Self-monitoring of intraocular pressure using Icare HOME tonometry in clinical practice

Impact of self-tonometry on glaucoma treatment decision

PURPOSE

The aim of this study was to examine the impact of self-tonometry on clinicians' decision in glaucoma treatment.

MATERIALS AND METHODS

Medical records of 133 patients who had performed self-tonometry using iCare^® Home between January and December 2019 were retrospectively reviewed. Inclusion criteria were as follows: age over 18 years, all types of glaucoma, as well as ocular hypertension and glaucoma suspect, compliance with tonometer manufacturer's recommendations and monitoring over at least 2 days. The data consisted of age, gender, diagnosis, visual field index, rate of progression and type of treatment pre- and post-intraocular pressure (IOP) phasing. The following IOP measurements were used to calculate the mean and maximum IOP, and range over each day and consecutive days: Goldmann applanation tonometry (GAT) measurements from referral and training visits and iCare^® Home measurements made by the trainers and the patients themselves. A total of 90 patients were included.

RESULTS

Clinicians were satisfied with the actual treatment in 54.4% of the cases. There was a statistically significant difference between the clinicians' decision to maintain same treatment or to escalate therapy for all the mean and maximum IOPs measured on each single day and over a 2- or 3-day period (p < 0.002).

CONCLUSION

Our results suggest that the presence of high IOP values obtained with self-tonometry supports an intensification of glaucoma treatment. Self-tonometry provides clinicians with an important complement for clinical decision-making, and under- or over-treatment may be avoided for the benefit of patients.

Frequent self-monitoring of intraocular pressure can determine effectiveness of medications in eyes with normal tension glaucoma: A case report

RATIONALE

It is difficult to follow changes in the intraocular pressure (IOP) in glaucomatous eyes comprehensively because of the limited number of outpatient examinations. We report our findings in a case of normal tension glaucoma (NTG) in which frequent self-measurements of the IOP were used to evaluate the IOP-lowering effect of different medications.

PATIENT CONCERNS

A 50-year-old man with NTG had a nasal step visual field defect in his right eye and was being treated with 0.005% latanoprost (LAT) ophthalmic solution (XALATAN®).

DIAGNOSIS

The patient was diagnosed with NTG.

INTERVENTIONS

The patient had a mean IOP in the right eye of 10.9 ± 1.5 mm Hg (68 measurements in 1 month, Period A) during treatment with 0.005% LAT ophthalmic solution. During the second month (Period B), the mean IOP in the same eye was 9.8 ± 1.7 mm Hg (59 measurements) with treatment with a LAT and carteolol fixed combination (LCFC). And during the third month (Period C), the mean IOP was 7.4 ± 1.1 mm Hg (57 measurements) on the same right eye after the addition of brimonidine and brinzolamide fixed combination ophthalmic solution to the LCFC ophthalmic solution.

OUTCOMES

Comparisons of the IOPs between Periods A and B and between B and C showed that the reductions in the IOP were significant.

CONCLUSION

We conclude that frequent self-measurements of the IOP can determine that small changes of the IOPs are significant.

Real-Time Monitoring of Intraocular Pressure in Glaucoma Patients Using Wearable Mobile Medicine Devices

Glaucoma is caused by excessive aqueous humor in the eye, resulting in a continuous or intermittent increase of intraocular pressure, which exceeds the tolerance of the eyeball and damages the optic nerve. Existing treatments for glaucoma do not work well or have significant side effects. Intraocular pressure signal is a very important physiological signal that needs real-time and accurate monitoring in glaucoma patients, especially in severe glaucoma patients. Therefore, long-term, real-time, and accurate monitoring of intraocular pressure is of great significance for the diagnosis and treatment of glaucoma patients. The use of wearable devices for real-time ocular diagnosis and treatment of glaucoma patients is an effective approach. However, the current commonly used intraocular pressure measurement and monitoring technology is difficult to meet the diagnosis and monitoring needs of glaucoma patients in terms of size, measurement accuracy, power consumption, and intelligence. Therefore, facing the needs of glaucoma disease treatment, this topic studies an implantable flexible intraocular pressure sensor for long-term continuous monitoring of intraocular pressure in glaucoma patients and mainly focuses on the working principle, structural design, process fabrication, measurement and control system, characterization, and performance test of the intraocular pressure sensor. It is of great significance for personalized and accurate treatment of glaucoma patients.

