40 EyeWorld Asia Pacific | June 2024 If it’s clear that patients are medication compliant, their testing indicates progression that’s occurring with good control of IOP, and they say they’ve experienced a change in vision, Dr. Ramulu said his next step is home tonometry. His practice uses a service that helps patients rent out a home tonometer, allowing them to check pressures more regularly from home. There are three categories of patients that you’ll find with data from home tonometry. 1. People who always have very low pressures. When you check them at home, their pressure is never going above 12–13 mmHg, Dr. Ramulu said. Maybe there is the occasional reading of 15 mmHg, but the average may be 10 mmHg. He said the standard deviation or variability of the reading is small and the pressure is extremely well controlled. 2. People whose average pressure is 12–13 mmHg but who sometimes get into the upper teens and occasionally up to 20 mmHg. “You would think they would be controlled, but it’s believable that they could be getting worse,” Dr. Ramulu said. 3. People with extreme pressure fluctuations. Dr. Ramulu said these people might wake up with their pressure at 30 mmHg but then it comes down over the course of the day. “I’ve seen a handful of those. One heartbreaking story is someone who came in, and he was hand motioning. He was telling me that he was seeing worse and worse. His pressure was 10 mmHg on a bunch of medicines. We did a trial on him, and every morning he was up into the 30s. He had been losing vision for years, but no one found this out. It was very unfortunate that he lost so much vision in both eyes as a result,” Dr. Ramulu said. Treating progressing NTG Dr. Moster said her current strategy, when it’s clear that a patient has NTG that’s progressing despite low to normal IOP, is to look at the T-max, the highest pressure, and try to lower that by 30%, using caution to not go below episcleral venous pressure, which won’t happen without surgery. Because the pressures of these patients often rise at night, Dr. Moster said her topical therapy is tailored toward prostaglandins, which have been shown to lower pressure at night. She also said topical carbonic anhydrase inhibitors have been shown to lower pressure at night. Rhopressa (Netarsudil ophthalmic solution, Alcon), Rocklatan (Netarsudil/Latanoprost ophthalmic solution, Alcon), and Vyzulta (Latanoprostene bunod ophthalmic solution, Bausch + Lomb) are valuable for normal to low tension glaucoma because they lower pressure at night with a prostaglandin component, but they also work in symbiotic ways to lower pressure, Dr. Moster said. Dr. Moster will use alpha agonists in some low tension glaucoma patients and SLT early in patients who are admittedly non-compliant with topical therapies. She also sees a place for Durysta (Bimatoprost intracameral implant, Allergan) for patients who are non-compliant. For patients who are not yet ready for surgery, she’ll combine Durysta with SLT before or after to lower the pressure 20–30%. There is still a role for beta blockers, according to Dr. Moster, because they are once daily and can be taken in the morning. “I have patients put it near their toothbrush,” Dr. Moster said. “For prostaglandins in people who are non-compliant, I ask them to put it on the kitchen table and have them use it earlier in the evening right after dinner.” When surgery is the best option for the patient, Dr. Moster said she’s a “big fan of combining cataract surgery and MIGS because in NTG every millimeter of mercury counts.” She mentioned the full range of MIGS options that she likes to use. “They’re all very effective in helping the pressure come down an extra few millimeters of mercury,” Dr. Moster said. “If they’re still progressing, I’m in favor of the XEN Gel Stent [Allergan] in normal tension, even though the success rate is not as high as a trabeculectomy. Trabeculectomies are the gold standard for bringing the pressure into the single digits, but then I’m worried about the increase of complications.” Dr. Ramulu said the group whose home tonometry shows large spikes in pressure are the “low-hanging fruit” for a pressure-lowering surgery. The type of procedure he’ll select depends on their disease stage, lens status, and other considerations. For patients whose pressure is averaging below their target pressure but who are having occasional jumps to 18–20 mmHg, he said it’s harder to know what to do. “I’ll usually offer it to them. The goal isn’t necessarily to get the pressure any lower than it is on average but to have all the readings be at that average.” In these cases, Dr. Ramulu said he will often first do the procedure in the worse eye, and monitor it closely over a year. If the visual fields appear stable and their progression trajectory has changed, he’s able to approach the second eye with more information. GLAUCOMA
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