Eyeworld

102 | EYEWORLD | SPRING 2024 G UCOMA Contact Moster: marlenemoster@gmail.com Ramulu: pramulu@jhmi.edu Relevant disclosures Moster: None Ramulu: Perfuse Therapeutics 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 com- bining 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 compli- cations." Dr. Ramulu said the group whose home tonometry shows large spikes in pressure are the "low-hanging fruit" for a pressure-lower- ing 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 mm Hg, 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 do the procedure in the worse eye first 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. 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 mm Hg, but you need to be careful with this group. "You're going to get some hypotony, mac- ular folds, maculopathy, choroidal effusions. When we create low pressures, we're not precise enough to dial someone in to 7 or 8," Dr. Ram- ulu said. continued from page 101 continued on page 103 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 need- ed to allow convenient, more frequent mea- surements 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 al- ready 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 tech- nology 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 compa- ny 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 24-hour continuous IOP data. Eyemate (Implandata Ophthalmic Products) This is a permanent implantable, biocom- patible microsensor that currently has the CE mark. Data from the implant is trans- mitted via a wireless connection to an app that can provide the patient with informa- tion about their disease and a medication schedule and the doctor with data to monitor therapeutic response.

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