Clinic to HOME2: An IOP Conversation with Dr. Craig Chaya

Why One Office Reading Is Not Enough

In this 63-minute provider webinar, Dr. Craig Chaya — director of the glaucoma fellowship and division chief at the University of Utah's Moran Eye Center — joins Dr. Barbara Wirostko, co-founder and chief medical officer of MyEyes, for a case-driven conversation about how home tonometry with the iCare HOME2 is changing glaucoma management at an academic center. The discussion centers on a fundamental gap in glaucoma care: with over 86,000 seconds in a 24-hour period, a single clinic reading captures only a fraction of the IOP stress an optic nerve endures. Dr. Chaya, who trained as an internist before becoming an ophthalmologist, draws a direct parallel to continuous glucose monitoring and explains why he gravitated naturally toward seeking more data for his glaucoma patients.

The Evidence: IOP Fluctuation as an Independent Risk Factor

Dr. Wirostko opens the clinical discussion by reviewing the evidence for IOP fluctuation as an independent driver of glaucoma progression. She cites the CIGTS study, a nine-year prospective trial that found IOP variations and fluctuations were independently linked to worsening of glaucoma — with patients exceeding an 8.5 mmHg delta facing a 96% risk of visual field progression over the study period. Critically, those fluctuations were detected during standard business-hour clinic visits; had home tonometry been available, the detected variability might have been even more dramatic. Research by Tom Johnson and colleagues at Wilmer confirmed that the majority of IOP spikes occur in the early waking hours, between 4:30 and 8 a.m. — a window that no routine clinic schedule captures.

How Dr. Chaya Uses HOME2 at Moran Eye Center

Dr. Chaya describes how his indications for home tonometry have expanded over the years. Initially driven by curiosity about what happens outside office hours, he now uses the HOME2 in three main ways: establishing a pre-intervention baseline, measuring post-intervention efficacy at the six-to-eight-week mark, and long-term monitoring of filtering surgery patients. One of his most powerful applications is detecting bleb failure before it is visible at the slit lamp. When a functional bleb is present, the diurnal IOP curve flattens dramatically — the signature of effective filtration. When fluctuation returns, it signals encapsulation, often before clinical signs appear. This early warning has allowed his team to intervene before significant damage accumulates.

Case Presentations: Matching Procedure to Fluctuation Pattern

Dr. Chaya presents several cases that demonstrate how HOME2 data changes surgical decision-making. In one case, a patient previously labeled as normal-tension glaucoma based on office readings was found to have dramatic fluctuation — pressures ranging from 10 to 24 in both eyes — once home data was captured. The delta of 13 to 14 mmHg far exceeded the CIGTS threshold of 8.5 mmHg. The patient initially chose a XEN gel stent to avoid the risks of trabeculectomy, but when the XEN encapsulated and fluctuation returned, Dr. Chaya recommended trabeculectomy. The patient has been stable for over a year and a half, and because she owns her HOME2, she will be the first to detect if the bleb begins to fail.

In another case, a patient with moderate bilateral glaucoma showed the "Wasatch pattern" — named for Utah's mountain range — with IOP swinging from 10 to 26, with peak pressures occurring at 7:18 a.m. and overnight. Because the patient was earlier on the disease continuum, Dr. Chaya opted for a phacoHydrus rather than a trabeculectomy. Post-intervention HOME2 data showed the peaks reduced from the mid-20s to 18, with a much narrower delta. The less invasive approach was appropriate because the earlier-stage nerve could tolerate some residual fluctuation.

A third case illustrated the use of HOME2 data to set target IOP goals and justify trabeculectomy in a patient already at low office pressures. One eye had been stabilized with a XEN procedure at pressures ranging 7 to 13. The fellow eye, on drops alone, showed the same 7-to-13 range but was clearly progressing on serial visual fields. Dr. Chaya used the HOME2 data to demonstrate that a ZEN could not deliver the 30% additional reduction needed — only trabeculectomy could achieve the single-digit target required to halt progression in an eye already at low absolute pressures.

Remote Management and Pediatric Glaucoma

Both physicians describe the practical advantages of remote monitoring for patients who live far from their specialists. Dr. Wirostko recounts managing a patient in Arizona who owned her HOME2 after a tube shunt — when the valve opened and pressure dropped to 5, the patient contacted them remotely and they tapered her medications without requiring a trip to Salt Lake City. Dr. Chaya describes his pediatric glaucoma patients whose families live hours from Moran in rural Utah. Parents can correlate symptoms like headaches with pressure readings, and Dr. Chaya can adjust medications via text updates without requiring the family to drive for a simple pressure check.

Sleep Apnea, Blood Pressure, and Systemic Correlates

The Q&A discussion explores the connection between systemic health and IOP. Dr. Wirostko reports that patients with sleep apnea who track their apneic events have found correlation between worse apnea and more IOP spikes — physiologically consistent with increased intrathoracic pressure reducing venous return. Dr. Chaya adds that this has changed their clinical intake: they now routinely ask about blood pressure medication timing and refer for sleep studies when sleep apnea is suspected. Dr. Wirostko previews a planned initiative to offer blood pressure monitoring alongside HOME2 to study ocular perfusion pressure. One anecdote highlights a pulmonary fellow who was a glaucoma suspect and discovered his IOP spiked into the 40s after inverted bench pressing — data that led him to modify his workout.

Proactive Care: The Most Transformative Tool Since OCT

Dr. Chaya closes with a reflection on what home tonometry means for the field. He describes it as the most transformative development in his career since OCT — not because it always leads to intervention, but because it enables proactive, preventative care rather than reactive management. Home data sometimes confirms that a patient is safely tolerating their fluctuation, which is equally valuable: it prevents unnecessary surgery and its associated risks. He emphasizes that the data is about pattern recognition, not individual numbers, and that the value compounds when combined with frequent visual field testing, OCT, and emerging tools like polygenic risk scores. For providers hesitant about adding "more data" to an already complex decision tree, Dr. Chaya argues that the pattern-based approach actually simplifies decisions by showing whether to intervene, watch closely, or reassure.