1. The Royal Victorian Eye and Ear Hospital 24-hour eye pressure and glaucoma Dr Simon Skalicky FRANZCO, MPhil, MMed (Ophthal Sci), MBBS (Hons 1) Visiting Medical Officer, Royal Victorian Eye and Ear Hospital Visiting Medical Officer, Royal Melbourne Hospital Clinical Senior Lecturer, University of Melbourne Clinical Senior Lecturer, University of Sydney

2. The Royal Victorian Eye and Ear Hospital What is glaucoma? Optic nerve damage Related to (usually high) eye pressure It is important to control eye pressure throughout the entire day

3. The Royal Victorian Eye and Ear Hospital Glaucoma looks like…

4. The Royal Victorian Eye and Ear Hospital Glaucoma can be monitored: 1.Eye pressure check

5. The Royal Victorian Eye and Ear Hospital Glaucoma can be monitored: 2. Visual Field test

6. The Royal Victorian Eye and Ear Hospital Glaucoma can be monitored: Optic nerve imaging

7. The Royal Victorian Eye and Ear Hospital Eye pressure (IOP) can vary Time of day Differences in measurement type Different people have different safety levels: -20 mm Hg is OK for Jack -16 mm Hg is too high for Jill It is not just about the eye pressure measured in clinic…

8. The Royal Victorian Eye and Ear Hospital 24 hour intraocular pressure IOP fluctuates throughout the day and night Time Daily Fluctuation IOP measured in clinic Peak IOP

9. The Royal Victorian Eye and Ear Hospital Liu JH et al. Invest Ophthalmol Vis Sci 2003;44(10):4439-42.. Sleep lab data: 24-hour patterns of mean IOP in healthy young adults lying

10. The Royal Victorian Eye and Ear Hospital What to make of it all? Most patients with glaucoma -are well controlled on current treatment Some patients with glaucoma: -The IOP remains high on current treatment -Stronger treatment is needed Other patients with glaucoma: -The measured IOP is always excellent -Yet the tests (Visual Field, Optic nerve scan) worsen

11. The Royal Victorian Eye and Ear Hospital Example case – Mrs AM 74 years old lady Diagnosed with glaucoma in 2011 Commenced on xalatan drops each evening both eyes IOP well controlled for 5 years But glaucoma damage has progressed over this time

12. The Royal Victorian Eye and Ear Hospital Mrs AM - IOP IOP (mm Hg) Date of visit

13. The Royal Victorian Eye and Ear Hospital Mrs AM Glaucoma is getting worse despite stable eye pressure Why??

14. The Royal Victorian Eye and Ear Hospital It is sometimes important to evaluate 24 hour eye pressure

15. The Royal Victorian Eye and Ear Hospital The water drinking test Fluid challenge – drink 1L water IOP is checked every 15 minutes following drinking Increased water to eye – increases IOP IOP lowers with normal drainage Eye drainage is stressed – like a cardiac stress test In hours office test, simple to perform A marker of 24 hour IOP fluctuation?

16. The Royal Victorian Eye and Ear Hospital Evaluating glaucoma treatments All currently available glaucoma treatments lower IOP How do glaucoma treatments influence the 24 hour IOP? How do glaucoma treatments influence the water drinking test?

17. The Royal Victorian Eye and Ear Hospital 24-Hour IOP control: Eye drops v Glaucoma surgery Surgical group Medical group The night time IOP spike reduced in the surgical group but persisted in the eye drop group Konstas AG et al. Ophthalmology 2006;113:761–5.e1.

18. The Royal Victorian Eye and Ear Hospital Patients with advanced glaucoma Water drinking test compared: Glaucoma surgery vs eye drops +/- laser Surgery protected against an IOP rise on water challenge Danesh-Mayer HV et al. Ophthalmology 2008;115:1566–70.

19. The Royal Victorian Eye and Ear Hospital Evaluating Selective Laser Trabeculoplasty with the water drinking test Selective Laser Trabeculoplasty: a common laser used to treat open angle glaucoma © Glaucoma Care

20. The Royal Victorian Eye and Ear Hospital SLT – does it work? Study: 20 individuals with glaucoma Effect of SLT on water drinking test evaluated Water drinking test 1 SLT (laser) Water drinking test 2 6 weeks 2 weeks Kerr NM et al. Submitted to J Glaucoma

21. The Royal Victorian Eye and Ear Hospital Does SLT reduce IOP rise on water drinking test?

22. The Royal Victorian Eye and Ear Hospital In conclusion… Most patients with glaucoma are controlled with eye drops or laser which reduces IOP and prevents vision loss Some patients have progressive vision loss despite normal IOP measurements This may be related to night or afternoon IOP spikes These patients may benefit from the water drinking test It is important to evaluate how different glaucoma treatments influence the 24 hour IOP cycle

23. The Royal Victorian Eye and Ear Hospital Thank you!