Skip to main content
Top
Published in: Advances in Therapy 10/2016

Open Access 01-10-2016 | Review

Systematic Review of Current Devices for 24-h Intraocular Pressure Monitoring

Authors: Sabita M. Ittoop, Jeffrey R. SooHoo, Leonard K. Seibold, Kaweh Mansouri, Malik Y. Kahook

Published in: Advances in Therapy | Issue 10/2016

Login to get access

Abstract

Glaucoma is a common optic neuropathy that can lead to irreversible vision loss, and intraocular pressure (IOP) is the only known modifiable risk factor. The primary method of treating glaucoma involves lowering IOP using medications, laser and/or invasive surgery. Currently, we rely on in-office measurements of IOP to assess diurnal variation and to define successful management of disease. These measurements only convey a fraction of a patient’s circadian IOP pattern and may frequently miss peak IOP levels. There is an unmet need for a reliable and accurate device for 24-h IOP monitoring. The 24-h IOP monitoring devices that are currently available and in development fall into three main categories: self-monitoring, temporary continuous monitoring, and permanent continuous monitoring. This article is a systematic review of current and future technologies for measuring IOP over a 24-h period.
Literature
1.
go back to reference Tham YC, Li X, Wong TY, Quigley HA, Aung T, Cheng CY. Global prevalence of glaucoma and projections of glaucoma burden through 2040: a systematic review and meta-analysis. Ophthalmology. 2014:121;2081–90. Tham YC, Li X, Wong TY, Quigley HA, Aung T, Cheng CY. Global prevalence of glaucoma and projections of glaucoma burden through 2040: a systematic review and meta-analysis. Ophthalmology. 2014:121;2081–90.
2.
go back to reference Quigley HA, Broman AT. The number of people with glaucoma worldwide in 2010 and 2020. Br J Ophthalmol. 2006;90(3):262–7. Quigley HA, Broman AT. The number of people with glaucoma worldwide in 2010 and 2020. Br J Ophthalmol. 2006;90(3):262–7.
3.
go back to reference Sit AJ. Continuous monitoring of intraocular pressure: rationale and progress toward a clinical device. J Glaucoma. 2009;18(4):272–9.CrossRefPubMed Sit AJ. Continuous monitoring of intraocular pressure: rationale and progress toward a clinical device. J Glaucoma. 2009;18(4):272–9.CrossRefPubMed
4.
go back to reference Orzalesi N, Rossetti L, Invernizzi T, Bottoli A, Autelitano A. Effect of timolol, latanoprost, and dorzolamide on circadian IOP in glaucoma or ocular hypertension. Investig Ophthalmol Vis Sci. 2000;41(9):2566–73. Orzalesi N, Rossetti L, Invernizzi T, Bottoli A, Autelitano A. Effect of timolol, latanoprost, and dorzolamide on circadian IOP in glaucoma or ocular hypertension. Investig Ophthalmol Vis Sci. 2000;41(9):2566–73.
5.
go back to reference Hughes E, Spry P, Diamond J. 24-hour monitoring of intraocular pressure in glaucoma management: a retrospective review. J Glaucoma. 2003;12(3):232–6. Hughes E, Spry P, Diamond J. 24-hour monitoring of intraocular pressure in glaucoma management: a retrospective review. J Glaucoma. 2003;12(3):232–6.
6.
go back to reference Barkana Y, Anis S, Liebmann J, Tello C, Ritch R. Clinical utility of intraocular pressure monitoring outside of normal office hours in patients with glaucoma. Arch Ophthalmol. 2006;124(6):793–7.CrossRefPubMed Barkana Y, Anis S, Liebmann J, Tello C, Ritch R. Clinical utility of intraocular pressure monitoring outside of normal office hours in patients with glaucoma. Arch Ophthalmol. 2006;124(6):793–7.CrossRefPubMed
7.
go back to reference Konstas AG, Mantziris DA, Stewart WC. Diurnal intraocular pressure in untreated exfoliation and primary open-angle glaucoma. Arch Ophthalmol. 2008;115(2):182–5. Konstas AG, Mantziris DA, Stewart WC. Diurnal intraocular pressure in untreated exfoliation and primary open-angle glaucoma. Arch Ophthalmol. 2008;115(2):182–5.
