Is there a place for home glaucoma monitoring?

Home monitoring for conditions, such as diabetes and hypertension (with 24-hour glucose monitoring and home blood pressure units, respectively) is both frequent and informative. Similarly, home monitoring is available for chronic ocular diseases, such as age-related macular degeneration.¹ Is there a place for home glaucoma monitoring?

THE PRESSURE EXISTS FOR IT

Several studies conclude that IOP is the single greatest modifiable risk factor for glaucoma development and progression.^2-8 Interestingly, peak IOP is usually not the same as peak clinic-IOP and is, in fact, most commonly elevated during sleeping hours and more so among those in the supine position.⁹

From implantable IOP sensors inserted at the time of intraocular surgery, to contact lens sensors and self-tonometry¹⁰ — with the latter providing more frequent, less invasive, almost real-time feedback for the patient and the provider via smart phone app platforms, moderate Goldmann applanation tonometry agreement, and modest user certification^11-17 — these innovative technologies can now help us better understand IOP ranges.

A HOME FIELD ADVANTAGE

Real-time IOP monitoring provides additional perspectives and trends that may help us better care for our glaucoma patients by changing our treatment strategies as needed to prevent structural or functional progression.¹⁸

Additionally, Chauhan et al state that, “The progression status of the patient is unknown unless there is enough information.”¹⁹ Although it is clinically challenging for patients to perform the recommended six VFs within a two-year period,¹⁹ perhaps we can supplement these visits to some degree with home monitoring.

Peristat online perimetry (FDA-approved, full-field remote physiological monitoring), tablet-based testing (such as the Moorfields Motion Displacement Test and Melbourne Rapid Field), and head-mounted virtual reality units^10,15,17 allow patients to perform functional testing at home, with the instructional support of virtual assistants. With the familiarity of tablets and devices, and increasing concordance with in-clinic VF testing, there really may be no place like home!

A HOMECOMING

At-home monitoring technologies on the horizon include anterior-segment photography, iridocorneal angle measurements, fundus photography, OCT retinal nerve fiber layer measurements, and artificial intelligence with deep learning algorithms — all with associated advantages and disadvantages. These innovations will help put into context IOP and VF.¹⁷

TAKE HOME

Wong et al recommend that a “…patient with well-controlled mild to moderate glaucoma can…be monitored remotely if one has IOP measurements performed regularly and that an in-person dilated examination is performed annually. A patient with uncontrolled or severe glaucoma should have face-to-face visits, as there is much less room for error and a high likelihood of needing laser or surgical procedures.”¹⁷

In summary, surely the increasing “…availability of home monitoring devices may play an important role to detect uncontrolled or progressive disease, and [at the same time] reassure patients that the glaucoma is well controlled.”¹⁰ OM