Teleophthalmology and Artificial Intelligence As Game Changers in Ophthalmic Care After the COVID-19 Pandemic

The current COVID-19 pandemic has boosted a sudden demand for telemedicine due to quarantine and travel restrictions. The exponential increase in the use of telemedicine is expected to affect ophthalmology drastically. The aim of this review is to discuss the utility, effectiveness and challenges of teleophthalmological new tools for eyecare delivery as well as its implementation and possible facilitation with artificial intelligence. We used the terms: “teleophthalmology,” “telemedicine and COVID-19,” “retinal diseases and telemedicine,” “virtual ophthalmology,” “cost effectiveness of teleophthalmology,” “pediatric teleophthalmology,” “Artificial intelligence and ophthalmology,” “Glaucoma and teleophthalmology” and “teleophthalmology limitations” in the database of PubMed and selected the articles being published in the course of 2015-2020. After the initial search, 321 articles returned as relevant. A meticulous screening followed and eventually 103 published manuscripts were included and used as our references. Emerging in the market, teleophthalmology is showing great potential for the future of ophthalmological care, benefiting both patients and ophthalmologists in times of pandemics. The spectrum of eye diseases that could benefit from teleophthalmology is wide, including mostly retinal diseases such as diabetic retinopathy, retinopathy of prematurity, age-related macular degeneration but also glaucoma and anterior segment conditions. Simultaneously, artificial intelligence provides ways of implementing teleophthalmology easier and with better outcomes, contributing as significant changing factors for ophthalmology practice after the COVID-19 pandemic.

Clinical Trial: Diurnal IOP Fluctuations in Glaucoma Using Latanoprost and Timolol with Self-Tonometry

SIGNIFICANCE

Assessment of treatment efficacy via comparison with a target IOP is fundamental in monitoring patients with open-angle glaucoma and ocular hypertension. This article highlights that diurnal IOP fluctuations obtained using self-tonometry may more accurately reflect IOP responses to therapy.

PURPOSE

This study aimed to investigate fluctuations in diurnal IOP measurements in patients with open-angle glaucoma and ocular hypertension treated with latanoprost 0.005% and timolol 0.25%.

METHODS

In this crossover treatment trial, 14 participants performed self-tonometry with iCare HOME 4 times daily for (1) 1 week using latanoprost, (2) 4 weeks using no medications, and (3) 2 weeks using timolol. Daily peak IOPs, IOP fluctuations, and mean IOPs from different treatments were compared on an individual basis. Treatment efficacy between medications was assessed by comparing mean percentage IOP reductions with latanoprost and timolol across participants. In addition, effects of age, years since commencing latanoprost, sex, and diagnosis were investigated, and peak IOP times were compared with assess impacts on diurnal profiles.

RESULTS

Between individuals, IOP responses ranged from reductions in peak IOPs, IOP fluctuations, and mean IOPs on both medications to no change in any parameter and medication. IOP fluctuations showed greater mean percentage reductions than did peak and mean IOPs (χ2 = 16.51, P = .002). There were significant associations between years since commencing latanoprost and peak and mean IOP responses on timolol (r = 0.69, P = .007), and sex and relative reductions in IOP fluctuations on both medications (P = .03). There were no differences in peak IOP times between treatment conditions.

CONCLUSIONS

Despite variability in IOP responses to latanoprost and timolol, IOP fluctuation with self-tonometry was more consistent in evaluating target IOP, reflecting its importance in ascertaining true IOP response to topical therapies. These findings may impact clinical decision making based on target IOP criteria in patients on topical therapy.

Accuracy of Using Generative Adversarial Networks for Glaucoma Detection During the COVID-19 Pandemic: A Systematic Review and Bibliometric Analysis

Background

Glaucoma leads to irreversible blindness. Globally, it is the second most common retinal disease that leads to blindness, slightly less common than cataracts. Therefore, there is a great need to avoid the silent growth of this disease using recently developed generative adversarial networks (GANs).

Objective

This paper aims to introduce a GAN technology for the diagnosis of eye disorders, particularly glaucoma. This paper illustrates deep adversarial learning as a potential diagnostic tool and the challenges involved in its implementation. This study describes and analyzes many of the pitfalls and problems that researchers will need to overcome to implement this kind of technology.

