Managing glaucoma with personalized IOP monitoring

Robert N. Weinreb, MD, discusses how continuous 24-hour IOP monitoring will shape the future of glaucoma treatment. Dr. Weinreb delivered the first Drs. Henry and Frederick Sutro Memorial Lecture during the 3rd Annual Glaucoma 360 New Horizons Forum.

San Francisco-Patients with glaucoma can expect both transformative and disruptive changes in the monitoring and treatment of their disorder over the next 5 years, predicted Robert N. Weinreb, MD, chairman of ophthalmology and director of the Shiley Eye Center and Hamilton Glaucoma Center, University of California, San Diego (UCSD). Dr. Weinreb delivered the first Drs. Henry and Frederick Sutro Memorial Lecture here at the 3rd Annual Glaucoma 360 New Horizons Forum.

In the opening keynote address, Dr. Weinreb anticipated ophthalmologists will soon deliver more personalized IOP monitoring to individual patients, thereby improving glaucoma treatment. Today, most ophthalmologists see their patients with glaucoma 3 to 4 times a year. However, the future of IOP monitoring focuses on 24-hour monitoring to understand each patient’s specific condition better.

Based on his research at the Sleep Laboratory at UCSD, Dr. Weinreb noted that a single reading of IOP in a physician’s office does not capture the patient’s “real” IOP, since the highest IOP occurs at night in the supine position.

IOP fluctuates throughout the day and varies from day to day, has a circadian rhythm, rises if a patient lies on his or her side, can increase with extra pillow use, and is related to lowest aqueous flow and perfusion pressure.

Dr. Weinreb noted that IOP levels occur opposite blood pressure measurements, while glaucoma depends on transluminal pressure. Changes in uveoscleral outflow (lowest at night) compensate for the nocturnal IOP increases, research has determined.

More effective use of the current four classes of drugs for glaucoma therapy depends on understanding how these agents’ mechanism of action affects nocturnal IOP.

Prostaglandin analogues reduce nocturnal and diurnal habitual IOP and are first-line therapy, whereas alpha-agonists and beta-agonists work effectively on IOP during the day but not at night.

Physicians should consider drugs that lower IOP over 24 hours and that do not affect perfusion pressure or IOP overall. Laser trabeculoplasty has been found effective over 24 hours as well.

Dr. Weinreb forecasts the future is 24-hour monitoring of each patient’s IOP, which may disrupt ophthalmology practice while transforming glaucoma treatment.

One promising continuous IOP tool is a monitoring device attached to a contact lens that has been tested in humans. Other devices, such as an implantable IOP monitor, are currently in clinical trials for cataract patients in Europe.

No continuous 24-hour IOP monitoring device is licensed in the United States at present. Once ophthalmologists can refine IOP measurement and determine if peak or mean IOP is important, personalized treatment of the individual patient will become a reality, Dr. Weinreb noted.

The Drs. Henry and Frederick Sutro Memorial Lecture was established with a $3 million bequest from Henry A. Sutro, DDS, of Oakland, CA. The lecture, to be held each year at the Glaucoma 360 meeting, was created to promote innovation in glaucoma therapy in addition to a continuing education program for clinicians to highlight the latest advances in glaucoma management.

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