104 and the surface of the eye and / or to facilitate transmission of the shock waves from the shock wave generating device 5800 to the eye as described herein. The first and second electrodes 110, 112 may be coaxially aligned with one another such that a gap 114 is formed between the distal tips of the electrodes 110, 112. The shock wave generating device 5800 may be configured to generate one or more shock waves. The director 5802 may be configured to transmit shock waves from the electrodes to the eye contact surface 104.

[0255] In some embodiments, the shockwave generator 5800 may further comprise a fluid inlet 108 and a fluid outlet 109 in fluid communication with the fluid-filled chamber 106 as described herein. Fluid may be circulated within the fluid-filled chamber via the fluid inlet and the fluid outlet. The fluid inlet may be configured to supply fluid to a distal portion of the shockwave generator (e.g., a distal portion of the director) and the fluid outlet may be configured to remove fluid from a proximal portion of the shockwave generator (e.g., near the electrodes) such that the fluid flows through the housing in a direction opposite to the direction of shockwave travel.

[0256] The shock wave director may be constructed from a stainless steel tube having an outer diameter within the range of about 1 mm to about 8 mm.

[0257] In some embodiments, the director may have a length in the range of about 1 cm to about 2 cm. In some embodiments, the director may have a length of about 12 mm or more. For example, the director may have a length in the range of about 12 mm to about 80 mm.

[0258] In some embodiments, one or more shock wave generating devices comprising a director may be coupled to a fluid-filled contact lens as described herein.

[0259] In some embodiments, one or more shockwave generators with directors may be attached to a trial frame, such as adjustable goggles, as described herein.

[0260] FIG. 59 is a schematic diagram of a wireframe tube shape of a shock wave director 5800.

[0261] FIG. 60 is a side cross-sectional view of an exemplary shockwave generator 6000 including a director 6002. The shockwave generator 6000 may be substantially similar to any of the shockwave generators described herein. For example, the shockwave generator 6000 may include a first electrode 110 and a second electrode 112 disposed within a housing 102. The housing 102 may include a fluid-filled chamber 106 and an eye-contacting surface 104. The housing 102 may be substantially tubular, with the electrodes 110, 112 disposed near a proximal end of the fluid-filled chamber 106 and the eye-contacting surface 104 disposed at a distal end of the fluid-filled chamber 106 having an elongated central portion that provides the director 6002 between the fluid-filled chamber 106 and the eye. The eye-contacting surface 104 may be constructed, for example, by a PET film as described herein. The proximal end of the fluid-filled chamber 106 may be configured to act as a reflector to focus the shockwaves via the director toward a desired predetermined location. Alternatively, or in combination, one or more reflectors may be coupled to the inner surface of the fluid-filled chamber 106 to focus the shock waves. The inner wall of the fluid-filled chamber 106 may be ellipsoidal. Alternatively, or in combination, the distal portion of the director 6002 may be configured to focus the shock waves at a predetermined location on or below the surface of the eye. The eye-contacting surface 104 may be configured to be coupled to the surface of the patient's eye. A coupling fluid or gel, such as, for example, a water column, may be disposed on or below the eye-contacting surface to facilitate contact between the eye-contacting surface 104 and the surface of the eye and / or to facilitate transmission of the shock waves from the shockwave generating device 6000 to the eye as described herein. The first and second electrodes 110, 112 may be coaxially aligned with one another such that a gap 114 is formed between the distal tips of the electrodes 110, 112. The shockwave generating device 6000 may be configured to generate one or more shock waves. The director 6002 may be configured to transmit shock waves from the electrode to the eye contact surface.

[0262] In some embodiments, a rod stop 6004 may be disposed at the proximal end of the housing 102. The rod stop 6004 may reflect acoustic energy from the proximal end of the housing 102 into tissue.

[0263] In some embodiments, the shockwave generator 6000 may further comprise a fluid inlet 108 and a fluid outlet 109 in fluid communication with the fluid-filled chamber 106, as described herein. Fluid may be circulated within the fluid-filled chamber 106 via the fluid inlet 108 and the fluid outlet 109. The fluid inlet 108 may be configured to supply fluid to a distal portion of the shockwave generator 6000 (e.g., a distal portion of the director 6002), and the fluid outlet 109 may be configured to remove fluid from a proximal portion of the shockwave generator 6000 (e.g., near the electrodes 110, 112) such that the fluid flows through the housing 102 in a direction opposite to the direction of shockwave travel.

[0264] The shock wave director 6002 may be constructed from a stainless steel tube having an outer diameter in the range of about 1 mm to about 8 mm, for example, about 1 mm, about 2 mm, about 3 mm, about 5 mm, or about 8 mm. The director may have a wall thickness of about 0.5 mm.

[0265] In some embodiments, the director 6002 may have a length in the range of about 1 cm to about 2 cm. In some embodiments, the director 6002 may have a length of about 12 mm or more. For example, the director 6002 may have a length in the range of about 12 mm to about 80 mm, e.g., about 20 mm.

[0266] In some embodiments, one or more shock wave generating devices 6000 comprising a director 6002 may be coupled to a fluid-filled contact lens as described herein.

[0267] In some embodiments, one or more shockwave generators 6000 including a director 6002 may be attached to a trial frame, such as adjustable goggles, as described herein.

[0268] FIG. 61 is a side cross-sectional view of an exemplary shockwave generator 6100 including a director 6102. The shockwave generator 6100 may be substantially similar to any of the shockwave generators described herein. For example, the shockwave generator 6100 may include a first electrode 110 and a second electrode 112 disposed within a housing 102. The housing 102 may include a fluid-filled chamber 106 and an eye-contacting surface 104. The housing 102 may be substantially tubular, with the electrodes 110, 112 disposed near a proximal end of the fluid-filled chamber 106 and the eye-contacting surface 104 disposed at a distal end of the fluid-filled chamber 106 having an elongated central portion 6102 that provides a director between the eye and the shockwave generator 6100. The eye-contacting surface 104 may be constructed of, for example, a PET film as described herein. The proximal end of the fluid-filled chamber 106 may be configured to act as a reflector to focus the shock waves via the director 6102 towards a desired pre-determined location. Alternatively, or in combination, one or more reflectors may be coupled to an inner surface of the fluid-filled chamber 106 to focus the shock waves. The inner wall of the fluid-filled chamber 106 may be ellipsoidal. Alternatively, or in combination, the distal portion of the director 6102 may be configured to focus the shock waves at a pre-determined location on or below the surface of the eye. The eye-contacting surface 104 may be configured to be coupled to the surface of the patient's eye. A coupling fluid or gel, such as, for example, a water column, may be disposed on or below the eye-contacting surface to facilitate contact between the eye-contacting surface 104 and the surface of the eye and / or to facilitate transmission of the shock waves from the shockwave generating device to the eye as described herein. The first and second electrodes 110, 112 may be coaxially aligned with one another such that a gap 114 is formed between the distal tips of the electrodes 110, 112. The shock wave generator 6100 may be configured to generate one or more shock waves. The director 6102 may be configured to transmit the shock waves from the electrodes to the eye contact surface 104.

[0269] In some embodiments, the distal end of the director 6102 may comprise one or more reflectors 6106. The one or more reflectors 6106 may be configured to focus the shock waves at a predetermined location on or below the surface of the eye, as described herein.

[0270] In some embodiments, a rod stop 6104 can be disposed at the proximal end of the housing 102. The rod stop 6104 can reflect acoustic energy from the proximal end of the housing 102 into tissue.

[0271] In some embodiments, the first and second electrodes 110, 112 may be heat shrunk. The heat shrink can protect the electrodes from unwanted moisture contact that could lead to false high voltage discharges.

[0272] In some embodiments, the shockwave generator 6100 may further comprise a fluid inlet 108 and a fluid outlet 109 in fluid communication with the fluid-filled chamber 106, as described herein. Fluid may be circulated within the fluid-filled chamber 106 via the fluid inlet 108 and the fluid outlet 109. The fluid inlet 108 may be configured to supply fluid to a distal portion of the shockwave generator 6100 (e.g., a distal portion of the director), and the fluid outlet 109 may be configured to remove fluid from a proximal portion of the shockwave generator 6100 (e.g., near the electrodes) such that the fluid flows through the housing 102 in a direction opposite to the direction of shockwave travel.

[0273] The shock wave director 6102 may be constructed from a stainless steel tube having an outer diameter in the range of about 1 mm to about 8 mm, for example about 2 mm. The director 6102 may have a wall thickness of about 0.5 mm.

[0274] In some embodiments, the director 6102 may have a length in the range of about 1 cm to about 2 cm. In some embodiments, the director 6102 may have a length of about 12 mm or more. For example, the director 6102 may have a length in the range of about 12 mm to about 80 mm.

[0275] In some embodiments, one or more shock wave generating devices 6100 comprising a director 6102 may be coupled to a fluid-filled contact lens, as described herein.

