I would like to know more about the different approaches to performing home eye pressure monitoring (self-tonometry) that are used by FitEyes members. Can you give some examples?
Elizabeth's Method - Easy Pressure Monitoring
One common approach to self-tonometry is simply to check one's intraocular pressure one or more times daily and use the software provided with your tonometer to either track the measurements or to share them with your doctor.
This method requires minimal thought, minimal effort and does not involve self-experimentation. This is a very valuable approach to self-tonometry, and it is one almost anyone can undertake. Multiple times over the years I have heard reports of how this simple monitoring has saved someone's vision. Open angle glaucoma is typically symptom-free (and is sometimes called the "silent thief of eyesight"). Even one day of very high intraocular pressure could lead to significant vision loss or blindness. For most of us, we won't experience such an "IOP spike". But it has happened to a sufficient number of people I know that I can confidently say, there will come a day when it is recommended that all glaucoma patients monitor their own intraocular pressure, the same way that it is recommended for diabetics to monitor their own blood glucose.
For many of us in the FitEyes community, that day arrived 15 years ago, and we have been enjoying the benefits of self-tonometry for the last decade and a half. In 2009 I wrote a paper arguing that there is no need to wait for new technologies before the ophthalmology profession can endorse self-tonometry. The technology exists now. This was true in 2009 and it is even more true now. Indeed, glaucoma patients can now rent a tonometer on a weekly basis from Enlivened. See this link:
Tonometers | Enlivened Online Dispensary https://www.enlivened.com/tonometers/
I would like to give a specific example of a variation of the "monitoring" approach to self-tonometry. Elizabeth is a long time member of FitEyes.com and she has many years of experience with self-tonometry. (If my memory is correct, she started self-tonometry in 2006.) She has had good success with her approach to self-tonometry and I have a lot of respect for what she, and others like her, are doing.
Her goal is to use the minimal amount of medication while maintaining her intraocular pressure at or below her target IOP. She allows her intraocular pressure to fluctuate a bit and she mainly utilizes medication to keep the peak IOP under the maximum her doctor has recommended.
Thanks to self-tonometry she has been able to reduce her medication while maintaining her target IOP range.
Elizabeth is not as interested as I am in conducting extensive research due to the demands of data collection, experimentation and analysis. (Conducting experimentation and data analysis is not a requirement for participating in the FitEyes.com self-tonometry research project.)
However, Elizabeth does look for trends she can discover by "seat of the pants" techniques. She has noticed some connection between what she eats and her intraocular pressure and these observations have been helpful to her. Seeing the same patterns repeatedly gives on confidence in the validity of the conclusion (in this case, that pastries raise her IOP). When following our own intraocular pressure, one does not need statistics in order to see real and valid connections like this.
However, this approach goes beyond simple monitoring. In true "monitoring only" (as I define it) one does not attempt to relate one's intraocular pressure changes to anything other than one's use of the prescribed glaucoma medications.
Elizabeth is going beyond that to conduct informal self-tonometry research. This is research she can do without much effort, without any training, etc. She does contributes her intraocular pressure data to our self-tonometry research project and that has scientific value in the long term. Her informal observations have value to the rest of us as well. We can all discuss what she observes and, if we desire, we can follow up on her observations with further research -- whether formal or informal.
Elizabeth is quite happy that her self-tonometry allows her to maintain her eye pressure in an acceptable range on a minimal amount of medication. She does not require new discoveries or breakthrough new knowledge in order to derive benefit from her self-tonometry efforts. She reports that she has reduced certain glaucoma medications from daily (or even multiple daily) use previously; now it is typical for her to need glaucoma medication only once every few days or even every few weeks while managing to maintain excellent intraocular pressure values. As I understand it, her doctor is happy with the results of her visual field tests and other tests.
The biofeedback approach to self-tonometry
A FitEyes member recently asked about using biofeedback with self-tonometry. This question made me realize that I have never properly shared my views on that topic. For me, self-tonometry is a form of biofeedback. I have been using techniques of biofeedback for the entire 15 years I have been doing self-tonometry.
Biofeedback is a type of therapy that uses physiological sensors to measure key bodily functions. Biofeedback helps you learn more about how your body works. This feedback helps you to develop better control over certain body functions and address health concerns.
This tonometer is a sensor and the feedback it provides absolutely can be used in that way. It has been one of the main ways I have used self-tonometry. However, if someone has no experience with meditation or biofeedback, it may not be obvious how self-tonometry is a type of biofeedback. I think it will be very helpful for us to discuss this in a lot more depth.