Methods

To organize this review comprehensively, articles and reviews were collected using the following keywords: (“Glaucoma,” “optic disc,” “blood vessels”) and (“receptive field,” “loss function,” “GAN,” “Generative Adversarial Network,” “Deep learning,” “CNN,” “convolutional neural network” OR encoder). The records were identified from 5 highly reputed databases: IEEE Xplore, Web of Science, Scopus, ScienceDirect, and PubMed. These libraries broadly cover the technical and medical literature. Publications within the last 5 years, specifically 2015-2020, were included because the target GAN technique was invented only in 2014 and the publishing date of the collected papers was not earlier than 2016. Duplicate records were removed, and irrelevant titles and abstracts were excluded. In addition, we excluded papers that used optical coherence tomography and visual field images, except for those with 2D images. A large-scale systematic analysis was performed, and then a summarized taxonomy was generated. Furthermore, the results of the collected articles were summarized and a visual representation of the results was presented on a T-shaped matrix diagram. This study was conducted between March 2020 and November 2020.

Results

We found 59 articles after conducting a comprehensive survey of the literature. Among the 59 articles, 30 present actual attempts to synthesize images and provide accurate segmentation/classification using single/multiple landmarks or share certain experiences. The other 29 articles discuss the recent advances in GANs, do practical experiments, and contain analytical studies of retinal disease.

Conclusions

Recent deep learning techniques, namely GANs, have shown encouraging performance in retinal disease detection. Although this methodology involves an extensive computing budget and optimization process, it saturates the greedy nature of deep learning techniques by synthesizing images and solves major medical issues. This paper contributes to this research field by offering a thorough analysis of existing works, highlighting current limitations, and suggesting alternatives to support other researchers and participants in further improving and strengthening future work. Finally, new directions for this research have been identified.

Glaucoma care during the coronavirus disease 2019 pandemic

PURPOSE OF REVIEW

The current article reviews the impact of the coronavirus disease 2019 (COVID-19) pandemic on the delivery of ophthalmic, and specifically, glaucoma care.

RECENT FINDINGS

Literature from the review period includes case series demonstrating the presence of severe acute respiratory syndrome coronavirus 2 RNA in the conjunctival secretions of patients with laboratory-confirmed COVID-19. The global ophthalmology community published reports outlining the enhanced infection control measures undertaken by different institutions around the world to mitigate transmission of the novel coronavirus. Telemedicine has been increasingly implemented in glaucoma practices to reduce in-office patient volume. New data regarding the efficacy and feasibility of tools for home monitoring of intraocular pressure, virtual visual field testing, and remote disc photography are reviewed.

SUMMARY

COVID-19 has posed a global public health threat due to the severity of its contagion and associated morbidity and mortality. Glaucoma specialists have responded to the pandemic with innovative modifications to reduce viral transmission and optimize patient and staff safety in the office and operating room. The role of teleglaucoma has expanded and will continue to evolve as remote diagnostic devices undergo further refinement and validation.

Disruption of 24-Hour Rhythm in Intraocular Pressure Correlates with Retinal Ganglion Cell Loss in Glaucoma

Parameters of 24-h rhythm in intraocular pressure (IOP) were assessed in patients with stable or advanced primary open-angle glaucoma (S-POAG/A-POAG) and referenced to the phase of “marker” circadian temperature rhythm of each patient. Body temperature and IOP were measured over a 72-h span in 115 participants (65 S-POAG and 50 A-POAG). Retinal Ganglion Cell (RGC) damage was assessed by high-definition optical coherence tomography. The 24-h IOP rhythm in A-POAG patients peaked during the night, opposite to the daytime phase position in S-POAG patients (p < 0.0001). The 24-h IOP phase correlated with RGC loss (p < 0.0001). The internal phase shift between IOP and body temperature gradually increased with POAG progression (p < 0.001). Angiotensin converting enzyme Alu-repeat deletion/insertion (ACE I/D) emerged as a candidate gene polymorphism, which may play a role in the alteration of the circadian IOP variability in advanced glaucoma. To conclude, a reliable estimation of the 24-h rhythm in IOP requires the degree of RGC damage to be assessed. In advanced POAG, the 24-h phase of IOP tended to occur during the night and correlated with RGC loss, being progressively delayed relative to the phase of temperature.

Icare Home Tonometer: A Review of Characteristics and Clinical Utility

The Icare HOME (TA022, Icare Oy, Vanda, Finland) is rebound tonometer recently approved by the US Food and Drug Administration in March 2017 designed for self-measurement of intraocular pressure (IOP). IOP remains a major modifiable risk factor for glaucoma progression; however, IOP measurements typically occur through single office measurements on Goldmann applanation tonometry (GAT) and do not always reveal the complete picture of patient’s IOP patterns and daily fluctuations, which are important for accurate diagnosis and evaluation. Numerous studies have now compared the efficacy of the Icare HOME to that of GAT. The objective of this article is to review the existing literature surrounding the Icare HOME tonometer and its efficacy as a self-tonometer in comparison to GAT. The available literature has shown promising results in its accuracy of measuring IOP but suggests cautious usage in patients with central corneal thicknesses or IOP ranges that are outside of a certain range. This article will also provide details and example cases for when the Icare HOME may be most clinically useful.

