Monitoring IOP 24/7/365

Andrew Rixon OD, FAAO

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Disclosure Statement:Nothing to disclose

Why do we need Continuous IOP monitoring?• IOP is a dynamic parameter• IOP has a circadian rhythm/Nocturnal IOP• IOP fluctuates-­‐Short and Long term diurnals are NOT reproducible• Positional affect to IOP• Peak IOP may be greatest predictor of progression• Diurnal Tension Curves poorly sample peak IOP• Sleep studies/”Office Diurnals” are limited

1) Aptel F, et al. Prog Retin Eye Res 2016;55:) 108-­‐148 2) Sit A, Pruet C. Asia Pac J Ophthalmol. 2016;5(1):17-­‐22.3) Mansouri K. J Ophthalmic Vis Res 2014;9(2):260-­‐268. Liu J, et al. IOVS. 2003;44:1586-­‐1590

The current paradigm is a problem

• Paradigm of single “IOP” by GAT every 3-4 months• “In a patient seen 3 to 4 times a year, we obtain about 12 seconds

worth of IOP data. Realizing there are more than 31 million seconds in a year, we are not even looking at the tip of the iceberg when it comes to measuring IOP”-Kaweh Mansouri M.D., M.P.H.

What is happening when we aren’t looking??????

http://www.ophthalmologytimes.com/modern-­‐medicine-­‐cases/continuous-­‐iop-­‐monitoring-­‐tools-­‐addressing-­‐unmet-­‐need last accessed Nov 5, 2018

Mrs. Smith your pressure is doing great………

Jonas J, et al. AJO. 2005;139:1136–1137.

Highest at midnight!!!! Wait it’s lowest at midnight!!!!!!

Currently available 24h IOP devices

Ittoop SM, et al. Adv Ther. 2016 Aug 16

Home Tonometry-Temporary/Noncontinuous

• 74%-­‐98% of pts able to perform1-­‐3,6

• Well received by subjects1-­‐7

• Average tech to patient success time 21min7

• Good correlation between OMD and Pt IOP2

• Patient does NOT have access to the data

1) Dabasia PL, et al. BJO 2016 2) Takagi D, et al. J Glaucoma 2017 3) Querat L, Chen E. Acta Ophthalmol. 2017 4) Sood V, Ramanathan US. J Glaucoma. 2016 5) Mudie L, et al. Ophthalmology 2016;123:1675-­‐1684 6) Huang J, et al. Optom Vis Sci 2018 7) Scientific Reports7:42067 | DOI: 10.1038/srep42067

Self Tonometry Study• 18 patients with progressive NTG • IOP was “Controlled” in office, did not explain progression• 24hr phasing at 2hr intervals (8am-­‐4pm diurnal, 6pm-­‐6am Nocturnal)• Results…….

-­‐15.78±4.8 (Noctural Peak) -­‐12.83±2.7mmHg (Diurnal peak)-­‐ Over 50% had peak outside office hrs-­‐ Change in management in 56%

Sood V, Ramanathan US. J Glaucoma. 2016;25:807–811

There’s an App for that…..

Images screenshot from Icare App, copyright Icare USA

Sensimed Triggerfish®-Temporary Continuous• FDA approved as a “diurnal pattern recorder”• Soft pure silicone lens Dk/t 119• Embedded platinum–titanium strain gauges that measure changes in the radius of curvature of the cornea• Small changes in ocular circumference attributed to changes in IOP, volume, and biomechanical properties• Measured in mVeq, NOT mmHg• 30 sec of data every 5min x 24hr=288 data sets

Mansouri K, et al. Arch Ophthalmol. 2012;130(12):1534-­‐9Dunbar GE, et al. Clin Ophthalmol 2017:11 875–882

Triggerfish® CLS Studies•Has been studied in Healthy, OHT, POAG, NTG, PXG patients1

•Has shown decreased nocturnal mVeq pattern post SLT vs baseline1

•Has NOT shown significant changes in 24hr IOP curve post topical therapy, including PGAs1

• Shown increased nocturnal mean peak ratio increases progression rate by -0.20dB/yr2

• 24hr CLS variable were better associated with prior rates of progression than in office DTC with TAG3

1) Ittoop SM, et al. Adv Ther. 2016 Aug 16. Epub ahead of print 2) Demoraes CG, et al. Ophthalmology 2016;;123:744-­7533) De Moraes CG, et al Triggerfish Consortium JAMA Ophthalmol 2018

24hr “IOP Related”Patterns

Tojo N, et al. J Glaucoma 2017;26:195–200

Permanent Continuous

• Implantable wireless transducer (11.3mm diameter/0.9mm thick)• Allows IOP measurements through radiofrequency• Strong correlation between device and direct manometry• Implanted concurrent with cataract extraction and intraocular lens implantation• Placed in the ciliary sulcus• Powered by high frequency field from external reader unit

Todani et al., IOVS. 2011;52:9573–9580

Eyemate® First Generation

http://implandata.com/en/

IOVS 2011;52:9573–9580

Surgical Implantation/IOP Acquisition

Melki S, et al. JAMA Ophthalmol. 2014;132(10):1221-­‐1225

http://archopht.jamanetwork.com/multimediaPlayer.aspx?mediaid=6838764

ARGOS Study- 4yr results

Koutsonas A, et al. Clin Exp Ophthalmol 2018; 46: 473–479

Smaller! Mouse AC smaller!

• 1st device 8x8x3mm1

• Current device 2.8mm diameter x 200um2

• Sensor occupies 0.38mm2

• Recall EyeMate is ~12mm

1) Chow EY, Chlebowski AL, Irazoqui PP. IEEE Transactions Biomed Circ Sys. 2010;4(6):340-92) Bhamra H, et al. IEEE Trans Biomed Circuits Syst. 2017 Dec;11(6):1204-­‐1215.3) Ha D, et al. Biomed Microdevices (2012) 14:207–215

Images/Information courtesy Kim Tietz and Doug Adams Qura Inc.

Get Qsmarter with Qura

The paradigm is changing………

Images/Information courtesy Kim Tietz and Doug Adams Qura Inc.

But……• There is no evidence that progression of glaucoma can be slowed down by obtaining additional IOP measurements• All currently available products have limitations• Once we are actually able to acquire the data, what will we do with it?

Meier-­‐Gibbons F, et al. Curr Opin Ophthalmol 2018, 29:111 – 115F. Aptel et al. / Progress in Retinal and Eye Research 55 (2016) 108e148Sit A. J Glaucoma 2009;18:272–279

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