The other answers to this question highlight other approaches to self-tonometry. However, I also utilze a biofeedback approach on its own, as well as in conjunction with my experiments. For example, the way I discovered the most effective way to walk to achieve an IOP reduction was by incorporating concepts commonly used in biofeedback. I usually speak of these concepts more in terms of meditation, but they fit the definition of biofeedback when coupled with self-tonometry.
Here's a definition from Psychology Today magazine:
By harnessing real-time information on one’s bodily state and demonstrating how it connects to conscious behaviors—such as thinking about certain images, breathing in a certain way, or relaxing muscles—biofeedback therapy is designed to help patients take more control over the functioning of their bodies. In the course of therapy, they may learn to better manage symptoms linked to the observed physiological activity.
If you review my various posts over the last 15 years, I think you will see that theme consistently running through my descriptions of my own practice of self-tonometry. One of my top goals has always been to enable myself (to empower myself) to manage my intraocular pressure through my thoughts, breathing and relaxation.
In formal biofeedback training, the subject is taught techniques for relaxing, breathing, visualizing, etc. And often the software is designed to assist the subject in those things. I believe meditation is a better training method for biofeedback skills, so when I discuss this subject, I don't usually call it biofeedback even though it certainly can be discussed in that way. Also, meditation and biofeedback can be complimentary.
When first exploring this, I would spend long sessions (an hour or more) exploring the biofeedback from my tonometer while monitoring my thoughts, my breathing, my muscle relaxation, and all the other factors that are commonly incorporated into biofeedback.
The technique I use is to explore one thing at a time, such as consciously relaxing the muscles around my eyes (to give one of many examples). As I relax the muscles around my eyes, I take a series of measurements with my tonometer. The Reichert 7CR with the FitEyes software is best for this. (I think you could also do it with other tonometers, although I don't because the Reichert 7CR with the FitEyes software frees me of all distractions and allows me to do pure biofeedback.)
I have done with with relaxing my glute muscles, for example. Or relaxing my shoulders & neck. Breathing is another example of a very profound connection between a consciously controllable physiological process and IOP.
I have done lots of experiments with thoughts too. In short, the more active or agitated the mind, the higher my IOP. You have probably seen me frequently write about the synergy between self-tonometry and the Serene Impulse meditation practice.
I do have biofeedback lab equipment, including EEG, EKG, EMG, feedback thermometer (highly sensitive), EDG (electrodermograph, also called skin conductance or GSR) and others. But in my experience, I have not needed to combine any of those with the tonometer. Most commonly, I use the tonometer alone as the biofeedback device.
More about doing biofeedback with my tonometer
With the FitEyes software, I turn on the audio feature so that I can get audio feedback of my IOP immediately, without even taking my head or eyes away from the Reichert 7CR tonometer. With the FitEyes software and the Reichert 7CR, I get the real-time feedback that is essential for good biofeedback results. I also have the ability to conduct my biofeedback without any distraction. If any of you are doing the same with an Icare, please let me know. In the future, if there is demand for it, and support for it, we could develop the FitEyes software to support biofeedback even better.
The FitEyes software has other features that are useful for biofeedback training. You can choose to hear -- via spoken audio from the software -- different IOP values (IOPcc, IOPg), you can choose to hear either each measure immediately or an average of multiple measures. You can choose to hear the quality score instead of IOP. You can change the number of puffs and the timing between puffs too.
Dr. Baumgarten's Method: The Engineer's Approach
Dr. Baumgarten was a true self-tonometry pioneer. He passed away recently. He lived in Germany and he was a retired director of the Calibration Institute of Berlin. He was not a medical doctor - he was a glaucoma patient like the rest of us.
He published an article on self-tonometry in a German magazine: Baumgarten D: Selbstkontrolle durch den Patienten. Der Augenspiegel. 2003; 10: 26-29
He also wrote the Ocuton S supplemental manual in German. The Ocuton S was the tonometer model he used. (A FitEyes member owns an Ocuton S. Compared to the tonometers we normally recommend, the Ocuton S is not a good choice today.)
Dr. Baumgarten, as an engineer, took an engineer's approach to intraocular pressure management. As I understand it from conversations with a FitEyes member who knew him, Dr. Baumgarten's goal was to maintain very tight control over his intraocular pressure and he has achived this through frequent self-tonometry and a complex routine of glaucoma medication.
Dr. Baumgarten checked his IOP on a regular schedule multiple times throughout the day and night. He even set his alarm to wake up at specific times during the night. He administered glaucoma medications at these times and did so in a manner that tightly regulated his intraocular pressure. He followed this routine for multiple decades, including waking up (twice I believe) during the night each night to perform self-tonometry and administer glaucoma medications.