Tele-consultations in the wake of COVID-19 - Suggested guidelines for clinical ophthalmology

While telemedicine has been around for a few decades, it has taken great importance and prominence in recent times. With the fear of the virus being transmitted, patients and physicians across specialties are using consultation via a telephone call or video from the safety of their homes. Though tele-ophthalmology has been popular for screening, there are no clear guidelines on how to comprehensively manage patients seeking advice and treatment for a particular eye condition. Some major barriers to diagnosis and management are compromised detailed examination, no measurement of the visual acuity or intraocular pressure and a retinal evaluation not being feasible. Despite these limitations, we do need to help those patients who need immediate care or attention. Hence, this article has put together some guidelines to follow during such consultations. They are important and timely due to the medicolegal and financial implications.

Management of the glaucoma patient progressing at low normal intraocular pressure

PURPOSE OF REVIEW

Patients with glaucoma with disease progression despite low or normal intraocular pressure (IOP) present special challenges to the treating clinician. Treatment goals may depend on whether patients have apparent low IOP with concurrent treatment or have low IOP at baseline without treatment. We review the diagnostic and therapeutic approaches to these patients.

RECENT FINDINGS

Apparent progression at low IOP should start with confirmation of IOP, made easier by devices enabling patient home self-tonometry. Suspected visual field progression should be confirmed by repeat testing prior to advancement of therapy. Trabeculectomy remains the most effective surgical method of achieving long-term success, particularly when there is a low starting IOP. Drainage tube implantation or the use of novel micro-incisional non-bleb-forming procedures are less likely to be successful in achieving low IOP goals.

SUMMARY

Diagnostic testing is important in confirming progressive glaucomatous disease at low IOP levels. The most effective way of slowing the progression of glaucoma in a patient with low IOP is to lower the IOP further, sometimes to single digit levels, which is most often achievable with trabeculectomy.

The impact of artificial intelligence in the diagnosis and management of glaucoma

Deep learning (DL) is a subset of artificial intelligence (AI), which uses multilayer neural networks modelled after the mammalian visual cortex capable of synthesizing images in ways that will transform the field of glaucoma. Autonomous DL algorithms are capable of maximizing information embedded in digital fundus photographs and ocular coherence tomographs to outperform ophthalmologists in disease detection. Other unsupervised algorithms such as principal component analysis (axis learning) and archetypal analysis (corner learning) facilitate visual field interpretation and show great promise to detect functional glaucoma progression and differentiate it from non-glaucomatous changes when compared with conventional software packages. Forecasting tools such as the Kalman filter may revolutionize glaucoma management by accounting for a host of factors to set target intraocular pressure goals that preserve vision. Activation maps generated from DL algorithms that process glaucoma data have the potential to efficiently direct our attention to critical data elements embedded in high throughput data and enhance our understanding of the glaucomatous process. It is hoped that AI will realize more accurate assessment of the copious data encountered in glaucoma management, improving our understanding of the disease, preserving vision, and serving to enhance the deep bonds that patients develop with their treating physicians.

Role of 24-Hour Intraocular Pressure Monitoring in Glaucoma Management

Glaucoma is the leading cause of irreversible blindness worldwide and the prevalence is on the rising trend. Intraocular pressure (IOP) reduction is the mainstay of treatment. The current practice of IOP monitoring is based on spot measurements during clinic visits during office hours. However, there are up to 50% of glaucoma patients who had normal initial IOP, while some treated patients continued to have progressive glaucomatous optic nerve damage even with a low IOP. Recent studies have shown that the IOP of glaucoma patients fluctuated during the day with different patterns, and some of them had peak IOP outside office hours. These findings provided us with new insights on the role of 24-hour IOP monitoring in managing normal tension glaucoma and patients with progressive deterioration despite apparently well-controlled IOP. Nevertheless, results to date are rather inconsistent, and there is no consensus yet. In this review, we briefly highlighted the current modalities of 24-hour IOP monitoring and summarized the characteristic 24-hour IOP pattern and the clinical relevance of IOP parameters in predicting glaucomatous progression in different glaucoma subtypes. We also discussed the therapeutic efficacy of current glaucoma treatment modalities with respect to the mentioned 24-hour IOP profiles, so as to strengthen the role of 24-hour IOP monitoring in identifying and stratifying the risks of progression in glaucoma patients, as well as optimizing treatments according to their IOP profiles.