[0276] In some embodiments, one or more shockwave generators 6100 including a director 6102 may be attached to a trial frame, such as adjustable goggles, as described herein.

[0277] In some embodiments, an array of shockwave generators 6100 with directors 6102 may be placed adjacent to the eye (e.g., coupled to a fluid-filled contact lens) to target one or more treatment locations, as described herein. For example, eight directors may be placed in a first row 12 mm from the center of the eye, ten directors may be placed in a second row 16 mm from the center of the eye, and a single large director may be placed at the center of the eye (0 mm), similar to the array of FIG. 63. One skilled in the art will appreciate that any number of directors may be placed adjacent to the eye in any desired pattern to treat the targeted tissue of interest.

[0278] Figure 62 is a side cross-sectional view of an exemplary parabolic shock wave director 6202. The shock wave generator 6200 and director 6202 may be substantially similar to the shock wave director shown in Figures 60 and 61, except that the distal end 6204 of the director 6202 may be curved. The parabolic shock wave director 6202 may include a parabolic reflector 6206 configured to allow peripheral access to the eye.

[0279] FIG. 63 is a top view of an exemplary contact lens 6300 comprising an array of shock wave directors 6302. Any of the shock wave directors described herein may be coupled to the contact lens 6304 as an array of shock wave generators 6302, as well as other arrays described herein. In some embodiments, an array of shock wave generators comprising directors 6302 may be positioned adjacent to the eye to target one or more treatment locations as described herein. For example, a central large (8 cm outer diameter) director 6302a may be coupled to the center of the contact lens to treat the lens and / or retina as described herein. A first row of shock wave directors 6302b may be positioned approximately 12 mm radially outward from the center to treat the trabecular meshwork and / or Schlemm's canal as described herein. A second row of shock wave directors 6302c may be positioned approximately 16 mm from the center to treat the pars plana and PVZ as described herein. A suction ring (approximately 19 mm in diameter) located on the outer edge of the contact lens allows the contact lens 6304 to bond to the surface of the eye or eyelid as described herein.

[0280] 64 is a top view of an exemplary contact lens 6400 with an array of shockwave generators 6402 for meibomian gland treatment. The contact lens 6400 may have a radius of curvature of about 7.8 mm and about 12 mm.

[0281] 65 is a top view of an exemplary contact lens 6500 for treating dry eye disease. The contact lens 6500 may comprise a corneal contact lens that may be configured (e.g., shaped, constructed of a suitable material, etc.) to act as an efficient acoustic reflector as described herein.

[0282] FIG. 66 is a side view of an exemplary treatment system 6600 with an integrated imaging system 6602. The system 6600 may include any of the shockwave generators described herein. For example, the system 6600 may include a shockwave generator with a director 6604 coupled to a docking contact lens 6606. The shockwave generator may include a central aperture 6608 configured to allow the imaging system 6602 to be integrated therein. The imaging system 6602 may have a slit-wrap configuration in which the central aperture 6608 provides a viewing area. The viewing area may allow the physician to view the eye before, during, or after treatment as described herein. The viewing area may be referenced. In some embodiments, the imaging system 6602 may comprise an OCT imaging system. A near-infrared (NIR) (e.g., 1064 nm) wavelength laser of the OCT imaging system may be configured to penetrate water and into tissue to provide intraoperative imaging feedback as described herein. In some embodiments, multiple shockwave generators may be arranged in one or more annular rings around the viewing area. In some embodiments, the electronics and fluidics of the shockwave generators, including saline pumps, degassing, and vacuum, may be housed in a slit lamp assembly. The slit lamp assembly configuration may be configured for use with the patient in a seated position.

[0283] FIG. 67 is a side view of an exemplary treatment system with an integrated imaging system 6706. The system 6700 may include any of the shockwave generators described herein. For example, the system 6700 may be comprised of a shockwave generator with a director 6702 coupled to a trial frame 6704 and a docking contact lens. The shockwave generator may include a central opening 6708 configured to allow the imaging system 6706 to be integrated therein. The imaging system 6706 may include an ultrasound biomicroscopy (UBM), ultrasound (US) imaging, and / or optical coherence tomography (OCT) device or system. The imaging system 6706 may be used to capture one or more images of the eye before, during, or after treatment as described herein. A processor or controller may be connected to the energy source and the imaging system and configured with instructions to provide energy to the shockwave generator and image the tissue during treatment. The system 6700 may include a display connected to the processor that allows a user to visualize the tissue before, during, or after treatment. The display can display images that allow the user to see the tissue to be treated and plan the treatment. The images displayed on the display can be provided in real time and can be used prior to treatment (e.g., to reposition ocular structures relative to one another if undesired) to allow the user to align the tissue and / or monitor tissue effects of the treatment (e.g., cavitation) to ensure that unintended effects of the treatment are not occurring.

[0284] In some embodiments, the shockwave generator electronics, director(s), and fluid interface may be mounted on a trial frame 6704 as described herein. The fluid enclosure including the saline pump, degasser, and vacuum may be housed on an IV pole as described herein. The trial frame configuration may be configured for use with the patient in a supine / standing position.

[0285] FIG. 68 is a side view of an exemplary treatment system 6800 with an integrated imaging system 6802. The system 6800 may include any of the shockwave generators described herein. For example, the system 6800 may include a shockwave generator having a director 6804 coupled to a surgical microscope 6802. The shockwave generator may include a central opening configured to allow an imaging system to be integrated therein. The imaging system 6802 may include an ultrasound biomicroscopy (UBM), ultrasound (US) imaging, and / or optical coherence tomography (OCT) device or system. The imaging system 6802 may be used to capture one or more images of the eye before, during, or after treatment as described herein. A processor or controller may be connected to the energy source and the imaging system 6802 and configured with instructions to provide energy to the shockwave generator and image the tissue during treatment. The system 6800 may also include a display connected to the processor that allows a user to visualize the tissue before, during, or after treatment. The display can display images that allow the user to see the tissue to be treated and plan the treatment. The images displayed on the display can be provided in real time and can be used prior to treatment (e.g., to reposition ocular structures relative to one another if undesired) to allow the user to align the tissue and / or monitor tissue effects of the treatment (e.g., cavitation) to ensure that unintended effects of the treatment are not occurring.

[0286] In some embodiments, the shockwave generator electronics and fluidics may be mounted on an arm or IV pole of a surgical microscope 6802, as described herein. The surgical microscope configuration may be configured for use in supine / standing patient positions.

[0287] FIG. 69 is a schematic diagram of an exemplary system 6900 for air bubble extraction. Any of the shockwave generation systems described herein may be configured for real-time intraoperative air bubble extraction. The system 6900 may include one or more shockwave generators 6902, which may be substantially similar to any of the shockwave generators described herein. The shockwave generator(s) 6902 may be configured to generate one or more shockwaves. The one or more shockwave generators 6902 may comprise a fluid-filled chamber comprising a fluid, such as saline, disposed therein. In some embodiments, the shockwave generator 6902 may further comprise a fluid inlet 108 and a fluid outlet 109 in fluid communication with the fluid-filled chamber. The fluid may be used to couple the shockwaves generated by the fiber to the surface of the eye. The fluid may circulate within the fluid-filled chamber via the fluid inlet 108 and the fluid outlet 109. Circulation of the fluid may allow for continuous extraction of heat buildup, cavitation bubbles, and ions generated during shock wave formation as the delivery of shock wave pulses continues. Efficient removal of bubbles formed during shock wave generation may be desirable to prevent interference and associated unanticipated effects of residual bubbles in the fluid on the formation and / or direction of additional shock waves. Removal of bubbles may also improve acoustic energy delivery. In some embodiments, it may be desirable to degas and recirculate the fluid through the fluid-filled chamber. The recirculation system may include a first pump 6904 that moves fluid from the fluidic components of the shock wave generator(s) 6902 to a bubble extractor 6906 (e.g., PermaSelect 2500 by MedArray). Fluid may be drawn through the bubble extractor 6906 and into the vacuum chamber 6908 (e.g., an air-sealed Duran® glass container by SCHOTT) by a vacuum pump 6910 coupled to the vacuum chamber 6908. A saline reservoir bag 6912 may be in fluid communication with the vacuum chamber 6908 for fluid exchange and equilibration.The degassed fluid may be drawn from the vacuum chamber 6908 into the shockwave generator(s) 6902 by a first pump 6904 to complete the recirculation system 6900. The recirculation system 6900 may operate in the range of typical peristaltic pump flow rates and vacuum pumps. In some embodiments, the fluid exiting the fluid-filled chamber via the fluid outlet 109 may be sampled periodically or continuously as described herein.