Dr. Baumgarten was a machine! I mean that in a complimentary way. Not all of us have the discipline to follow such a rigid schedule 24 hours a day year after year. But Dr. Baumgarten, as a true engineer down to his core, has devised this engineering approach to self-tonometry that worked for him.
One great feature of Dr. Baumgarten's program was the meticulous record keeping he maintained. This is a common feature in the way many of us approach self-tonometry. I encourage everyone participating in the FitEyes.com self-tonometry research to strive to maintain excellent records including not just IOP values but extensive notes about activities, mental and emotional state, and all the other factors we discuss in the self-tonometry research website here at FitEyes.com.
Based on the existing scientific knowledge about glaucoma management, Dr. Baumgarten's approach comes close to the idea of allopathic medicine. He used what seems like heroic effort to minimize intraocular pressure fluctuations through appropriate (and rather high, in my opinion) use of allopathic glaucoma medication. I think most medical doctors would be very comfortable with Dr. Baumgarten's approach to self-tonometry. However, Dr. Baumgarten's approach is more about IOP management than about research. (And I think most medical doctors would not want their patients conducting research anyway!)
However, my personal approach to self-tonometry is all about discovering new knowledge and I actively experiment in order to achieve that goal. I will post another answer here describing my approach and other approaches to self-tonometry. Please post your own or vote on your favorite.
David's Method: research into non-medical factors, remove medication as a variable
One key defining characteristic of my approach is that it is research-oriented with a focus on discovering non-medical factors that affect intraocular pressure. In order to achieve this goal, I hold my glaucoma medication constant. Otherwise I would not be able to clearly see the effect of non-medical factors (such as stress management, exercise, diet, or supplements) in my data.
My long range goal is to reduce or eliminate glaucoma medications and to substitute them with lifestyle factors such as Serene Impulse (a meditation technique that I have found to be very helpful in managing my own intraocular pressure), exercise and the other things I usually discuss on my FitEyes.com blog. With my focus on non-medical approaches to managing intraocular pressure, I effectively remove glaucoma medication from any significant role in my research by holding it to non-changing level.
With the influence of glaucoma medication neutralized, I then aggressively search for non-medical factors that influence intraocular pressure by monitoring my IOP frequently while also monitoring other physiological parameters such as end-tidal carbon dioxide, SpO2, perfusion index, heart rate variability (HRV), galvanic skin response (GSR), respiration rate, breathing style, skin temperature and any others that are within my capabilities. I institute practices that are designed to alter the paramters I am monitoring and I carefully track intraocular pressure changes as a result of my experimental manipulations.
I am no longer the only person taking this approach to self-tonometry. Multiple FitEyes members are doing their own versions of this approach. It is not necessary to have any special equipment (such as the examples I mentioned above) other than your tonometer.
One of the most productive ways to go about this type of self-tonometry is to check your intraocular pressure before and after (and during, if possible) various activities. For example, check your IOP before and after walking.
If you keep good records (which the FitEyes software will help you do), and you test one thing at a time, you can conduct very product self-experimentation simply by monitoring your eye pressure before and after (and during, if possible) various activities.
For a period of time (e.g., weeks), try not to make big changes in your life. Then engage in the activity, record your IOP, and after enough repetitions of the activity, look for trends in your IOP. Is your eye pressure usually higher, lower or unchanged during and after the activity?
The be even more confident in your observation, take a little break (e.g., a few weeks) and do it again. Do you get the same results?
Next you can check another activity, such as, for example, gardening or weight lifting (with good technique and proper breathing) or drinking wine. All of those can lower intraocular pressure.
Doing experiments with dietary supplements takes a little more planning. With activities you are looking for short-term IOP changes before and after the activity (or duing it). With dietary supplements you have to look for a trend that manifests over months. It's still a "before and after" type of experiment, but it takes more time to complete. It's still a good idea to repeat an experiment with dietary supplements more than once.
To get an idea of which dietary supplements to test for intraocular pressure reduction, please ask a question here.
There's one more level we can explore in this type of research. Once you know the effect this activity has on your intraocular pressure, you can ask yourself (or your tonometer) if there is a way to alter the outcome.
In the following blog post I discuss my finding that walking more slowly was more beneficial:
Doing things slowly in a fast world | FitEyes.com
I found that when I tried to be productive during my walk (such as planning my tasks, or talking on the phone, or even walking at a faster pace to improve the cardiovascular benefits) I lost some or all of the benefits to my intraocular pressure. In fact, even though walking generally reduces intraocular pressure, if I engage in certain "productive" activities while walking, I can sometimes have higher IOP after the walk!
