Experience Counts: Unveiling Patients' Willingness to Pay for Remote Monitoring and Patient Self-Measurement.

OBJECTIVES: This study aimed to (1) estimate patients' willingness to pay (WTP) for remote monitoring (RM) and patient self-measurement (PSM) for pregnant women at risk of gestational hypertensive disorders, (2) assess the impact of experience with these technologies on WTP, and (3) determine their impact on health-related quality of life (HRQoL). METHODS: Data collection was part of a multicentric randomized controlled trial, Pregnancy Remote Monitoring II, with 2 interventions: RM and PSM. A contingent valuation survey, combining a payment card and open-ended question, was completed twice by 199 participants. Two-part models analyze the impact of experience on WTP, regression models estimated using ordinary least squares the impact of RM and PSM on HRQoL. RESULTS: The mean WTP amount was approximately €120 for RM and €80 for PSM. Compared with having no experience, WTP RM was €63 higher after a long-term exposure to RM (P = .01) and WTP PSM was €26 lower after a short-term exposure to RM (P = .07). No significant impact of RM or PSM on HRQoL was found. CONCLUSIONS: This study contributes to the discussion on the impact of experience on WTP. Those who had a long-term experience with RM, were willing to pay more for RM than those without experience. This confirms our hypothesis that involving patients without experience with the valued treatment, possibly underestimates WTP. A long-term experience has, however, no impact on the WTP for technologies for which the potential benefits are apparent without experiencing them, such as PSM.

Feasibility of caregiver-administered anthropometric measurements of children under age 5: evidence from Zambia.

BACKGROUND: Accurate measurement of children's anthropometry is of central importance for the assessment of nutritional status as well as for the evaluation of nutrition-specific interventions. Social distancing requirements during the recent Covid-19 pandemic made administration of standard assessor-led measurement protocols infeasible in many settings, creating demand for alternative assessment modalities. OBJECTIVE: To assess the feasibility and reliability of caregiver-administered anthropometric assessments of children under age 5. DESIGN: We compared standard and caregiver-administered assessments within an ongoing nutrition trial in Zambia (NCT05120427). We developed a "no-contact" protocol whereby trained staff verbally instruct caregivers from an appropriate distance to measure the height, weight and MUAC of their children. We captured measurements of height, weight and MUAC among a sample of caregivers and infants in Zambia using both the "no-contact" protocol and a standard assessor-led protocol. We analyzed each anthropometric variable, comparing means between protocol group, the proportions yielding standardized z-scores outside the plausible ± 6SD range and the proportions of children classified stunted, underweight and wasted. RESULTS: Anthropometric measurements were captured for 76 children using both the no-contact protocol and the standard protocol. An additional 1430 children were assessed by the standard protocol only and an additional 748 children by the no-contact protocol only. For the 76 children measured by both methods, we find no differences in average height, weight and MUAC between caregivers and interviewer assessments. The estimated kappa for the binary stunting and underweight classifications were 0.84 and 0.93, respectively. In the larger samples measured only following one protocol, we find no differences in average outcomes after adjusting for child, caregiver and household characteristics. CONCLUSIONS: Anthropometric measurement protocols administered by caregivers with verbal instruction from trained assessors are a promising alternative to standard protocols in situations where study staff are unable to come in close contact with study participants. Clinical trials registration This study was conducted within a larger trial registered at clinicaltrials.gov as trial NCT05120427. https://clinicaltrials.gov/ct2/show/NCT05120427 .

Non-Targeted Self-Measurement of Blood Pressure: Association with Self-Medication, Unscheduled Emergency Visits and Anxiety.

Background and Objective: The routine practice of self-medication of blood pressure (BP) not oriented with pulse devices may not be precisely useful in the control of BP and can lead the patient to self-medicate in error. Thus, we need to evaluate the non-oriented self-assessment of BP in real-life circumstances in hypertensive patients. The objective of this study was to evaluate in hypertensive patients the association of BP self-measurement with its control, as well as the presence of anxiety disorders, the occurrence of unscheduled visits to the emergency room, and self-medication. Materials and Methods: An observational study was carried out with 1000 hypertensive volunteers (age: 61.0 ± 12.5). Using a questionnaire, sociodemographic and clinical data on BP control were collected. Anxiety was assessed by the State-Trait Anxiety Inventory (STAI). Results: The group that performed non-oriented self-measurement of BP, showed that they had higher frequencies of self-medication (57.9%, p < 0.05) and more unscheduled visits to the emergency room (68%, p < 0.05). In addition, a lower level of BP control (46.8%, p < 0.05) was associated with higher levels of anxiety (52.3%, p < 0.05) in the group that performed non-oriented self-measurements of BP. Conclusion: The practice of non-oriented self-assessment of BP was associated with negative factors such as high levels of anxiety and higher frequencies of self-medication and unscheduled emergency visits.