8.
go back to reference Liu JHK, Weinreb RN. Monitoring intraocular pressure for 24 h. Br J Ophthalmol. 2011;95:599–600. Liu JHK, Weinreb RN. Monitoring intraocular pressure for 24 h. Br J Ophthalmol. 2011;95:599–600.
9.
go back to reference Whitacre MM, Stein R. Sources of error with use of Goldmann-type tonometers. Surv Ophthalmol. 1993;38:1–30. Whitacre MM, Stein R. Sources of error with use of Goldmann-type tonometers. Surv Ophthalmol. 1993;38:1–30.
10.
go back to reference Akram A, Yaqub A, Dar AJ, Fiaz. Pitfalls in intraocular pressure measurement by Goldmann-type applanation tonometers. Pak J Ophthalmol. 2009;25:22–4. Akram A, Yaqub A, Dar AJ, Fiaz. Pitfalls in intraocular pressure measurement by Goldmann-type applanation tonometers. Pak J Ophthalmol. 2009;25:22–4.
12.
go back to reference Hessemer V, Rössler R, Jacobi KW. Tono-Pen, a new tonometer. Int Ophthalmol. 1989;13:51–6. Hessemer V, Rössler R, Jacobi KW. Tono-Pen, a new tonometer. Int Ophthalmol. 1989;13:51–6.
13.
go back to reference Kao SF, Lichter PR, Bergstrom TJ, Rowe S, Musch DC. Clinical comparison of the Oculab Tono-Pen to the Goldmann applanation tonometer. Ophthalmology. 1987;94(12):1541–4. Kao SF, Lichter PR, Bergstrom TJ, Rowe S, Musch DC. Clinical comparison of the Oculab Tono-Pen to the Goldmann applanation tonometer. Ophthalmology. 1987;94(12):1541–4.
14.
go back to reference Liang SYW, Lee GA, Shields D. Self-tonometry in glaucoma management-past, present and future. Surv Ophthalmol. 2009:54;450–62. Liang SYW, Lee GA, Shields D. Self-tonometry in glaucoma management-past, present and future. Surv Ophthalmol. 2009:54;450–62.
15.
go back to reference Judge AJ, Najafi K, Lee DA, Miller KM. Corneal endothelial toxicity of topical anesthesia. Ophthalmology. 1997;104(9):1373–9.CrossRefPubMed Judge AJ, Najafi K, Lee DA, Miller KM. Corneal endothelial toxicity of topical anesthesia. Ophthalmology. 1997;104(9):1373–9.CrossRefPubMed
16.
go back to reference De Smedt S. Noninvasive intraocular pressure monitoring: current insights. Clin Ophthalmol. 2015;9:1385–92. De Smedt S. Noninvasive intraocular pressure monitoring: current insights. Clin Ophthalmol. 2015;9:1385–92.
17.
go back to reference Rietveld E, van den Bremer DA, Völker-Dieben HJ. Clinical evaluation of the pressure phosphene tonometer in patients with glaucoma. Br J Ophthalmol. 2005;89(5):537–9. Rietveld E, van den Bremer DA, Völker-Dieben HJ. Clinical evaluation of the pressure phosphene tonometer in patients with glaucoma. Br J Ophthalmol. 2005;89(5):537–9.
18.
go back to reference Li J, Herndon LW, Asrani SG, Stinnett S, Allingham RR. Clinical comparison of the Proview eye pressure monitor with the Goldmann applanation tonometer and the Tonopen. Arch Ophthalmol. 2004;122(8):1117–21. Li J, Herndon LW, Asrani SG, Stinnett S, Allingham RR. Clinical comparison of the Proview eye pressure monitor with the Goldmann applanation tonometer and the Tonopen. Arch Ophthalmol. 2004;122(8):1117–21.
20.
go back to reference Cervino A. Rebound tonometry: new opportunities and limitations of non-invasive determination of intraocular pressure. Br J Ophthalmol. 2006;90(12):1444–6.CrossRefPubMedPubMedCentral Cervino A. Rebound tonometry: new opportunities and limitations of non-invasive determination of intraocular pressure. Br J Ophthalmol. 2006;90(12):1444–6.CrossRefPubMedPubMedCentral
22.
go back to reference Iliev ME, Goldblum D, Katsoulis K, Amstutz C, Frueh B. Comparison of rebound tonometry with Goldmann applanation tonometry and correlation with central corneal thickness. Br J Ophthalmol. 2006;90(7):833–5. Iliev ME, Goldblum D, Katsoulis K, Amstutz C, Frueh B. Comparison of rebound tonometry with Goldmann applanation tonometry and correlation with central corneal thickness. Br J Ophthalmol. 2006;90(7):833–5.