[0288] In some embodiments, the fluid recirculation system 6900 may be configured to remove fluid from the fluid-filled chamber at a rate in the range of about 0.5 L / min to about 1 L / min. For example, the fluid may be recirculated at a rate in the range of about 750 ml / min to about 1000 ml / min. In some embodiments, the entire volume of the fluid-filled chamber (or fluid-filled contact lens / balloon) may be replaced with fresh degassed fluid by the fluid recirculation system 5900 after each shock wave event.

[0289] In some embodiments, the recirculation rate may be about 100 mL / min.

[0290] In some embodiments, one or more of the pumps may be a peristaltic pump.

[0291] In some embodiments, the fluid recirculation tube 6914 may be constructed from a hollow tube. In some embodiments, the fluid recirculation tube 6914 may be constructed from a silicone tube or sleeve.

[0292] In some embodiments, the fluid recirculation tube 6914 may have an inner surface configured with a chemical that reduces or prevents the trapping of cavitation bubbles within the tube 6914. For example, the tube 6914 may be coated with a surfactant.

[0293] In some embodiments, the IV pole may be positioned in close proximity to the eye to accommodate one or more of a reservoir bag 6912 for saline, a programmable pulse generator (2 kV / 10 kHz), a vacuum pump 6910 for the bubble extraction device, a pump 6904 for extracting saline from the contact lens and injecting it into the bubble extraction device, an eye aspirator, a reservoir bottle for fluid exchange and equilibration, and / or tubing 6914 with a valve for control.

[0294] Fig. 70 is a schematic diagram of an exemplary system 7000 for air bubble extraction. The air bubble extraction system 7000 may involve integration into a trial frame goggles 6704 and may be substantially similar to the system of Fig. 69. The trial frame goggles 6704 may be configured to support the shockwave generator electronics, optional director(s) and fluid interface described herein and may be substantially similar to any of the goggles described herein.

[0295] FIG. 71 is a schematic diagram of an exemplary system 7100 for air bubble extraction coupled to a contact lens balloon 7102 positioned on a patient's eye 200. The air bubble extraction system 7100 may be substantially similar to the system of FIG. 70, with a large vacuum tank mounted on an IV pole. The contact lens balloon 7102 may be substantially similar to any of the contact lenses or balloons described herein. The vacuum tank may hold a larger volume of saline, e.g., 7 liters, as compared to the system of FIG. 70, which is configured to hold a smaller volume, e.g., 500 milliliters.

[0296] FIG. 72 is an electrical schematic diagram of an exemplary treatment system 7200 configuration. A low voltage power supply module (LVPS) may be configured to generate one or more voltages, such as, for example, +5V, +24V, and +12V. A programmable 0 kV to 2 kV high voltage power supply module (HVPS) may be configured to provide power to the capacitor. The HVPS unit may be configured to provide, for example, about 125 watts to the capacitor. The capacitor may be rapidly (about 1 microsecond) discharged by a high voltage switch (HVSW) into a saline container. The saline container may direct the pressure wave to the tissue (e.g., through an acoustically transparent, fluid-tight membrane). A microcontroller (e.g., Arduino class) may be configured to control the timing and PCT interface, as well as monitor the safety interlocks.

[0297] FIG. 73 is a side cross-sectional view of an exemplary variable focus therapy system 7300. The system 7300 may be substantially similar to the system shown in FIG. 40 and may be used to treat the lens 2302 (or IOL), the retina 2208, and / or other target locations within the eye. The system 7300 may include a large aperture shockwave generator 7302 configured to deliver shockwaves to the lens and / or retina. The shockwave generator 7302 may be substantially similar to any of the shockwave generators described herein. For example, the shockwave generator 7302 may include a first electrode 110 and a second electrode 112 disposed within a housing 102. The housing 102 may include a fluid-filled chamber 106 and an eye-contacting surface 104. The fluid-filled chamber 106 may be configured to function as a parabolic reflector to focus planar shockwaves toward a desired predetermined location. Alternatively, or in combination, one or more reflectors may be coupled to the inner surface of the fluid-filled chamber 106 to focus the shock waves. The one or more reflectors may comprise, for example, an electronically variable acoustic lens 7304, which may enable variable or adjustable focusing of the shock waves along the z-plane on the crystalline lens 2302 (or IOL) and / or the macula of the retina 2208. The inner wall of the fluid-filled chamber 106 may be an ellipsoid. The eye-contact surface 104 may be configured to be coupled to the surface of the patient's eye. A coupling fluid or gel, e.g., a water column, may be disposed on or under the eye-contact surface 104 to facilitate contact between the eye-contact surface 104 and the surface 500 of the eye and / or to facilitate transmission of the shock waves from the shockwave generator 7302 to the eye. A suction ring may be disposed on the outer edge of the shockwave generator to couple the shockwave generator to the cornea or sclera of the eye. The first and second electrodes 110, 112 may be coaxially aligned with one another such that a gap 114 is formed between the distal tips of the electrodes 110, 112. The shockwave generator 7302 may be configured to generate one or more shockwaves.The electronically variable acoustic lens 7304 may have a first shape 7304a configured to focus the shock waves at a first location (e.g., the lens 2302 to be softened) and a second shape 7304b configured to focus the shock waves at a second location (e.g., the retina 2208 to be sonostimulated). The electronically variable acoustic lens 7304 may be configured to electronically steer the shock waves to any desired treatment location or combination of treatment locations.

[0298] FIG. 74 is a side cross-sectional view of an exemplary treatment system 7400 for dry eye disease. The system 7400 may be substantially similar to the system shown in FIG. 41 and may be used to provide shockwave therapy to the eyelid 2802 while protecting the cornea 2206 from shockwaves. The system 7400 may include a large diameter shockwave generator 7402 configured to deliver shockwaves to the eyelid 2802 of the eye 200. The shockwave generator 7402 may be substantially similar to any of the shockwave generators described herein. For example, the shockwave generator 7402 may include a first electrode 110 and a second electrode 112 disposed within a housing 102. The housing 102 may include a fluid-filled chamber 106 and an eye-contacting surface 104. The fluid-filled chamber 106 may be configured to function as a parabolic reflector to focus planar shockwaves toward a desired predetermined location. Alternatively, or in combination, one or more reflectors may be coupled to the inner surface of the fluid-filled chamber 106 to focus the shock waves. The reflectors coupled to the inner wall of the fluid-filled chamber 106 or to the inner surface of the fluid-filled chamber 106 may be ellipsoidal. The eye-contacting surface 104 may be configured to be coupled to the patient's eyelid 2802 (e.g., when the patient's eye is closed). The eye-contacting surface 104 may be constructed of a highly conformable membrane material to facilitate coupling to the eyelid 2802. A cornea-sparing contact lens 4104 may be placed on the patient's cornea 2206 under the eyelid 2802 and may function as an acoustic reflector to direct shock waves passing through the eyelid 2802 away from the cornea 2206. A thermal diffusion contact lens 4104 may be configured to function as an acoustic reflector and direct shock waves toward one or more meibomian glands 2800 to treat dry eye as described herein. A suction ring may be disposed on the outer edge of the shockwave generator to couple the shockwave generator to the eyelid. The first and second electrodes 110, 112 may be coaxially aligned with one another such that a gap 114 is formed between the distal tips of the electrodes 110, 112. The shockwave generator 7402 may be configured to generate one or more shockwaves.

[0299] FIG. 75 is a side cross-sectional view of an exemplary treatment system 7500 for transdermal treatment. The system 7500 may comprise any of the shockwave generators described herein. In some embodiments, the eye contact surface of the shockwave generator may be coupled to the patient's eyelid 2802 when the patient's eye is closed. In some embodiments, the system 7500 may comprise an eyelid contact lens 7502 configured to be coupled to the patient's eyelid 2802. In some embodiments, the eye contact surface of the shockwave generator may comprise an eyelid contact lens 7502. In some embodiments, the eye contact surface of the shockwave generator may be configured to contact the eyelid contact lens 7502. In some embodiments, the shockwave generator may be configured to deliver shockwaves through the eyelid contact lens 7502 to a predetermined location on or under the surface of the eye (or eyelid). The shockwaves may pass through the eyelid 2802 to reach the predetermined treatment location.