[Who should provide diabetes care to elderly diabetic patients in long-term care homes?]

As a result of rapid aging, the number of elderly diabetic patients with decreased self-management ability in Japan is increasing. Currently, family members primarily perform self-injection at home and self-measurement of blood glucose for patients that require these procedures. Patients who cannot receive assistance from family members, will be admitted into long-term care homes. Due to the shortage of nurses in many long-term care homes, the homes can only accept a limited number of diabetic patients with decreased self-management abilities. There are two measures that may be considered: the first is to significantly increase the number of nurses; the second is to delegate diabetes care to non-medical and non-nursing care workers in long-term care homes. However, both options should be carefully considered before making a choice.

Reducing salt intake by urine chloride self-measurement in non-compliant patients with chronic kidney disease followed in nephrology clinics: a randomized trial.

BACKGROUND: Adherence to low salt diets and control of hypertension remain unmet clinical needs in chronic kidney disease (CKD) patients. METHODS: We performed a 6-month multicentre randomized trial in non-compliant patients with CKD followed in nephrology clinics testing the effect of self-measurement of urinary chloride (69 patients) as compared with standard care (69 patients) on two primary outcome measures, adherence to a low sodium (Na) diet (<100 mmol/day) as measured by 24-h urine Na (UNa) excretion and 24-h ambulatory blood pressure (ABPM) monitoring. RESULTS: In the whole sample (N = 138), baseline UNa and 24-h ABPM were143 ± 64 mmol/24 h and 131 ± 18/72 ± 10 mmHg, respectively, and did not differ between the two study arms. Patients in the active arm of the trial used >80% of the chloride strips provided to them at the baseline visit and at follow-up visits. At the third month, UNa was 35 mmol/24 h (95% CI 10.8-58.8 mmol/24 h; P = 0.005) lower in the active arm than the control arm, whereas at 6 months the between-arms difference in UNa decreased and was no longer significant [23 mmol/24 h (95% CI -5.6-50.7); P = 0.11]. The 24-h ABPM changes as well as daytime and night-time BP changes at 3 and 6 months were similar in the two study arms (Month 3, P = 0.69-0.99; Month 6, P = 0.73-0.91). Office BP, the use of antihypertensive drugs, estimated Glomerular Filtration Rate (eGFR) and proteinuria remained unchanged across the trial. CONCLUSIONS: The application of self-measurement of urinary chloride to guide adherence to a low salt diet had a modest effect on 24-h UNa and no significant effect on 24-h ABPM.

Reduced incidence of early preterm birth in the State of Thuringia following an intravaginal pH-self-monitoring screening program.

BACKGROUND: Effective prevention of preterm birth as cause of serious risks for the infant as well as the mother pre- and postpartum is one of the still unsolved problems in modern medicine. METHOD: The government of the State of Thuringia in cooperation with the professional organization of obstetricians and gynecologists decided in 2016 to reestablish and promote a self-care screening program based on intravaginal (i.vag.) pH measurement to reduce the incidence of preterm birth by early diagnosis and therapy of genital infection. RESULTS: Starting at zero in 2016, > 80% of pregnant women in the state had their vaginal pH monitored at the end of 2018 (n = 17.180). This was associated with a reduced incidence of early preterm birth measured by gestational week ≤ 32 (1.46 vs. 1.26%). CONCLUSION: The fourth millennium goal missed worldwide in 2015 as well as the newly declared third objective of the UN could come closer using the simple and cheap i.vag. pH-self-screening regime in prevention of preterm birth, an approach partly turning the woman from being object of medical care to being the subject in self-control of her pregnancy. This is also a well perceived change in paradigm from the perspective of females as well as physicians.

Home Blood Pressure Monitoring in Children and Adolescents: Systematic Review of Evidence on Clinical Utility.

PURPOSE OF REVIEW: For the accurate diagnosis and management of hypertension, out-of-office blood pressure evaluation using ambulatory (ABPM) or home monitoring (HBPM) is currently recommended. In children, there is considerable evidence on the clinical utility of ABPM, whereas the evidence on HBPM is limited. This systematic review presents (i) the benefits of HBPM in children; (ii) the evidence on normal range, diagnostic accuracy, and relationship with preclinical organ damage; and (iii) guidance for devices, monitoring schedule, and interpretation. RECENT FINDINGS: HBPM is a useful adjunct to the conventional office measurements for the evaluation of children with suspected or treated hypertension. HBPM is feasible in children and has good reproducibility, diagnostic accuracy and acceptability by users, and relatively low cost. Thus, it has greater potential for widespread and long-term use than ABPM, which is more expensive and often not available or not tolerated. Automated monitors that have been clinically validated specifically in children should be used with appropriate cuff size. HBPM for 7 days (minimum 3) with duplicate morning and evening measurements (minimum 12 readings) should be performed in children with suspected or treated hypertension before each office visit. Until more data become available, in case of diagnostic disagreement between office blood pressure and HBPM, treatment decisions should be based on ABPM. HBPM is clinically useful in children with hypertension. More research is needed on its clinical application, and more automated devices need to be clinically validated in this population.