23.
go back to reference Salim S, Du HWJ. Comparison of intraocular pressure measurements and assessment of intraobserver and interobserver reproducibility with the portable ICare rebound tonometer and Goldmann applanation tonometer in glaucoma patients. J Glaucoma. 2013;22(4):325–9.CrossRefPubMed Salim S, Du HWJ. Comparison of intraocular pressure measurements and assessment of intraobserver and interobserver reproducibility with the portable ICare rebound tonometer and Goldmann applanation tonometer in glaucoma patients. J Glaucoma. 2013;22(4):325–9.CrossRefPubMed
24.
go back to reference Brusini P, Salvetat ML, Zeppieri M, Tosoni C, Parisi L. Comparison of ICare tonometer with Goldmann applanation tonometer in glaucoma patients. J Glaucoma. 2006;15(3):213–7.CrossRefPubMed Brusini P, Salvetat ML, Zeppieri M, Tosoni C, Parisi L. Comparison of ICare tonometer with Goldmann applanation tonometer in glaucoma patients. J Glaucoma. 2006;15(3):213–7.CrossRefPubMed
25.
go back to reference Shin J, Lee JW, Kim EA, Caprioli J. The effect of corneal biomechanical properties on rebound tonometer in patients with normal-tension glaucoma. Am J Ophthalmol. 2015;159(1):144–54.CrossRefPubMed Shin J, Lee JW, Kim EA, Caprioli J. The effect of corneal biomechanical properties on rebound tonometer in patients with normal-tension glaucoma. Am J Ophthalmol. 2015;159(1):144–54.CrossRefPubMed
26.
go back to reference Jorge JMM, González-Méijome JM, Queirós A, Fernandes P, Parafita MA. Correlations between corneal biomechanical properties measured with the ocular response analyzer and ICare rebound tonometry. J Glaucoma. 2008;17(6):442–8. Jorge JMM, González-Méijome JM, Queirós A, Fernandes P, Parafita MA. Correlations between corneal biomechanical properties measured with the ocular response analyzer and ICare rebound tonometry. J Glaucoma. 2008;17(6):442–8.
27.
go back to reference González-Méijome JM, Jorge J, Queirós A, et al. Age differences in central and peripheral intraocular pressure using a rebound tonometer. Br J Ophthalmol. 2006;90(12):1495–500.CrossRefPubMedPubMedCentral González-Méijome JM, Jorge J, Queirós A, et al. Age differences in central and peripheral intraocular pressure using a rebound tonometer. Br J Ophthalmol. 2006;90(12):1495–500.CrossRefPubMedPubMedCentral
28.
go back to reference Muttuvelu DV, Baggesen K, Ehlers N. Precision and accuracy of the ICare tonometer—peripheral and central IOP measurements by rebound tonometry. Acta Ophthalmol. 2012;90(4):322–6.CrossRefPubMed Muttuvelu DV, Baggesen K, Ehlers N. Precision and accuracy of the ICare tonometer—peripheral and central IOP measurements by rebound tonometry. Acta Ophthalmol. 2012;90(4):322–6.CrossRefPubMed
29.
go back to reference Jóhannesson G, Hallberg P, Eklund A, Lindén C. Pascal, ICare and Goldmann applanation tonometry–a comparative study. Acta Ophthalmol. 2008;86(6):614–21. Jóhannesson G, Hallberg P, Eklund A, Lindén C. Pascal, ICare and Goldmann applanation tonometry–a comparative study. Acta Ophthalmol. 2008;86(6):614–21.