REFERENCES

1. Yu, HJ, Kiernan DF, Eichenbaum D, Sheth VS, Wykoff CC. Home Monitoring of Age-Related Macular Degeneration: Utility of the ForeseeHome Device for Detection of Neovascularization. Ophthalmol Retina. 2021;5(4):348-356. doi: 10.1016/j.oret.2020.08.003.
2. Kass MA, Heuer DK, Higginbotham EJ, et al. The Ocular Hypertension Treatment Study: a randomized trial determines that topical ocular hypotensive medication delays or prevents the onset of primary open-angle glaucoma. Arch Ophthalmol. 2002;120(6):701-13; discussion 829-30. doi: 10.1001/archopht.120.6.701.PMID: 12049574
3. Miglior S, Zeyen T., Pfeiffer N, et al. Results of the European Glaucoma Prevention Study. Ophthalmology. 200;112(3):366-75. doi: 10.1016/j.ophtha.2004.11.030.
4. Heijl A, Leske MC, Bengtsson B, et al. Reduction of intraocular pressure and glaucoma progression: results from the Early Manifest Glaucoma Trial. Arch Ophthalmol. 2002;120(10): 1268–1279. doi: 10.1001/archopht.120.10.1268.
5. Musch DC, Gillespie BW, Niziol LM, Lichter PR, Varma R; CIGTS Study Group. Intraocular pressure control and long-term visual field loss in the Collaborative Initial Glaucoma Treatment Study. Ophthalmology. 2011;118(9): 1766–1773. doi: 10.1016/j.ophtha.2011.01.047.
6. The Advanced Glaucoma Intervention Study (AGIS): 7. The relationship between control of intraocular pressure and visual field deterioration. The AGIS Investigators. Am J Ophthalmol. 2000;130(4): 429–440. doi: 10.1016/s0002-9394(00)00538-9.
7. Sommer A., Tielsch JM, Katz J., Quigley HA, Gottsch JD, Singh JJK, et al. Relationship between intraocular pressure and primary open angle glaucoma among white and black Americans. Arch Ophthalmol. 1991;109(8):1090-5. doi: 10.1001/archopht.1991.01080080050026.
8. Comparison of glaucomatous progression between untreated patients with normal-tension glaucoma and patients with therapeutically reduced intraocular pressures. Collaborative Normal-Tension Glaucoma Study Group. Am J Ophthalmol. 1998;126(4): 487-97. doi: 10.1016/s0002-9394(98)00223-2.
9. Liu JH, Kripke DF, Twa MD, et al. Twenty-four-hour pattern of intraocular pressure in the aging population. Invest Ophthalmol Vis Sci. 1999;40(12): 2912-7.
10. Che Hamzah J, Daka Q, Azuara-Blanco A. Home monitoring for glaucoma. Eye (Lond). 2020;34(1):155-160. doi: 10.1038/s41433-019-0669-7.
11. Mudie LI, LaBarre S, Varadaraj V, Karakus S, Onnela J, Munoz B, Friedman DS. The Icare HOME (TA022) Study: Performance of an Intraocular Pressure Measuring Device for Self-Tonometry by Glaucoma Patients. Ophthalmology. 2016;123(8): 1675-1684. doi: 10.1016/j.ophtha.2016.04.044.
12. Termühlen J, Mihailovic N, Alnawaiseh M, Dietlein TS, Rosentreter A. Accuracy of Measurements With the iCare HOME Rebound Tonometer. J Glaucoma. 2016;25(6): 533-8. doi: 10.1097/IJG.0000000000000390.
13. Cvenkel B, Velkovska MA, Jordanova VD. Self-measurement with Icare HOME tonometer, patients’ feasibility and acceptability. Eur J Ophthalmol. 2020;30(2): 258-263. doi: 10.1177/1120672118823124.
14. Rosenfeld E, Rabina G, Barequet D, Mimouni M, Fischer N, Kurtz S. Role of home monitoring with iCare ONE rebound tonometer in glaucoma patients management. Int J Ophthalmol. 2021;14(3): 405-408. Int J Ophthalmol. 2021 Mar 18;14(3):405-408. doi: 10.18240/ijo.2021.03.12.
15. Aboobakar IF, Friedman DS. Home Monitoring for Glaucoma: Current Applications and Future Directions. Semin Ophthalmol. 2021;36(4): 310-314. doi: 10.1080/08820538.2021.1896759.
16. Mansouri K, Kersten-Gomez I, Hoffmann EM, Szurman P, Choritz L, Weinreb RN. Intraocular Pressure Telemetry for Managing Glaucoma during the COVID-19 Pandemic. Ophthalmol Glaucoma. 2021;4(5):447-453. doi: 10.1016/j.ogla.2020.12.008.
17. Wong SH, Tsai JC. Telehealth and Screening Strategies in the Diagnosis and Management of Glaucoma. J Clin Med. 2021 Aug 4;10(16):3452. doi: 10.3390/jcm10163452.
18. Barkana Y, Anis S, Liebmann J, Tello C, Ritch R. Clinical utility of intraocular pressure monitoring outside of normal office hours in patients with glaucoma. Arch Ophthalmol. 2006;124(6): 793-7. doi: 10.1001/archopht.124.6.793.
19. Chauhan, B C, Garway-Heath DF, Goni FJ, et al. Practical recommendations for measuring rates of visual field change in glaucoma. Br J Ophthalmol. 2008;92(4): 569-73. doi: 10.1136/bjo.2007.135012.

DR. LIFFERTH practices at Center for Sight. He is a member of the Optometric Glaucoma Society and a Glaucoma Diplomate of the American Academy of Optometry.” For additional glaucoma cases, you can also follow Dr. Lifferth on his Instagram account: glaucomaqd. Disclosures: None. Email him at glaucomaqd@yahoo.com.