Eyeworld

117 February 2015 EW MEETING REPORTER is inherited as a complex trait, and gene variants influence the disease risk but are not necessarily causative. Dr. Wiggs said to consider ge- netic testing if the patient is diag- nosed before the age of 50. She also recommended targeting surveillance and therapy specifically to mutation carriers by eliminating unnecessary surveillance, reassuring patients who are not mutation carriers, and personalizing treatment plans. Editors' note: Dr. Wiggs has financial interests with Genentech (San Francisco). 24-hour IOP monitoring in reach with new devices, physician says Malik Kahook, MD, Aurora, Colo., discussed 24-hour IOP monitoring, with his presentation touching on the impact of IOP fluctuations, the method of assessing IOP fluctuation, and non-invasive devices. IOP is the only modifiable risk factor in glau- coma, and every treatment relates to IOP. All medical therapies aim to lower IOP, all laser therapies aim to lower IOP, and all surgical therapies aim to lower IOP, Dr. Kahook said. With current monitoring for IOP, 99.99% of IOP data could be out of reach, he said. IOP is dynam- ic, and for that reason, a single, stat- ic office IOP reading may not reflect true range, peak level, and variation throughout the day, he said. "Two-thirds of glaucoma pa- tients have peak IOP outside of what we see in the office hours," Dr. Kahook said. IOP can show short-term fluctuation (seconds to minutes), like from blinking or heartbeat; intermediate-term fluctu- ation (minutes to hours), like from the effect of medication, activity, and positional changes; and long- term fluctuation (days to months), like from disease progression and treatment changes. Dr. Kahook also discussed po- tential ways to get more IOP data. These include using diurnal tension curves (DTC), sleep studies, and home monitoring. He highlighted a number of up-and-coming devices to track 24-hour IOP. Home tonometry is a potential option, with 2 mod- els for home or office. With home tonometry, there is access to daily variation, readings during normal daily activities and in the patient's normal environment, and there is no need for a sleep lab. However, disadvantages of this option in- clude a dependence on appropriate patient use, there is no nocturnal data, it is expensive, and it still only obtains periodic data points. Home tonometry is also not currently Food and Drug Administration (FDA) approved. Continuous IOP monitor- ing implants are a potential option being developed, but Dr. Kahook said this option is not yet ready for prime time. He spoke about non-in- vasive devices, specifically a wireless contact lens, Triggerfish (Sensimed, Lausanne, Switzerland), that mea- sures IOP indirectly using a built-in strain gauge. It is sensitive to cir- cumferential changes at the limbus and, importantly, offers continuous 24-hour monitoring. Currently the device is CE marked, and although not FDA approved, is considered a non-significant risk device. While it is the only modifiable risk factor for glaucoma, assessment of IOP is not rigorous, Dr. Kahook concluded. Performing DTC and 24-hour IOP sleep studies might identify factors for progression that are not observed in normal clinical visits. Though implantable devices are still years away from approval, non-invasive devices could provide useful information for some pa- tients, he said. If glaucoma contin- ues to advance in a patient despite apparent IOP control, Dr. Kahook suggested that varying visit time, using DTC, or 24-hour sleep studies might be useful. Editors' note: Dr. Kahook has financial interests with Sensimed. Management pearls for glaucoma in 2015 Thomas Samuelson, MD, Minne- apolis, offered attendees pearls for managing glaucoma. His first pearl was to avoid "unforced errors." This means to avoid complications by performing a less risky procedure if it will do the job as well as a high risk one. The second pearl was enhanced MIGS. "It's a fact that we have superb glaucoma drugs," Dr. Samuelson said. "It's also a fact that we overuse them." Meanwhile, he said that in its current form, MIGS has modest efficacy. So the best of both of these situations is needed, as well as the understanding that procedures do not necessarily have to eliminate all medications to be successful. Dr. Samuelson suggested the need to convert from an unrealistic and unsustainable medication schedule to what he calls MIST—minimally intrusive sustainable therapy. MIST generally involves 1 or 2 medica- tions postoperatively, he said. Other pearls included the point that phaco trumps trabeculectomy in angle closure glaucoma and that intraoperative gonioscopy is abso- lutely worth mastering. His last pearl applied specifically to the iStent (Glaukos, Laguna Hills, Calif.). Take the time to get it right, Dr. Samuelson said. Editors' note: Dr. Samuelson has financial interests with Abbott Medical Optics, Alcon, Aerie (Bedminster, N.J.), Allergan, AqueSys (Aliso Viejo, Calif.), Ivantis (Irvine, Calif.), and Transcend Medical (Menlo Park, Calif.). Care for patients with dry eyes and ocular allergy Dry eye and ocular allergy were two topics highlighted in early sessions on Thursday, January 22. James McCulley, MD, Dallas, spoke about dry eye, while Jodi Luchs, MD, Wantagh, N.Y., focused on ocular allergy. "The tear film is the most important refracting surface of the eye," Dr. McCulley said. A number of factors can influence dry eye in patients, such as arid conditions, windy environments, pollutants, visual tasking, systemic medications, and certain food or drinks. Addi- tionally, lipid deficiency, aqueous deficiency, and mucin deficiency can result in a dry eye condition. One of the hottest topics currently, Dr. McCulley said, is the association of dry eye disease with refractive surgery. About a third of patients will have dry eye after refractive procedures, he said. Dry eye is usually transient, lasting from a few weeks up to a year, and the recovery generally correlates with the recovery of corneal nerves and corneal sensation. Meanwhile, after cataract surgery, Dr. McCulley said about 10% of patients develop dry eyes, and it is most common in cases with relaxing incisions. With risks for development of dry eye after surgery, Dr. McCulley continued on page 118 View it now: Hawaiian Eye 2015 ... EWrePlay.org Sumit "Sam" Garg, MD, discusses intraoperative aberrometry and its role in cataract surgery.

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