Telematisch assistierte Selbsttonometrie (TAS)

SALUS-a non-inferiority trial to compare self-tonometry in glaucoma patients with regular inpatient intraocular pressure controls: study design and set-up

Purpose

The SALUS study aims to improve the healthcare situation for glaucoma patients in Germany. In order to detect diurnal intraocular pressure (IOP) fluctuations, inpatient monitoring of IOP in an eye hospital for a minimum of 24 h is the current standard. SALUS assesses the benefits of a new form of outpatient care, where IOP can be measured by the patients themselves at home using a self-tonometer. This approach should promote the patient’s health competence and empowerment within the healthcare system while reducing treatment costs.

Methods

The SALUS study is a randomized controlled, open non-inferiority trial, alongside an economic analysis, determining whether outpatient monitoring of IOP with self-tonometry is at least as effective as current standard care and would reduce treatment costs. Participants (n = 1980) will be recruited by local ophthalmologists in the area of Westphalia-Lippe, Germany, and randomized to receive 7-day outpatient or 24-h inpatient monitoring. Participants in both study arms will also receive 24-h blood pressure monitoring. Furthermore, patient data from both study groups will be collected in an electronic case file (ECF), accessible to practitioners, hospitals, and the study participants. The primary endpoint is the percentage of patients with IOP peaks, defined as levels 30% above the patient-specific target pressure. Data will also be collected during initial and final examinations, and at 3, 6, and 9 months after the initial examination.

Results

The study implementation and trial management are represented below.

Conclusion

SALUS is a pioneering prospective clinical trial focused on the care of glaucoma patients in Germany. If SALUS is successful, it could improve the healthcare situation and health literacy of the patients through the introduction of various telemedical components. Furthermore, the approach would almost certainly reduce the treatment costs of glaucoma care.

Trial registration

ClinicalTrials.gov ID: NCT04698876, registration date: 11/25/2020.

DRKS-ID: DRKS00023676, registration date: 11/26/2020.

[Possibilities and limitations of telemedical home monitoring in ophthalmology]

For medical professionals, home monitoring represents an innovative health service for remote patient care: The patient may remain in his or her domestic environment and continue normal activities. The physician can also, through technical and organizational integration, provide medical attendance from his or her usual working environment. All in all, in the near future home monitoring can help provide sufficient health services while also enabling medical resources to be used more effectively. The patient may benefit from individually optimized treatment and active integration into medical care. The better we manage the technical, organizational, medical, legal, and economic challenges of telemedicine, the better we can minimize the limitations of telemedical home monitoring. Other existing subjective concerns will be eliminated only if telemedical concepts are adapted to the specific needs of affected patients and physicians.

Selbstmedikation mit Lokalanästhetika durch Glaukompatienten bei der Teletonometrie

BACKGROUND

Self-tonometry, a supplementary measurement of the intraocular pressure in ophthalmology by glaucoma patients using an automatic tonometer, will become more and more important in the future. As long as the self-tonometry has to work in the contact modus with the ocular surface, home application of a topical anaesthetic by the glaucoma patient will be a requirement for a successful measurement. So far no severe problems within this controlled self-medication have been seen. Nevertheless, public health authorities believe patient health is put at high risk by the application of local anaesthetics during self-tonometry. As there are no clinical studies of the health care, we evaluated the local tolerability of a topical anaesthetic in line with self-tonometry employing a modified tonometer OCUTON S.

MATERIAL AND METHODS

A total of 100 glaucoma patients participated in a prospective clinical study of the routine clinical service in which each was monitored for 1 year. The telemonitoring involved self-tonometry for at least 6 months in every case and Ocuton S Proparakain-POS 0.5% eyedrops (proxymetacaine-HCl) were applied by the probands before every measurement of the intraocular pressure with a modified self-tonometer. Information regarding the local tolerability of the topical anaesthetic was analysed using a standardised questionnaire. The intensity of the following subjective symptoms was listed in separate visual analogue scales for: lacrimation, burning, foreign body sensation, mucus aggregation, pruritus and pain.

RESULTS

Information from 83 glaucoma patients on local tolerability of proparacaine eyedrops could be analysed. For several reasons no data could be gathered from 17 probands, which were refusal to complete the questionnaire, cancelled participation and, in two test persons, there emerged an allergic reaction (local eyelid redness and swelling) which necessitated a change to a different topical anaesthetic. In all other participants the application was carried out without any significant local or systemic symptoms or side-effects. Immediately after application of the eyedrops 36.1% of the test persons suffered a minor conjunctival hyperaemia which eased off within 1 h in 20.4% of these patients. Of the interviewed glaucoma patients 91.5% judged the single symptoms on the visual analogue scale between zero and medium intensity. The severest effects, according to the subjective evaluation, were felt in symptoms of burning with a score of 94 and lacrimation graded 96. The least intensity was established in the symptom of mucus aggregation where 72.3% rated this symptom in the visual analogue scale between 0 and 10. The other symptoms pruritus, feeling of pressure and foreign body sensation hardly differed in subjective ratings.

CONCLUSION

A self-medication with topical anaesthetics on undamaged ocular surfaces for self-tonometry purposes can be performed by glaucoma patients without a high risk potential. However, the application presupposes that routine ophthalmological examinations are carried out according to the ophthalmological associations' recommendations. Therefore, medical care concepts which integrate self-tonometry into routine ophthalmological services and comply with the complex requirements of a modern glaucoma management should be applied more often.