[0300] FIG. 76 is a side cross-sectional view of an exemplary treatment system 7600 for dry eye disease. The system 7600 may include any of the shockwave generators described herein. For example, the system may include a shockwave generator having a wave director 7602 coupled to a trial frame and a docking contact lens 7604. The system 7600 may be used to provide shockwave therapy to the eyelid 2802 while protecting the cornea 2206 from the shockwaves. The shockwave generator may be substantially similar to any of the shockwave generators described herein. For example, the shockwave generator may include a first electrode and a second electrode disposed within the housing. The housing 102 may include a fluid-filled chamber 106 and an eye-contacting surface 104. The fluid-filled chamber 106 may be configured to function as a parabolic reflector to focus planar shockwaves toward a desired predetermined location. Alternatively, or in combination, one or more reflectors may be coupled to an inner surface of the fluid-filled chamber 106 to focus the shockwaves. The reflector coupled to the inner wall of the fluid-filled chamber 106 or the inner surface of the fluid-filled chamber 106 may be ellipsoidal. The eye-contacting surface 104 may be configured to be coupled to the patient's eyelid 2802 (e.g., when the patient's eye is closed). The eye-contacting surface 104 may be constructed of a highly conformable membrane material to facilitate coupling to the eyelid 2802. The cornea-sparing contact lens 7606 may be placed on the patient's cornea 2206 under the eyelid 2802 and may act as an acoustic reflector to direct shock waves passing through the eyelid 2802 away from the cornea. The acoustic reflecting lens 7606 may direct shock waves toward one or more meibomian glands 2800 to treat dry eye as described herein. The acoustic reflecting lens 7606 may be a scleral contact lens constructed of PET and / or PMMA with air 7608 filled. The cornea-contacting surface 7610 of the lens may be made from PMMA and the eyelid-contacting surface 7612 of the lens may be made from PET, or the cornea-contacting surface 7610 of the lens may be made from PET and the eyelid-contacting surface 7612 of the lens may be made from PMMA.The impedance mismatch between the fluid-filled chamber 106 and the air-filled reflective lens 7606 may be large enough (e.g., about 3500 times) to reflect energy directed at the cornea 2206 back to the eyelid 2802. A suction ring may be disposed on the outer edge of the shockwave generator to couple the shockwave generator to the eyelid 2802. The first and second electrodes may be coaxially aligned with each other such that a gap is formed between the distal tips of the electrodes. The shockwave generator may be configured to generate one or more shockwaves.

[0301] In some embodiments, the air-filled scleral contact lens 7606 may be sterilizable and / or disposable.

[0302] In some embodiments, the air-filled scleral contact lens 7606 may have a total thickness of about 300 μm. In some embodiments, the PET side of the lens may have a thickness of about 12 μm. In some embodiments, the PMMA side of the lens may have a thickness of about 200 μm. In some embodiments, the air chamber 7608 may have a thickness of about 100 μm.

[0303] In some embodiments, the air-filled scleral contact lens 7606 may have a diameter of about 19 mm.

[0304] In some embodiments, the air-filled scleral contact lens 7606 may have a dual curve with an arch shape.

[0305] FIG. 77 is a schematic diagram of an exemplary system 7700 for conductivity measurement. Any of the systems described herein may include a conductivity sensor 7702 configured to measure the conductivity of a fluid in or exiting the fluid-filled chamber 106. In some embodiments, the conductivity sensor 7702 may be fluidly coupled to the fluid outlet 109, but may not be located within the fluid-filled chamber 106. In some embodiments, the conductivity sensor 7702 may be embedded within the fluid-filled chamber 106. The conductivity sensor 7702 may periodically or continuously sample the conductivity of the fluid in the fluid-filled chamber 106 to determine the extent of electrode erosion. For example, the conductivity of the saline solution may be sampled (e.g., as a surrogate for measuring the gap distance between the shockwave electrodes as the electrodes erode and metal ions are released into the saline solution), and the voltage sent to the shockwave electrodes 110, 112 may be adjusted to account for the change in sensed conductivity. In some embodiments, the conductivity sensor 7702 may consist of a pair of platinum electrodes 7704, 7706 placed a fixed distance apart (e.g., 2 cm). Two constant current sources 7708, 7710 (e.g., 1 mA) may inject a known current at a known distance (e.g., 1 cm) from a ground electrode (e.g., electrode 112 in some embodiments). The cell constant can be calibrated using a circulating solution of known conductivity such as phosphate buffered saline, potassium chloride, saline, etc. at a fixed concentration. For example, 0.9% sodium chloride has a conductivity of approximately 16 mS / cm (K=1 cell calibration) and can be used to calibrate the conductivity sensor 7702. The cell constant is a multiplication constant that is specific to the conductivity sensor. The measured current is multiplied by the cell constant to determine the electrical conductivity of the solution. The cell constant, known as K, refers to a theoretical electrode consisting of two 1 cm square plates spaced 1 cm apart. An increase in conductivity may indicate metal leaching into the fluid in the fluid-filled chamber 106. A decrease in conductivity may indicate the formation and retention of air bubbles within the fluid-filled chamber 106 .If the conductivity changes beyond an acceptable threshold, treatment can be stopped and the system 7700 can be flushed with fresh fluid to remove metal / air bubbles and / or the shockwave generating electrodes 110, 112 can be evaluated.

[0306] In some embodiments, the two current sources 7708, 7710 may be pulsed synchronously (but 180° out of phase) at approximately 10 kHz. The pulsing may have a duty cycle of approximately 20%. For example, the current sources may be pulsed "on" for approximately 20 microseconds and "off" for approximately 80 microseconds at 10 kHz. The 80 microseconds may provide sufficient time for detection and / or comparison of the DC voltage at the conductive electrodes.

[0307] In some embodiments, the platinum conductive electrodes 7704, 7706 may have a diameter of about 6 mm and a width of about 2 mm. The platinum conductive electrodes 7704, 7706 may be insulated with stainless steel about 0.1 mm thick.

[0308] In some embodiments, the platinum conductive electrodes 7704, 7706 may have a diameter of about 0.5 mm. The platinum conductive electrodes 7704, 7706 may be insulated with parylene. In some embodiments, the platinum conductive electrodes 7704, 7706 may have an exposed tip that is synchronized (out of phase) with the high voltage pulses of the shockwave generating electrodes 110, 112.

[0309] In some embodiments, the conductive cell may further include a passive cavitation detector or an ultraviolet radiation source as described herein (eg, as in Figures 84-85).

[0310] FIG. 78 is a side view of an exemplary shockwave generator 7800 including a director 7802 and an embedded conductivity sensor 7702. The shockwave director 7802 may be substantially similar to any of the shockwave directors described herein. The shockwave generator 7800 may be substantially similar to any of the shockwave generators described herein. For example, the shockwave generator 7802 may include a first electrode 110 and a second electrode 112 disposed within a housing 102. The housing 102 may include a fluid-filled chamber 106 and an eye-contacting surface 104. The housing 102 may be substantially tubular, with the electrodes disposed near a proximal end of the fluid-filled chamber 106 and the eye-contacting surface 104 disposed at a distal end of the fluid-filled chamber 106 with an elongated central portion 7802 providing a director between the eye and the eye. The eye-contacting surface 104 may be constructed of, for example, a PET film as described herein. The eye-contacting surface 104 may be configured to be coupled to a surface of the patient's eye. A coupling fluid or gel, e.g., a water column, may be disposed on or under the eye-contacting surface to facilitate contact between the eye-contacting surface and the surface of the eye and / or to facilitate transmission of shock waves from the shockwave generating device to the eye, as described herein. In some embodiments, the distal end of the fluid-filled chamber 106 may be referred to as an acoustic wave emitter. The proximal end of the fluid-filled chamber 106 may include a conductivity cell 7804 that includes a conductivity sensor 7702. The conductivity sensor 7702 may include a pair of platinum electrodes 7704, 7706 spaced a fixed distance apart. The pair of platinum electrodes 7704, 7706 may be configured to periodically or continuously sample the conductivity of the fluid in the fluid-filled chamber 106, as described herein.

[0311] FIG. 79 is a side view of an exemplary acoustic bridging shockwave generator 7900 comprising a shockwave director 7902. Acoustic bridging may be used to treat keratoconus or corneal ectasia. The shockwave director 7902 may be substantially similar to any of the shockwave directors described herein. The shockwave generator 7900 may be substantially similar to any of the shockwave generators described herein. For example, the shockwave generator 7900 may comprise a first electrode 110 and a second electrode 112 disposed within a housing 102. The housing 102 may comprise a fluid-filled chamber 106 and an eye-contacting surface 104. The housing 102 may be substantially tubular, with the electrodes 110, 112 disposed near a proximal end of the fluid-filled chamber 106 and the eye-contacting surface 104 disposed at a distal end of the fluid-filled chamber 106 comprising an elongated central portion 7902 that provides a wave director between the fluid-filled chamber 106 and the eye-contacting surface 104. The eye-contacting surface 104 may be constructed, for example, of a PET film as described herein. The eye-contacting surface 104 may be configured to be coupled to a surface 500 of the patient's eye 200. A coupling fluid or gel, e.g., a water column, may be disposed on or under the eye-contacting surface 104 to facilitate contact between the eye-contacting surface 104 and the surface 500 of the eye and / or to facilitate transmission of shock waves from the shockwave generator to the eye as described herein. In some embodiments, a reservoir 7904 of oxygen and / or one or more therapeutic substances may be disposed on or under the eye-contacting surface 104 for drug delivery to the cornea 2206. The reservoir 7904 may be coupled to the eye 200 by a vacuum-sealed retaining ring 1202. Shock waves generated by the shockwave generator may enhance drug delivery to the cornea 2206 (e.g., to the epithelium) by causing surface fragmentation and / or micro-perforation of the subject's corneal tissue to improve drug permeability.