My experiments led me to find that walking at a slower pace, enjoying the sights and sounds around me, and not engaging in any directed thinking was the best way to manage my eye pressure.
Another example is weight lifting. Some glaucoma specialists caution against weight lifting for glaucoma patients. However, I have found it to be an incredibly valuable tool in my personal intraocular pressure management toolbox. It can reduce my IOP to a greater degree and faster than many glaucoma medications.
However, in order to achieve these good results I had to learn to habitually practice proper breathing techniques during my weight lifting. When I use good techniques on my exercises, a good order of exercises and good breathing, weight lifting is fantastic for lowering my IOP. In contrast, a naive evaluation of weight lifting could lead one to dismissing it as an activity that raises IOP -- it can do that if you strain, hold your breath, or do a few other things that I consider improper technique for a glaucoma patient who is weight lifting.
It is true that those of us living with glaucoma can achieve better eye pressure management by avoiding certain activities and emphasizing others. It is also true that we can discover which activites are best and worst for us though self-tonometry. However, my examples highlight that we can go one step further if we wish: we can consider not just the activities we do, but also how we perform those activities.
For example, most of us have found that exercise lowers our intraocular pressure. However, many FitEyes members have reported that in a "desperate attempt" to lower IOP with exercise while in a worried state of mind, it does not work. That's a more extreme example of me trying to be "productive" while I walk.
My final example might be the most extreme. I have found that I can do activities that are considered "bad for IOP" but if I do them in a mindful or meditative state of mind, I can mitigate or eliminate any harmful effects on my IOP. An example of this is inverted yoga postures. We are warned repeatedly not to do these. But I have measured my IOP while in an inverted yoga posture and found that I can avoid a significant increase in IOP by using the techniques I learned from Serene Impulse meditation.
It might help to get a definition on record first: An IOP exam generally consists of complete IOP measurements on each eye (left and right lateral exams). Each lateral exam will typically consist of multiple measurements (e.g., six with an Icare and at least 3 with a Reichert) until the exam quality score is satisfactory. Therefore, an IOP exam typically consists of multiple measurements of each eye.
If you are new to self-tonometry, just experiment for a while before you try to follow any specific program of IOP monitoring or tracking. Also, get comfortable with your tonometer before you give your IOP data serious consideration. On your first day using a tonometer, you should expect some meaningless values and you should not over-react to anything you see on day one. If you are using a handheld tonometer, it may require weeks (or months) of practice to become totally comfortable and relaxed when using it. That doesn't mean you cannot use it and get meaningful data from it much sooner than that. It means that at a certain point, using a tonometer will become nearly automatic and effortless. If you are using a Reichert 7CR tonometer (or similar model), no user skill is required to conduct a measurement, so it becomes effortless even sooner. Either way, allow yourself time to get comfortable with self-tonometry before you start tracking your data more seriously.
Define a set of daily IOP exams that fit your routine or schedule and your eye care needs.
The first thing to decide is whether you will schedule your IOP exams by the clock (such as 7:00am, 11:00am, etc.) or by activities (upon awakening, after morning exercise, etc.).
Next decide on the important times or activities you would like to monitor as well as roughly the minimum number of times you will check your IOP each day. Here are some examples:
If your glaucoma is stable and well-controlled and you have been doing self-tonometry for a fairly long time (hence, ruling out previously undetected spikes or similar issues that might need attention), you may decide that you only need to check your IOP once a day. In this case, I would recommend you check it immediately upon awakening and record that value every day.
At the other extreme, if you have unexplained progression and your glaucoma specialist is looking for an explanation, you might be asked to (or choose to) check your IOP every hour as well as once or more during sleeping hours, for some period of time. You could end up completing 18 or more IOP exams each day for a period of time.
Here's a practical example showing 7 IOP exams:
I prefer conducting IOP exams according to activities. But you can schedule by clock time if that works for you. (The times don't have to be exact.)
Record your IOP exam results. If you use software with your tonometer, the software will do this for you. I encourage you to records some notes about your daily activities, life events, etc. along with your IOP. A journal or diary would be a good companion to your IOP data.
You should record your IOP results for each of the IOP exams you have scheduled for your typical day. You can record more IOP exams if you wish, but these defined exams should be recorded as reliably as is practical each day. (Ocassionally missing a day is OK in most cases, unless your doctor says otherwise.)
You should also note your highest and your lowest IOP values for the day, regardless of when they occurred. Again, the software can do this for you.