30.
go back to reference Rosentreter A, Jablonski KS, Mellein AC, Gaki S, Hueber A, Dietlein TS. A new rebound tonometer for home monitoring of intraocular pressure. Graefe’s Arch Clin Exp Ophthalmol. 2011;249(11):1713–9.CrossRef Rosentreter A, Jablonski KS, Mellein AC, Gaki S, Hueber A, Dietlein TS. A new rebound tonometer for home monitoring of intraocular pressure. Graefe’s Arch Clin Exp Ophthalmol. 2011;249(11):1713–9.CrossRef
31.
go back to reference Kim KN, Jeoung JW, Park KH, Yang MK, Kim DM. Comparison of the new rebound tonometer with Goldmann applanation tonometer in a clinical setting. Acta Ophthalmol. 2013;91(5):e392–6. Kim KN, Jeoung JW, Park KH, Yang MK, Kim DM. Comparison of the new rebound tonometer with Goldmann applanation tonometer in a clinical setting. Acta Ophthalmol. 2013;91(5):e392–6.
32.
go back to reference Sakamoto M, Kanamori A, Fujihara M, Yamada Y, Nakamura M, Negi A. Assessment of IcareONE rebound tonometer for self-measuring intraocular pressure. Acta Ophthalmol. 2014;92(3):243–8.CrossRefPubMed Sakamoto M, Kanamori A, Fujihara M, Yamada Y, Nakamura M, Negi A. Assessment of IcareONE rebound tonometer for self-measuring intraocular pressure. Acta Ophthalmol. 2014;92(3):243–8.CrossRefPubMed
33.
go back to reference Halkiadakis I, Stratos A, Stergiopoulos G, et al. Evaluation of the Icare-ONE rebound tonometer as a self-measuring intraocular pressure device in normal subjects. Graefes Arch Clin Exp Ophthalmol. 2012;250(8):1207–11.CrossRefPubMed Halkiadakis I, Stratos A, Stergiopoulos G, et al. Evaluation of the Icare-ONE rebound tonometer as a self-measuring intraocular pressure device in normal subjects. Graefes Arch Clin Exp Ophthalmol. 2012;250(8):1207–11.CrossRefPubMed
34.
go back to reference Moreno-Montañés J, Martínez-de-la-Casa JM, Sabater AL, Morales-Fernandez L, Sáenz C, Garcia-Feijoo J. Clinical evaluation of the new rebound tonometers Icare PRO and Icare ONE compared with the Goldmann tonometer. J Glaucoma. 2015;24(7):527–32. doi:10.1097/IJG.0000000000000058. Moreno-Montañés J, Martínez-de-la-Casa JM, Sabater AL, Morales-Fernandez L, Sáenz C, Garcia-Feijoo J. Clinical evaluation of the new rebound tonometers Icare PRO and Icare ONE compared with the Goldmann tonometer. J Glaucoma. 2015;24(7):527–32. doi:10.​1097/​IJG.​0000000000000058​.
36.
go back to reference Greene M, Gilman B. Intraocular pressure measurement with instrumented contact lenses. Invest Ophthalmol Vis Sci. 1974;13(4):299–302. Greene M, Gilman B. Intraocular pressure measurement with instrumented contact lenses. Invest Ophthalmol Vis Sci. 1974;13(4):299–302.
37.
go back to reference Mansouri K. The road ahead to continuous 24-hour intraocular pressure monitoring in glaucoma. J Ophthalmic Vis Res. 2014;9(2):260–8.PubMedPubMedCentral Mansouri K. The road ahead to continuous 24-hour intraocular pressure monitoring in glaucoma. J Ophthalmic Vis Res. 2014;9(2):260–8.PubMedPubMedCentral
39.
go back to reference Twa MD, Roberts CJ, Karol HJ, Mahmoud AM, Weber PA, Small RH. Evaluation of a contact lens-embedded sensor for intraocular pressure measurement. J Glaucoma. 2010;19(6):382–90.CrossRefPubMedPubMedCentral Twa MD, Roberts CJ, Karol HJ, Mahmoud AM, Weber PA, Small RH. Evaluation of a contact lens-embedded sensor for intraocular pressure measurement. J Glaucoma. 2010;19(6):382–90.CrossRefPubMedPubMedCentral
42.
go back to reference Mansouri K, Medeiros FA, Tafreshi A, Weinreb RN. Continuous 24-hour monitoring of intraocular pressure patterns with a contact lens sensor: safety, tolerability, and reproducibility in patients with glaucoma. Arch Ophthalmol. 2012;130(12):1534–9.CrossRef Mansouri K, Medeiros FA, Tafreshi A, Weinreb RN. Continuous 24-hour monitoring of intraocular pressure patterns with a contact lens sensor: safety, tolerability, and reproducibility in patients with glaucoma. Arch Ophthalmol. 2012;130(12):1534–9.CrossRef
43.