[0312] The PET membrane 104 can separate the high voltage fluidic device from the eye and the drug / oxygen reservoir 7904. The PET membrane 104 can be acoustically transparent. The PET membrane 104 can have a thickness in a range of about 2.5 micrometers to about 12.5 micrometers. The PET membrane 104 can be configured to withstand a saline pressure of at least about 100 PSI in the fluid-filled chamber 106. In some embodiments, the PET membrane 104 can be replaced by a focusing / defocusing acoustic lens and / or a plane wave meniscus lens.

[0313] In some embodiments, the therapeutic agent may include a photosensitizer such as riboflavin, riboflavin nanoparticles, or rose bengal.

[0314] Acoustic radiation force (i.e., force from a shock wave) can drive the therapeutic agent(s) into the tissue. Alternatively, or in combination, electrospray via Taylor cone formation and Coulomb fission may be used to disperse the therapeutic agent(s) onto the tissue surface.

[0315] In some embodiments, the reservoir 7904 may include a fluid inlet 7908 and a fluid outlet 7910 for circulating oxygen and / or therapeutic substances from an external source / reservoir(s) to the cornea 2206 below the eye contacting surface 104. In some embodiments, the same fluid inlet 7908 and fluid outlet 7910 may be used for each substance. In some embodiments, each substance may have a dedicated fluid inlet and fluid outlet. In some embodiments, oxygen may be generated using an electrochemical cell for electrolysis and delivery to the eye (e.g., 95% oxygen at 15 ml / min).

[0316] The proximal end of the fluid-filled chamber 106 may include or be coupled to a light source 7906. For example, the light source 7906 may be an ultraviolet light emitting diode (LED) (e.g., 365 nm wavelength) or an optical fiber coupled to an external ultraviolet LED or laser, or the like. In some embodiments, the light source 7906 may be a green LED (e.g., 525 nm wavelength) or an optical fiber coupled to an external green LED or laser, or the like. During or following delivery of oxygen and / or riboflavin (or other ultraviolet sensitive or photosensitizing therapeutic substances), the ultraviolet light source 7906 may be used to crosslink the cornea 2206 (e.g., for the treatment of keratoconus). Oxygenation and / or photosensitization may facilitate crosslinking.

[0317] In some embodiments, the light source 7906 has an illumination of about 20 mW / cm 2 In some embodiments, the light source 7906 may have an intensity of about 3 mW / cm 2 In some embodiments, the light source 7906 may have an intensity of about 9 mW / cm 2 In some embodiments, the light source 7906 may have an intensity of about 10 mW / cm 2 In some embodiments, the light source 7906 may have an intensity of about 15 mW / cm 2 The strength of the material may be

[0318] In some embodiments, oxygen and / or other therapeutic substances may be delivered to the eye 200 using the shock wave generating device 7900 without simultaneous or subsequent crosslinking.

[0319] In some embodiments, the shockwave generator 7900 may further comprise a fluid inlet 108 and a fluid outlet 109 in fluid communication with the fluid-filled chamber 106, as described herein. Fluid may be circulated within the fluid-filled chamber 106 via the fluid inlet 108 and the fluid outlet 109. The fluid inlet 108 may be configured to supply fluid to a distal portion of the shockwave generator 7900 (e.g., a distal portion of the director 7902), and the fluid outlet 109 may be configured to remove fluid from a proximal portion of the shockwave generator 7900 (e.g., near the electrodes 110, 112) such that the fluid flows through the housing 102 in a direction opposite to the direction of shockwave travel.

[0320] The shock wave director 7902 may be constructed from a stainless steel tube having an outer diameter in the range of about 1 mm to about 8 mm, for example, about 1 mm, about 2 mm, about 3 mm, about 5 mm, or about 8 mm. The shock wave director 7902 may be constructed from a stainless steel tube having an outer diameter of about 7 mm. The director 7902 may have a wall thickness of about 0.5 mm.

[0321] In some embodiments, the director 7902 may have a length in the range of about 1 cm to about 2 cm. In some embodiments, the director 7902 may have a length of about 12 mm or more. For example, the director may have a length in the range of about 12 mm to about 80 mm, such as about 20 mm. The shock wave director 7902 may be constructed from a stainless steel tube having a length of about 40 mm.

[0322] In some embodiments, one or more acoustic bridging shockwave generators 7900 may be coupled to a fluid-filled contact lens, as described herein.

[0323] In some embodiments, one or more acoustic bridging shockwave generators 7900 including directors 7902 may be attached to a trial frame, such as adjustable goggles, as described herein.

[0324] FIG. 80 is a side view of an exemplary acoustic bridging shockwave generator 8000 including a shockwave director 7902. The acoustic bridging shockwave generator 8000 may be substantially similar to the shockwave generator shown in FIG. 79. The acoustic bridging shockwave generator 8000 may include a light source 7906 (e.g., green or ultraviolet LED) as described herein. The light source 7906 may be cycled on and off. In some embodiments, the light source off cycle may correspond to an on cycle of the high voltage electrodes 110, 112 in the fluid-filled chamber 106 for simultaneous shockwave-mediated drug (e.g., oxygen and riboflavin) delivery. The on / off cycle of the light source 7906 (and optionally the shockwave-generating electrodes 110, 112) may be approximately every 5 seconds. Oxygen may be generated by an electrolytic cell driven by a low power current source (e.g., AA battery) from the atmosphere and delivered to the fluid inlet 8002 of the suction ring 1202 of the patient interface. Riboflavin may be delivered to the same fluid inlet 8002 or a different fluid inlet 8004, as described herein. Oxygen (and riboflavin, etc.) may be forced into the cornea 2206 with shock waves, as described herein. The on / off light cycle may be repeated as necessary to achieve the desired level of crosslinking of the cornea.

[0325] For example, tissue may be immersed in 0.1% riboflavin for 30 minutes and then exposed to at least about 3 mW / cm 2 UV irradiation of 9mW / cm may be administered for 30 minutes per eye. In some embodiments, riboflavin delivery can be enhanced by acoustic radiation force shock wave therapy. The acoustic radiation force (i.e., the force from the shock wave) can drive the therapeutic agent(s) into the tissue. Then, 9mW / cm 2 UV irradiation at an intensity of 100 nm may be applied for 10 minutes with simultaneous oxygen immersion (e.g., electrochemical cell flow rate of about 16 ml / min). Shock wave therapy may be delivered by a system mounted on a pair of trial frame goggles.

[0326] In some instances, riboflavin delivery is achieved using corneal targeted acoustic waves in 5-minute cycles that spare the epithelium, followed by cell-generated (-90% pure) oxygen and approximately 10 mW / cm 2 The treatment can be intensified with approximately 10 minutes of UV light at an intensity of 100 nm to 200 nm. Total treatment time is approximately 15 minutes per eye.

[0327] FIG. 81 is a schematic diagram of an exemplary system 8100 for passive cavitation detection. Any of the shockwave generators described herein may include a passive cavitation detector 8104. During pulsing, the passive cavitation detector 8104 may be configured to detect shockwave generation by the shockwave generator 8102 (e.g., "main band delay" 8108) and the formation and dissipation 8110 of cavitation within the tissue 200. In some embodiments, the passive cavitation detector 8104 may be comprised of a piezoelectric detector, such as a hydrophone. In some embodiments, the passive cavitation detector 8104 may detect a signal 8106 indicative of the formation and dissipation 8110 of cavitation bubbles within the tissue 200. The signal 8106 may include timing and spectral information (e.g., rebound lag, intensity, etc.) regarding the bubbles that may be extracted intraoperatively. Because the rate of bubble collapse can be related to intraocular pressure (IOP), passive cavitation detection can be utilized to indirectly measure IOP non-invasively and intraoperatively. Intraocular pressure measurements may be particularly useful during glaucoma treatment and / or to improve the safety and efficiency of selective shockwave therapy.

[0328] The steady-state cavitation bubble dissolution time in the aqueous humor of the treated eye may be inversely proportional to the intraocular pressure. A passive cavitation detector 8104 may be used to record the signal (e.g., reflection amplitude and time to disappearance) of the tissue bubbles from the anterior chamber. The size of the bubbles induced in the tissue by the spark gap 114 in the fluid-filled impulse chamber 106 can be set (e.g., by pulse frequency and voltage adjustment) to two selected average bubble cloud sizes, and the tissue steady-state bubble dissolution rate may be extracted following averaging and filtering of the passive cavitation detector signal 8106. This process is completely non-invasive and may be performed in real time during surgery.