You can redefine your IOP exam schedule as required. You should note the dates on which you do this, as your IOP summary data from one schedule may not be comparable to another schedule. For example, let's imagine that last year you only recorded your "upon awakening" IOP each day. This year, you switched and began recording only up "before bedtime" IOP each day (not recommended, by the way). Most people will have higher "upon awakening" IOP than "before bed" IOP. If you try to directly compare last year's IOP to this year's IOP, it will look like your IOP decreased significantly. In reality all that changed was the time of day you took the IOP exams.
If you follow this advice even moderately well, you will end up with an intraocular pressure data set that is more reliable, more meaningful and overall superior to your own doctor's intraocular pressure records for you.
Your doctor's data will usually be limited to in-office measurements performed a few times per year. Even if it includes a hospital-based diurnal exam, that professional data set will be less comprehensive than your own that you carefully accumulate over years.
I assume you are mastered the technique of using your tonometer and that you keep your tonometer cleaned. (The Icare and Reichert do not generally require periodic calibration, unlike Goldmann tonometers.) Your clinical data may have been obtained by different examiners and different instruments (with unknown calibration status). Your own data is more uniform in that regard, which is good. But it is more diverse in terms of the times of day of exams, the life events that occur, and the activities in which you engage in proximity to an IOP exam; this is also good from a data science perspective. Your own data also includes far more measurements (assuming you've been at this for a while). By every data science attribute I can think of, your intraocular pressure data will be superior to your doctor's data, if you wish it to be. (It is, of courses, possible to make a mess of your own data, which is why FitEyes is providing guidance such as this.)
Don't be surprised if your doctor (or their staff) tell you otherwise. If they do, you may want to go back and read this post:
Is Goldmann Applanation Tonometer (GAT) the Gold Standard? | Ask FitEyes
If your doctor (or their staff) are offering you practical guidance (such as watching you perform an IOP exam with your tonometer) and offering helpful feedback, by all means accept their help and be thankful for their knowledge and care. However, if they simply dismiss your IOP data without a valid reason, you can investigate the topics I mentioned above in more detail. I am sure you will come to understand that your own self-tonometry intraocular pressure data can easily be, with only a very practical level of effort on your part, more reliable, more meaningful and overall superior to your own doctor's intraocular pressure records.
Regular Timing of measures seems to be a common method of home monitoring that can be settled upon AFTER an initial period of several months or longer of very frequently timed and activity based monitoring, experimenting, and adjusting. It is for a time when pressures are mostly regular and well controlled.
By Regular Timing I mean that one would take measures at the same time each day. For instance, immediately upon awaking, again 30 minutes later, and before going to bed are my minimum number of readings for each day. Because of previous months of much more frequent monitoring done over a few years, I can know with my two morning readings that today appears to be a “normal” day for my IOP. Additionally, a higher evening IOP would alert me to the necessitate of more careful monitoring the next day.
On a day where I get morning readings a bit higher than desired, I will then take more frequent measures throughout the day to be carefully watching the IOP to see how what I do and what I feel throughout the day affect these pressures. I can learn from yesterday’s actions perhaps that caused today to be high and I can learn the effects of today’s adjustments that perhaps lower an elevated IOP.
Regularly taken measures of IOP can show trends, especially those varying upward from a baseline of IOP’s specific to me established over time. For instance, I have learned over the years of timed home tonometry that moderate exercise, like my daily 2 mile walk, is my first line of dropping a moderately elevated morning pressure. But importantly, I have also learned through my tonometry that skipping more than 1 or 2 days of walking leads to a slight (maybe 2-3 points above average) rise in morning pressures and that this rise persists throughout the day.
Again, this method is not for beginners or for those wildly swinging IOP’s, but it seems to be commonly practiced by experienced home tonometry practicioners.
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Multiple approaches are suggested in the answers below. Regardless of the approach you choose, don't make any of this difficult or stressful. You do not need to approach home eye pressure monitoring ("self-tonometry") in a way that makes you feel uncomfortable.
As the answers below show, there is more than one valid method for conducting home IOP monitoring. Find an approach you feel comfortable with and do that. Over time, you will find the patterns and answers you seek. Unlike a formal experiment, when we are doing self-monitoring at home we are not constrained by artificial deadlines. We can take our time if we wish. Or we can do more extensive monitoring to get answers more quickly. It's our choice. Neither choice is wrong.
The most important thing is that we do self-tonometry in a way that we enjoy. We can and should have fun doing it. We can discover super interesting things about our bodies and minds. This process empowers us -- that's absolutely a fun and rewarding process.
Don't let your "concerns" or "worries" about doing it right (or anything else) take the fun out of this process. Some of the greatest scientists in history have approached their important world-changing research with a fun and playful attitude. Since that approach has worked extremely well for some of the greatest scientific discoveries in history, it can work for your home IOP monitoring too!