go back to reference Leonardi M, Pitchon EM, Bertsch A, Renaud P, Mermoud A. Wireless contact lens sensor for intraocular pressure monitoring: assessment on enucleated pig eyes. Acta Ophthalmol. 2009;87(4):433–7.CrossRefPubMed Leonardi M, Pitchon EM, Bertsch A, Renaud P, Mermoud A. Wireless contact lens sensor for intraocular pressure monitoring: assessment on enucleated pig eyes. Acta Ophthalmol. 2009;87(4):433–7.CrossRefPubMed
44.
go back to reference Agnifili L, Mastropasqua R, Frezzotti P, et al. Circadian intraocular pressure patterns in healthy subjects, primary open angle and normal tension glaucoma patients with a contact lens sensor. Acta Ophthalmol. 2015;93(1):e14–21.CrossRefPubMed Agnifili L, Mastropasqua R, Frezzotti P, et al. Circadian intraocular pressure patterns in healthy subjects, primary open angle and normal tension glaucoma patients with a contact lens sensor. Acta Ophthalmol. 2015;93(1):e14–21.CrossRefPubMed
45.
go back to reference Tojo N, Hayashi A, Otsuka M, Miyakoshi A. Fluctuations of the intraocular pressure in pseudoexfoliation syndrome and normal eyes measured by a contact lens sensor. J Glaucoma. 2016;25(5):e463–8. doi:10.1097/IJG.0000000000000292. Tojo N, Hayashi A, Otsuka M, Miyakoshi A. Fluctuations of the intraocular pressure in pseudoexfoliation syndrome and normal eyes measured by a contact lens sensor. J Glaucoma. 2016;25(5):e463–8. doi:10.​1097/​IJG.​0000000000000292​.
46.
go back to reference Parekh AS, Mansouri K, Weinreb RN, Tafreshi A, Korn BS, Kikkawa DO. Twenty-four-hour intraocular pressure patterns in patients with thyroid eye disease. Clin Exp Ophthalmol. 2015;43(2):108–14 Parekh AS, Mansouri K, Weinreb RN, Tafreshi A, Korn BS, Kikkawa DO. Twenty-four-hour intraocular pressure patterns in patients with thyroid eye disease. Clin Exp Ophthalmol. 2015;43(2):108–14
47.
go back to reference Lee JWY, Fu L, Chan JCH, Lai JSM. Twenty-four-hour intraocular pressure related changes following adjuvant selective laser trabeculoplasty for normal tension glaucoma. Medicine (Baltimore). 2014;93(27):e238. Lee JWY, Fu L, Chan JCH, Lai JSM. Twenty-four-hour intraocular pressure related changes following adjuvant selective laser trabeculoplasty for normal tension glaucoma. Medicine (Baltimore). 2014;93(27):e238.
48.
go back to reference Tojo N, Oka M, Miyakoshi A, Ozaki H, Hayashi A. Comparison of fluctuations of intraocular pressure before and after selective laser trabeculoplasty in normal-tension glaucoma patients. J Glaucoma. 2013;23(8):138–43. Tojo N, Oka M, Miyakoshi A, Ozaki H, Hayashi A. Comparison of fluctuations of intraocular pressure before and after selective laser trabeculoplasty in normal-tension glaucoma patients. J Glaucoma. 2013;23(8):138–43.
49.
go back to reference Mansouri K, Medeiros F, Weinreb R. Effect of glaucoma medications on 24-hour intraocular pressure-related patterns using a contact lens sensor. Clin Experiment Ophthalmol. 2015;43(9):787–95.CrossRefPubMed Mansouri K, Medeiros F, Weinreb R. Effect of glaucoma medications on 24-hour intraocular pressure-related patterns using a contact lens sensor. Clin Experiment Ophthalmol. 2015;43(9):787–95.CrossRefPubMed
50.
go back to reference Holló G, Kóthy P, Vargha P. Evaluation of continuous 24-hour intraocular pressure monitoring for assessment of prostaglandin-induced pressure reduction in glaucoma. J Glaucoma. 2014;23(1):e6–12. Holló G, Kóthy P, Vargha P. Evaluation of continuous 24-hour intraocular pressure monitoring for assessment of prostaglandin-induced pressure reduction in glaucoma. J Glaucoma. 2014;23(1):e6–12.