[0329] The eye 200 (i.e., pressure vessel) exerts a force on the size of the cavitation bubbles, which oscillate due to the intrinsic fluid pressure ("IOP"). The passive cavitation detector 8104 and the high frequency shock wave generator 8102 may interact to extract the "stimulus-free" bubble cloud size maximum. A second known stimulus (e.g., 1 / 11 of the primary high frequency resonance) may then be applied by a miniature ultrasound generator (e.g., 28 kHz) and the bubble cloud size maximum may be extracted by the PCD / PC software. This sequence may be repeated for hundreds of cycles (e.g., 0.1 to 1 second) to improve the accuracy of the intraocular pressure extraction.

[0330] In some embodiments, the IOP may be measured using other non-contact methods, such as an air-puff tonometer, instead of or in addition to the passive cavitation detector 8104.

[0331] In some embodiments, the passive cavitation detector 8104 may operate at a frequency of about 10 MHz and have a high acoustic impedance.

[0332] In some embodiments, it may be beneficial to characterize shockwave generation and repeatability prior to use to ensure that a uniform acoustic energy signal (mean, standard deviation) is emitted for repeated treatments. Any of the systems described herein can be quickly checked for its acoustic emission footprint prior to intraocular use. For example, an acoustic pressure color map may be captured on a Fujifilm prescale by shockwave irradiation. The acoustic pressure color map may be image processed and analyzed for comparison to a reference image utilizing typical treatment settings (e.g., voltage, frequency, etc.) in saline for a short period of time (e.g., 10 ms to 1 s). Precut Fujifilm prescales (highly accurate pressure sensitive ranges enclosed in a water-resistant plastic sleeve pocket) may be disposable. A color camera and white light illumination can capture the highest acoustic pressures on film. A borescope-like fiber optic can be used to transmit and receive uniform illumination and color map between the camera and film. ±15% accuracy can be targeted at the beginning of treatment.

[0333] FIG. 82 illustrates an exemplary treatment system 8200 with passive cavitation detection. The system 8200 may be substantially similar to any of the systems described herein. The system 8200 may be configured for the treatment of presbyopia, glaucoma, dry eye disease, AMD, keratoconus, etc., as described herein. The system 8200 may include a shockwave generator 8202 substantially similar to any of the shockwave generators described herein. For example, the shockwave generator 8202 may include a first electrode 110 and a second electrode 112 disposed within a housing 102. The housing 102 may include a fluid-filled chamber 106 and an eye-contacting surface 104. The housing 102 may be substantially tubular, with the electrodes 110, 112 disposed near a proximal end of the fluid-filled chamber 106 and the eye-contacting surface 104 disposed at a distal end of the fluid-filled chamber 106 with an elongated central portion 8202 providing a wave director between the fluid-filled chamber 106 and the eye-contacting surface 104. The eye-contact surface 104 may be constructed, for example, from a PET film as described herein. The eye-contact surface 104 may be configured to couple to a surface 500 of the patient's eye 200. A coupling fluid or gel, e.g., a water column, may be disposed on or under the eye-contact surface to facilitate contact between the eye-contact surface 104 and the ocular surface 200 and / or to facilitate transmission of shock waves from the shockwave generating device 8200 to the eye 200 as described herein.

[0334] In some embodiments, the shockwave generator 8200 may further comprise a fluid inlet 108 and a fluid outlet 109 in fluid communication with the fluid-filled chamber 106, as described herein. Fluid may be circulated within the fluid-filled chamber 106 via the fluid inlet 108 and the fluid outlet 109. The fluid may be circulated at a rate sufficient to remove bubbles and / or heat formed during shockwave generation (e.g., about 100 ml / min). The fluid inlet 108 may be configured to supply fluid to a distal portion of the shockwave generator 8200 (e.g., a distal portion of the director 8202), and the fluid outlet 109 may be configured to remove fluid from a proximal portion of the shockwave generator 8200 (e.g., near the electrodes 110, 112) such that the fluid flows through the housing 102 in a direction opposite to the direction of shockwave travel.

[0335] The fluid-filled chamber 106 may include a conductivity sensor 7702. The conductivity sensor 7702 may include a pair of low voltage platinum electrodes 7704, 7706 spaced a distance apart (e.g., flanked by the high voltage shockwave generating electrodes 110, 112). The pair of platinum electrodes 7704, 7706 may be configured to periodically or continuously sample the conductivity of the fluid in the fluid-filled chamber 106 as described herein.

[0336] In some embodiments, a reservoir 7904 of oxygen and / or one or more therapeutic substances may be disposed on or under the eye-contacting surface 104 for drug delivery to the cornea 2206. The reservoir 7904 may be coupled to the eye by a vacuum-sealed retaining ring 1202. Shock waves generated by the shockwave generator may enhance drug delivery to the cornea 2206 (e.g., to the epithelium) by causing surface fragmentation and / or micro-perforation of the subject's corneal tissue to improve drug permeability. In some embodiments, the therapeutic substance may include a photosensitizer, such as riboflavin, riboflavin nanoparticles, or rose bengal.

[0337] In some embodiments, the reservoir 7904 may include a fluid inlet and optionally a fluid outlet for circulating oxygen and / or therapeutic substances from an external source / reservoir(s) to the cornea below the eye-contacting surface. In some embodiments, the same fluid inlet and fluid outlet may be used for each substance. In some embodiments, each substance may have a dedicated fluid inlet and fluid outlet. In some embodiments, oxygen may be generated using electrochemical cell(s) 8206 for electrolysis and delivery to the eye (e.g., >90% oxygen at 15 ml / min). For example, oxygen may be generated by an electrolytic cell powered by a low power current source (e.g., AA battery) from the atmosphere and delivered to the fluid inlet 8002 of the suction ring 1202 at the patient interface. Riboflavin may be delivered from the reservoir 8204 to the same fluid inlet 8002 or a different fluid inlet 8004 as described herein. In some embodiments, the reservoir 8204 may be a sterile IV bag or syringe, or the like.

[0338] In some embodiments, oxygen and / or other therapeutic substances may be delivered to the eye using the shock wave generator 8200 without simultaneous or subsequent crosslinking.

[0339] In some embodiments, the proximal end of the fluid-filled chamber 106 may include a passive cavitation detector 8104. The passive cavitation detector may be configured to monitor cavitation and / or IOP during surgery as described herein. The passive cavitation detector may be used to verify that the intensity and occurrence of cavitation is within range and to ensure the presence and extraction of gas bubbles. The passive cavitation detector may also be used to detect the duration and intensity of cavitation of tissue to estimate intraocular pressure.

[0340] In some embodiments, the proximal end of the fluid-filled chamber 106 may comprise or be coupled to a light source 7906. For example, the light source may be an ultraviolet light emitting diode (LED) (e.g., 365 nm wavelength) or an optical fiber coupled to an external ultraviolet LED or laser, or the like. In some embodiments, the light source may be a green LED (e.g., 525 nm wavelength) or an optical fiber coupled to an external green LED or laser, or the like. During or following delivery of oxygen and / or riboflavin (or other ultraviolet sensitive or photosensitizing therapeutic substances), the ultraviolet light source may be used to crosslink the cornea (e.g., for the treatment of keratoconus).

[0341] The shock wave director 8202 may be constructed from a stainless steel tube having an outer diameter in the range of about 1 mm to about 8 mm, for example, about 1 mm, about 2 mm, about 3 mm, about 5 mm, or about 8 mm. The shock wave director may be constructed from a stainless steel tube having an outer diameter of about 7 mm. The director may have a wall thickness of about 0.5 mm.

[0342] In some embodiments, the director may have a length in the range of about 1 cm to about 2 cm. In some embodiments, the director may have a length of about 12 mm or more. For example, the director may have a length in the range of about 12 mm to about 80 mm, e.g., about 20 mm. The shock wave director may be constructed from a stainless steel tube having a length of about 40 mm.

[0343] In some embodiments, one or more acoustic bridging shockwave generators may be coupled to a fluid-filled contact lens as described herein.

[0344] In some embodiments, one or more acoustic bridging shockwave generators with directors may be attached to a trial frame, such as adjustable goggles, as described herein.

[0345] FIG 83 is a side view of an exemplary treatment system 8300 including a conductivity sensor, acoustic bridging, and / or passive cavitation detection. The system 8300 may be substantially similar to the system shown in FIG 82. The system 8300 may be configured to treat one or more conditions and / or target one or more locations on or under the surface of the eye as described herein.

[0346] In some embodiments, the eye-contacting surface (e.g., a PET film) 104 may be tightly sealed to the reservoir 7904 to fluidly isolate the shockwave fluid-filled chamber 106 from the oxygen / riboflavin reservoir 7904.

