Eyeworld

SPRING 2024 | EYEWORLD | 101 G drop in vision that is commensurate with what he would expect from the imaging and visual fields? He has a discussion with patients about whether they're using their topical IOP-lowering medications as directed. "I say, 'We're going to start talking about operations, and if you're not using your med- icines properly, please tell me because I don't want to do an operation if you're just not using your medications as you should be,'" he said of his patient conversation. "Usually at that point when faced with something tangible that has some risks, patients say, 'I haven't been using them consistently.'" He'll also check ability to administer drops. Patients might in fact be taking their drops, but if they're not getting onto the eye correctly, they're not working. You need to make sure they're taking what you say they should take, when you say, how often, and that the drop is making it into their eye, Dr. Ramulu said. If it's clear patients are medication com- pliant, their testing indicates progression that's occurring with good control of IOP, and they say they've experienced a change in vision, Dr. Ra- mulu said his next step is home tonometry. His practice uses a service that helps patients rent out a home tomometer, allowing them to check pressures more regularly at their home. There are three categories of patients that you'll find with data from home tonometry. 1) People who always have very low pres- sures. When you check them at home, their pressure is never going above 12–13 mm Hg, Dr. Ramulu said. Maybe there is the occasional reading of 15 mm Hg, but the average may be 10 mm Hg. He said the standard deviation or variability of the reading is small and the pressure is ex- tremely well controlled. 2) People whose average pressure is 12–13 mm Hg but who sometimes get into the up- per teens and occasionally up to 20 mm Hg. "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 mm Hg 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 motion. He was telling me … that he was seeing worse and worse. His pressure was 10 mm Hg 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 progress- ing 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 topi- cal 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 solu- tion, Alcon), Rocklatan (netarsudil/latanoprost ophthalmic solution, Alcon), and Vyzulta (lata- noprostene 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 continued on page 102

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