51.
go back to reference De Moraes CG, Jasien JV, Simon-Zoula S, Liebmann JMRR. Visual field change and 24-hour IOP-related profile with a contact lens sensor in treated glaucoma patients. Ophthalmology. 2015;15:S0161–6420. De Moraes CG, Jasien JV, Simon-Zoula S, Liebmann JMRR. Visual field change and 24-hour IOP-related profile with a contact lens sensor in treated glaucoma patients. Ophthalmology. 2015;15:S0161–6420.
52.
go back to reference Mansouri K, Weinreb RN. Meeting an unmet need in glaucoma: continuous 24-h monitoring of intraocular pressure. Expert Rev Med Dev. 2012;9:225–31.CrossRef Mansouri K, Weinreb RN. Meeting an unmet need in glaucoma: continuous 24-h monitoring of intraocular pressure. Expert Rev Med Dev. 2012;9:225–31.CrossRef
53.
go back to reference Melki S, Todani A, Cherfan G. An implantable intraocular pressure transducer: initial safety outcomes. JAMA Ophthalmol. 2014;132(10):1221–5. Melki S, Todani A, Cherfan G. An implantable intraocular pressure transducer: initial safety outcomes. JAMA Ophthalmol. 2014;132(10):1221–5.
55.
go back to reference Todani A, Behlau I, Fava MA, et al. Intraocular pressure measurement by radio wave telemetry. Invest Ophthalmol Vis Sci. 2011;52(13):9573–80. Todani A, Behlau I, Fava MA, et al. Intraocular pressure measurement by radio wave telemetry. Invest Ophthalmol Vis Sci. 2011;52(13):9573–80.
56.
go back to reference Kim Y, Kim M, Park K, et al. Preliminary study on implantable inductive-type sensor for continuous monitoring of intraocular pressure. Clin Exp Ophthalmol. 2015;43(9):830–7.CrossRefPubMed Kim Y, Kim M, Park K, et al. Preliminary study on implantable inductive-type sensor for continuous monitoring of intraocular pressure. Clin Exp Ophthalmol. 2015;43(9):830–7.CrossRefPubMed
57.
go back to reference Koutsonas A, Walter P, Roessler G, Plange N. Implantation of a novel telemetric intraocular pressure sensor in patients with glaucoma (ARGOS study): 1-year results. Invest Ophthalmol Vis Sci. 2015;56(2):1063–9.CrossRefPubMed Koutsonas A, Walter P, Roessler G, Plange N. Implantation of a novel telemetric intraocular pressure sensor in patients with glaucoma (ARGOS study): 1-year results. Invest Ophthalmol Vis Sci. 2015;56(2):1063–9.CrossRefPubMed
61.
go back to reference Varel Ç, Shih Y-C, Otis BP, Shen TS, Böhringer KF. A wireless intraocular pressure monitoring device with a solder-filled microchannel antenna. J Micromech Microeng. 2014;24(4):045012. Varel Ç, Shih Y-C, Otis BP, Shen TS, Böhringer KF. A wireless intraocular pressure monitoring device with a solder-filled microchannel antenna. J Micromech Microeng. 2014;24(4):045012.
63.
go back to reference Chow EY, Chlebowski AL, Irazoqui PP. A miniature-implantable RF-wireless active glaucoma intraocular pressure monitor. IEEE Trans Biomed Circuits Syst 2010;4:340–9. Chow EY, Chlebowski AL, Irazoqui PP. A miniature-implantable RF-wireless active glaucoma intraocular pressure monitor. IEEE Trans Biomed Circuits Syst 2010;4:340–9.
Metadata
Title
Systematic Review of Current Devices for 24-h Intraocular Pressure Monitoring
Authors
Sabita M. Ittoop
Jeffrey R. SooHoo
Leonard K. Seibold
Kaweh Mansouri
Malik Y. Kahook
Publication date
01-10-2016
Publisher
Springer Healthcare
Published in
Advances in Therapy / Issue 10/2016
Print ISSN: 0741-238X
Electronic ISSN: 1865-8652
DOI
https://doi.org/10.1007/s12325-016-0388-4

Other articles of this Issue 10/2016

Advances in Therapy 10/2016 Go to the issue