[0347] In some embodiments, the system 8300, or any of the systems described herein, may be used to segment the PVZ as described herein. For example, a transparent opening of a shockwave generator with a focal length of 3 mm may be positioned on the surface of the eye 200 above the PVZ using frame control. Saline may be circulated in the fluid-filled chamber 106, and electrical conductivity measurements and passive cavitation detection may be utilized during treatment. Treatment may be patterned annularly (e.g., as shown in FIG. 85B) to about four locations along the meridian of the eye in each of the four quadrants of the eye. The system 8300 may be positioned at a first location corresponding to the first quadrant and may treat the PVZ with shockwaves generated at a voltage of about 2 kV and a frequency of about 3 kHz for about one minute. The system 8300 may then be repositioned to a second location corresponding to the second quadrant for treatment, and so on. In some embodiments, eight or more locations may be treated annularly as described herein.

[0348] In some embodiments, the system 8300, or any of the systems described herein, may be used to break up the lens as described herein. For example, a transparent opening of an 8 mm square shockwave generator may be placed over the cornea of ​​the eye 200. Saline may be circulated within the fluid-filled chamber 106, and electrical conductivity measurements and passive cavitation detection may be utilized during treatment. The lens may be treated for about 1 minute with shockwaves generated at a voltage of about 0.5 kV and a frequency of about 4 kHz.

[0349] In some embodiments, the system 8300, or any of the systems described herein, may be used to dilate and / or remove the trabecular meshwork and / or Schlemm's canal as described herein. For example, a 3 mm square transparent opening of the shockwave generator may be positioned on the surface of the eye 200 above the limbus using frame control. Saline may be circulated in the fluid-filled chamber 106, and electrical conductivity measurements and passive cavitation detection may be utilized during treatment. Treatment may be annularly patterned (e.g., as shown in FIG. 85A) to four locations along the meridian of the eye in each of the four quadrants of the eye. The system 8300 may be positioned at a first location corresponding to the first quadrant and may treat the trabecular meshwork and / or Schlemm's canal with shockwaves generated at a voltage of about 1 kV and a frequency of about 4 kHz for about 30 seconds. The system 8300 may then be repositioned to a second location corresponding to the second quadrant for treatment, and so on. Treatment may be repeated if sufficient cavitation and / or sufficient intraocular pressure change is not detected using the passive cavitation detector 8104. In some embodiments, eight or more locations may be treated along the annulus as described herein.

[0350] In some embodiments, the system 8300, or any of the systems described herein, may be used to dilate and / or remove the meibomian glands as described herein. For example, an air-filled scleral contact lens 7606 may be placed on the eye 200 and the eyelids may be closed. Upper and lower shockwave generators may be placed on the eyelids over the meibomian glands. Saline may be circulated within the fluid-filled chamber 106, and electrical conductivity measurements and passive cavitation detection may be utilized during treatment. The meibomian glands may be treated for approximately 1 minute with shockwaves generated at a voltage of approximately 2 kV and a frequency of approximately 4 kHz.

[0351] In some embodiments, the system 8300, or any of the systems described herein, can be used to crosslink the cornea as described herein. For example, shock waves generated at a voltage of about 2 kV and a frequency of about 4 kHz can be applied at 30 second intervals to infiltrate the cornea with riboflavin until sufficient riboflavin has infiltrated the cornea. Thereafter, an ultraviolet laser 7906 (e.g., about 10 mW / cm 2 Oxygen may be injected for 30 seconds before activating the laser (laser with an intensity of 100 nm and wavelength of 365 nm). Simultaneous oxygenation and laser crosslinking may be performed for approximately 10 minutes. Saline may be circulated within the fluid-filled chamber 106 and electrical conductivity measurements and passive cavitation detection may be utilized during treatment.

[0352] FIG. 84 is a schematic diagram of an exemplary treatment system 8400 including acoustic bridging or passive cavitation detection. The system 8400 may be substantially similar to any of the systems described herein. The system 8400 may include a shockwave generator substantially similar to any of the shockwave generators described herein. For example, the shockwave generator may include a first electrode 110 and a second electrode 112 disposed within a housing 102. The housing 102 may include a fluid-filled chamber 106 and an eye-contacting surface 104. The housing 102 may be substantially tubular, with the electrodes 110, 112 disposed near a proximal end of the fluid-filled chamber 106 and the eye-contacting surface 104 disposed at a distal end of the fluid-filled chamber 106 with an elongated central portion 8402 providing a waveguide between the fluid-filled chamber 106 and the eye-contacting surface 104. The eye-contacting surface 104 may be comprised of, for example, a PET film as described herein. The eye-contacting surface 104 may be configured to be coupled to a surface of a patient's eye. A coupling fluid or gel, e.g., a water column, may be disposed on or under the eye-contact surface 104 to facilitate contact between the eye-contact surface and the surface of the eye and / or to facilitate transmission of shock waves from the shock wave generating device to the eye as described herein.

[0353] In some embodiments, the shockwave generator may further comprise a fluid inlet 108 and a fluid outlet 109 in fluid communication with the fluid-filled chamber 106, as described herein. Fluid may be circulated within the fluid-filled chamber 106 via the fluid inlet 108 and the fluid outlet 109. The fluid may be circulated at a rate sufficient to remove bubbles and / or heat formed during shockwave generation (e.g., about 100 ml / min). The fluid inlet 108 may be configured to deliver fluid to a distal portion of the shockwave generator (e.g., a distal portion of the director 8402), and the fluid outlet 109 may be configured to remove fluid from a proximal portion of the shockwave generator (e.g., near the electrodes 110, 112) such that the fluid flows through the housing 102 in a direction opposite to the direction of shockwave travel.

[0354] In some embodiments, the proximal end of the fluid-filled chamber 106 may be configured to act as a reflector to focus the shock waves via the director towards a desired predetermined location. Alternatively, or in combination, one or more reflectors 802 may be coupled to an inner surface of the fluid-filled chamber 106 to focus the shock waves. The inner wall of the fluid-filled chamber 106 may be ellipsoidal. Alternatively, or in combination, the distal portion of the director 8402 may be configured to focus the shock waves at a predetermined location on or below the surface of the eye.

[0355] Alternatively, or in combination, the proximal end of the fluid-filled chamber 106 may include a conductivity cell 7702 that includes a conductivity sensor configured to periodically or continuously sample the conductivity of the fluid in the fluid-filled chamber, as described herein.

[0356] Alternatively, or in combination, the proximal end of the fluid-filled chamber 106 may be equipped with a passive cavitation detector 8104, as described herein.

[0357] Alternatively, or in combination, the proximal end of the fluid-filled chamber 106 may include an acoustic crosslinking light source 7906, as described herein.

[0358] In some embodiments, a reservoir 7904 of oxygen and / or one or more therapeutic substances may be disposed on or under the eye-contacting surface 104 for drug delivery to the cornea as described herein. The reservoir 7904 may be coupled to the eye by a vacuum-sealed retaining ring 1202. Shock waves generated by the shockwave generator may enhance drug delivery to the cornea (e.g., to the epithelium) by causing surface fragmentation and / or micro-perforation of the subject's corneal tissue to improve drug permeability as described herein. In some embodiments, the therapeutic substance may include a photosensitizer, such as riboflavin, riboflavin nanoparticles, or rose bengal.

[0359] In some embodiments, the reservoir 7904 may include a fluid inlet 8406 and optionally a fluid outlet 8408 for circulating oxygen and / or therapeutic substances from an external source / reservoir(s) 8404 to the cornea below the eye-contacting surface. In some embodiments, the same fluid inlet 8406 and fluid outlet 8408 may be used for each substance. In some embodiments, each substance may have a dedicated fluid inlet and fluid outlet. In some embodiments, oxygen may be generated using electrochemical cell(s) 8206 for electrolysis and delivery to the eye (e.g., >90% oxygen at 15 ml / min). For example, oxygen may be generated by an electrolytic cell powered by a low power current source (e.g., AA battery) from the atmosphere and delivered to the fluid inlet 8002 of the suction ring 1202 at the patient interface. Riboflavin may be pumped from the reservoir 8204 to the same fluid inlet 8002 or a different fluid inlet 8004 as described herein.

[0360] In some embodiments, oxygen and / or other therapeutic substances may be delivered to the eye using a shock wave generating device without simultaneous or subsequent crosslinking.

[0361] The shock wave director 8402 may be constructed from a stainless steel tube having an outer diameter in the range of about 1 mm to about 8 mm, for example, about 1 mm, about 2 mm, about 3 mm, about 5 mm, or about 8 mm. The shock wave director may be constructed from a stainless steel tube having an outer diameter of about 3 mm or about 7 mm. The director may have a wall thickness of about 0.5 mm.

[0362] In some embodiments, the director 8402 may have a length in the range of about 1 cm to about 2 cm. In some embodiments, the director may have a length of about 12 mm or more. For example, the director may have a length in the range of about 12 mm to about 80 mm, e.g., about 20 mm. The shock wave director may be constructed from a stainless steel tube having a length of about 15 mm or about 30 mm.

