42 EyeWorld Asia Pacific | June 2024 Finally, Dr. Ramulu said the patients who are consistently presenting with low pressures based on home tonometry are tough. He noted publications that discuss trabeculectomy for people with pressures of 10 mmHg, but you need to be careful with this group. “You’re going to get some hypotony, macular folds, maculopathy, choroidal effusions. When we create low pressures, we’re not precise enough to dial someone into 7 or 8,” Dr. Ramulu said. If he does perform a trabeculectomy on patients with low pressures, Dr. Ramulu said he modifies his technique. “The best results I’ve gotten with these patients are when I’ve left the flap tighter than I normally would,” he said. Dr. Moster also engages primary care doctors for systemic conditions that can affect patients with NTG. She asks whether hypertensive medications they might be taking at night could be switched to during the day. She also asks for sleep apnea tests because if left untreated, obstructive sleep apnea can be associated with progression. In addition to traditional glaucoma therapies — drops, laser, and surgical procedures — and looking at how systemic conditions could affect progression, Dr. Moster asks her patients to take antioxidants, such as ginkgo, resveratrol, turmeric, and enzyme CoQ10. She said that there is evidence in the literature that these may help but acknowledged that it isn’t very well established. There are also behavioral elements that she discusses with patients to reduce the risk of progression. These include avoiding headstands if they do yoga and always keeping their head above their heart in general during exercise. She also said wearing tight neckties, playing wind instruments that require forceful blowing, or lifting heavy weights with Valsalva maneuvers are discouraged. While she’s treating and monitoring these patients, Dr. Moster said she regularly documents the optic nerves, especially looking for optic disc hemorrhages and treating them more aggressively. “It’s been shown that these patients progress faster when hemorrhages are occurring,” Dr. Moster said. Dr. Moster said that there is a new mindset for treatment of NTG, which is to test more frequently, treat earlier, treat more aggressively, and change therapy often. Also, you should choose a therapy that works for the patient’s lifestyle. “That’s very important because medicines don’t work in the bottle,” she said. Expanding IOP monitoring technology Ophthalmologists have been saying for some time that obtaining pressures just a few times a year is not enough for most glaucoma patients. Technology was needed to allow convenient, more frequent measurements of IOP. A few companies have responded to the call with some technology already in use and others in development. iCare HOME (iCare) This is a home tonometry system that is already FDA approved and is what Dr. Ramulu has some of his patients use. He said there is a charge for the service he uses to provide the device to patients. From a learning standpoint, he said most of his patients have been able to use the handheld technology without prior training. Some patients download the app and provide readings directly to their physician, while others send the device back to the facilitating company when the trial is complete, and the company provides the physician with the data. Dr. Moster said she has also used iCare HOME with some of her patients, as well as the Olleyes virtual visual field test. She said she’s changed therapies quite a bit based on the information provided by these sources. “iCare HOME makes great sense because the patient has skin in the game, they’re monitoring their pressure, they’re becoming more compliant based on this, and it’s all for their own benefit,” she said. Triggerfish (Sensimed) This FDA-approved contact lens is able to provide 24hour continuous IOP data. Eyemate (Implandata Ophthalmic Products) This is a permanent implantable, biocompatible microsensor that currently has the CE mark. Data from the implant is transmitted via a wireless connection to an app that can provide the patient with information about their disease and a medication schedule and the doctor with data to monitor therapeutic response. GLAUCOMA
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