[0363] Figures 85A to 85F show exemplary treatment patterns for various targeted indications. Any of the shockwave generators or systems described herein can be used to treat the indications as shown in Figures 85A to 85F. For example, one or more shockwave generators constituting a director may be attached to a pair of trial frame goggles as described herein in a pattern corresponding to the targeted indication.

[0364] FIG. 85A illustrates a glaucoma treatment pattern 8501. Planar waves may be directed toward the limbus and / or sclera for microsonoporation. Alternatively, or in combination, shock waves can be used for non-thermal ciliary process fractionation to reduce water production for glaucoma treatment. In some embodiments, microporation tracks can be generated to enhance blood, oxygen, nutrient, and / or lymph flow and / or increase fluid conduction velocity within tissue.

[0365] 85B shows a treatment pattern 8502 for presbyopia. Plane and / or focused waves can be directed towards the paralimbal sclera and / or posterior vitreous zonule for microsonoporation and / or fragmentation.

[0366] Figure 85C shows a treatment pattern 8503 (without epifluorescent crosslinking) for corneal drug (e.g., riboflavin) delivery. Low-power plane waves can be directed at the cornea (e.g., epithelium) to effect surface fragmentation and microporation thereof to enhance drug delivery thereto.

[0367] 85D shows a treatment pattern 8504 for acoustic / accelerated crosslinking. Plane waves can be directed to the cornea to enhance delivery of riboflavin and / or oxygen, as described herein. In that case, ultraviolet light can be used to irradiate and crosslink the cornea, as described herein.

[0368] Fig. 85E shows a treatment pattern 8505 for dry eye disease. Plane waves may be directed towards the meibomian ducts / glands of the eyelids for their vasodilation and / or ablation, optionally with the aid of a contact lens for corneal protection.

[0369] Figure 85F shows a treatment pattern 8506 for AMD. Planar waves may be directed towards the retina for dilation and / or sonic stimulation of the retina / lymphatic plexus.

[0370] In the case of dry AMD, non-selective low-power treatment can induce sufficient retinal acoustic stimulation to vasodilate and / or stimulate retinal senescent cells. In the case of wet AMD, which exhibits neovascularization, it may be beneficial to preferentially enhance shockwave treatment at the site of retinal neovascularization to reduce or eliminate (e.g., fragment) leakage of neovessels while sparing surrounding tissue. In at least some examples, shockwave therapy may be locally enhanced by selective seeding of nanoparticles and / or microbubbles into tissue. As described herein, low-dose shockwave energy, which may have limited effect on non-seeded tissue, may selectively fragment microbubble-seeded tissue (e.g., collapsing microbubbles may directly damage cells as described herein). In some embodiments, microbubbles or microbubble formation-enhancing particles may be injected into the bloodstream and accumulate in retinal tissue adjacent to the neovessels due to the leaky nature of retinal neovessels. Alternatively, laser energy may be focused on the desired treatment site of the retina to induce microbubble formation at that site. Multiple wavelength ranges, i.e., 532 nm, 590 nm, femto laser, near infrared, mid infrared, or wavelengths ranging from 6 μm to 10 μm, can be used to induce microbubble formation in tissue. The laser may be a pulsed picosecond, nanosecond, or microsecond laser. Once the microbubbles are seeded, low energy shockwave therapy may be directed to the retina as described herein, and treatment may be selectively enhanced in the microbubble-mediated seeded tissue.

[0371] Any of the systems described herein can be used to perform a capsulorhexis or capsulorhexis on the lens capsule of the eye. For example, microbubbles erupting from a soft contact lens placed on an intraocular lens inserted during phacoemulsification (PHACO) / cataract treatment can emulsify the insonified 5.5mm central lens and soften the cataract lens. In this treatment, a capsulorhexis or capsulorhexis can be performed depending on the interaction / patterning of the exposed and circulating microbubbles. The microbubbles and / or microparticles can selectively function as acoustic shields or cavitation seeding particles. Channeling these through a thin capsule-type IOL inserted during the shockwave surface incision during cataract surgery can deposit energy into the capsule and / or lens according to the spatial pattern of the channels and the timed flow of either (microparticles or microbubbles) therein.

[0372] As will be appreciated by those skilled in the art, any of the shock wave generating devices and systems described herein may be combined with or substituted for another, and therefore any number of combinations may be used. For example, any of the devices and systems described herein that include a pair of electrodes for shock wave generation may instead utilize a piezoelectric, laser, or magnetoelectric shock wave generating mechanism as described herein. In addition, various features of shock wave generating devices and systems, such as corneal sparing contact lenses, contact lens balloons, shock wave directors, focused shock wave generators, reflectors, variable focus lenses, unfocused shock wave generators, conductivity sensors, current sensors, pressure sensors, passive cavitation detectors, imaging systems, drug delivery reservoirs, cross-linking laser energy sources, and fluid recirculation systems for bubble removal, are described herein. As will be appreciated by those skilled in the art, any of these features may be combined with or substituted for another, and therefore any number of combinations may be used.

[0373] Described herein are a) treatment methods and patterns for presbyopia, glaucoma, dry eye disease, dry AMD, wet AMD, keratoconus, corneal ectasia, and the like, and b) target locations on or within the eye, including one or more of the trabecular meshwork, Schlemm's canal, ciliary body (e.g., selected portions such as ciliary processes, muscles, anterior / posterior / middle ciliary body), pars plana, ciliary folds, cornea, sclera, lens, retina, orbit, periorbital, intermediate vitreous zonule (IVZ), posterior vitreous zonule (PVZ), vitreous, eyelid, and / or meibomian gland. One skilled in the art will appreciate that these treatment methods, patterns, and target locations may be selected based on the indication, or combination of indications, being treated. The devices and systems may be configured to treat one or more target locations for one or more indications simultaneously or sequentially as desired. In some embodiments, the system may include multiple shockwave generators positioned at different locations adjacent the surface of the eye and focused (or not) on different target locations on or under the eye to treat multiple indications without removing the system from the patient's eye. Those skilled in the art will appreciate that these treatment locations, methods, and patterns may be combined with or substituted for one another, and thus any number of combinations may be used.

[0374] While preferred embodiments of the present invention have been shown and described herein, it will be apparent to those skilled in the art that such embodiments are provided by way of example only. Numerous variations, changes, and substitutions may be made by those skilled in the art without departing from the present invention. It should be understood that various alternatives to the embodiments of the present invention described herein may be employed in practicing the present invention. It is intended that the following claims define the scope of the present invention, and that methods and structures within the scope of these claims, and their equivalents, be covered thereby.

Claims

1. a housing including a fluid-filled chamber and an eye-contacting surface configured to contact a surface of the eye; a first electrode disposed within the housing; a second electrode disposed within the housing and coaxially disposed with the first electrode, a distal end of the first electrode and a distal end of the second electrode being separated by a gap; a fluid inlet and a fluid outlet in fluid communication with the fluid-filled chamber; 11. An apparatus for treating an eye, wherein the first electrode and the second electrode are configured to generate an electrical arc across the gap when energized to generate shock waves in fluid in the fluid-filled chamber.

2. 2. The device of claim 1, wherein an inner surface of the housing is configured to focus the shock waves at a predetermined location on or below the surface of the eye.

3. 3. The device of claim 1 or claim 2, further comprising a reflector disposed within the housing and configured to focus the shock waves to a predetermined location on or below the surface of the eye.

4. 4. The device of claim 1, further comprising one or more wires coupled to the first electrode or the second electrode and configured to deliver energy.

5. 5. The apparatus of claim 1, wherein the first electrode and the second electrode comprise a first tip of a first wire and a second tip of a second wire.

6. 6. The device of claim 1, wherein the fluid comprises saline or water.

7. 7. The apparatus of claim 1, wherein the first electrode and the second electrode are coated with graphene to reduce erosion due to shock wave generation during use.

8. 8. The apparatus of claim 1, wherein the housing is ellipsoidal.

9. 9. The device of claim 1, wherein the housing further comprises a fluid-filled waveguide disposed between the fluid-filled chamber and the eye-contact surface and configured to fluidly couple the fluid-filled chamber and the eye-contact surface.

10. 10. The apparatus of claim 1, further comprising an acoustic lens disposed within the housing and configured to focus the shock waves at one or more predetermined locations on or below the surface of the eye.

11. 11. The apparatus of claim 1, further comprising a conductivity sensor disposed at least partially within the fluid-filled chamber and configured to measure a conductivity of the fluid within the fluid-filled chamber.

12. The apparatus of claim 11 , wherein the conductivity sensor comprises a pair of platinum electrodes.

13. 13. The apparatus of claim 1, further comprising a light source disposed at least partially within the fluid-filled chamber and configured to emit light towards the surface of the eye.

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