Making sense with numbers. Unravelling ethico-psychological subjects in practices of self-quantification.

Prevention enthusiasts show great optimism about the potential of health apps to modify peoples' lifestyles through the tracking and quantification of behaviours and bodily signs. Critical sociologists warn for the disciplining effects of self-tracking. In this paper we use an empirical ethics approach to study the characteristics and strivings of the various types of 'ethico-psychological subjects' that emerge in practices of self-quantification by analysing how people and numbers relate in three cases of self-quantification: in prevention discourse, in testimonies from the quantified self (QS) movement and in empirical work we did with people with Diabetes type I and with 'every day self-trackers'. We show that a free subject that needs support to enact its will is crucial to understand the optimism about prevention. In the QS-movement the concern is with a lack of objective and personalised knowledge about imperceptible processes in the body. These subjects are decentered and multiplied when we trace how numbers in their turn act to make sense of people in our empirical study. We conclude that there are many different types of ethico-psychological subjects in practices of self-tracking that need to be explored in order to establish what good these practices of self-quantification might do.

[Who should provide diabetes care to elderly diabetic patients with decreased self-management skills?]

As a result of the rapid aging of society, the number of elderly diabetic patients with a decreased self-management ability in Japan is increasing. At present, family members primarily perform injection at home and measure the blood glucose levels for patients who require these procedures. However, as aging progresses and the birthrate further declines, it is expected that it will become difficult for such patients to receive assistance from their family members. Therefore, a discussion at the national level and development of urgent measures are required. In the future, the expanded involvement of those with medical qualifications and augmented multi-occupational collaboration-specifically, increasing the frequency of visiting nursing services, facilitating injections at home by pharmacists and making the most of "community-based integrated care systems", without major changes in the current legislation, will be foremost in reinforcing or taking the place of family members performing injections at home and measuring blood glucose levels. If cost is given the highest priority, injection at home and measurement of blood glucose levels by non-medical and non-nursing care workers seems to be the best option. However, careful deliberation is required.

Self-recordings of upper arm elevation during cleaning - comparison between analyses using a simplified reference posture and a standard reference posture.

BACKGROUND: To reduce ergonomic risk factors in terms of awkward and constrained postures and high velocities, it is important to perform adequate risk assessments. Technical methods provide objective measures of physical workload. These methods have so far mainly been used by researchers. However, if written instructions how to apply the sensors and how to adopt the reference posture are provided, together with triaxial accelerometers, it may be possible for employees to record their own physical workload. The exposure in terms of e.g. upper arm elevations could then easily be assessed for all workers in a workplace. The main aims of this study were: 1) to compare analyses for self-recording of upper arm elevation during work using a simplified reference posture versus using a standard reference posture, and 2) to compare the two reference postures. METHODS: Twenty-eight cleaners attached an accelerometer to their dominant upper arm and adopted a simplified reference according to a written instruction. They were thereafter instructed by a researcher to adopt a standard reference. Upper arm elevations were recorded for 2 or 3 days. Each recording was analysed twice; relative to the simplified reference posture and relative to the standard reference posture. The group means of the differences in recorded upper arm elevations between simplified and standard reference analyses were assessed using Wilcoxon signed ranks test. Furthermore, we calculated the group mean of the differences between the simplified reference posture and the standard reference posture. RESULTS: For arm elevation during work (50th percentile), the group mean of the differences between the two analyses was 0.2° (range -7 - 10°). The group mean of the differences between the two references was 9° (range 1 - 21°). The subjects were able to follow the instructions in the protocol and performed self-recording of upper arm elevation and velocity. CONCLUSIONS: The small difference between the two analyses indicates that recordings performed by employees themselves are comparable, on a group level, with those performed by researchers. Self-recordings in combination with action levels would provide employers with a method for risk assessment as a solid basis for prevention of work-related musculoskeletal disorders.

Efficient prevention of preterm birth as a primary political task-results of the Thuringia campaign 2017.

Prevention of preterm birth as a cause of serious risks for the infant as well as the mother is one of the still unsolved problems in modern medicine. The list of factors for miscarriage, prematurity and stillbirth is lengthy. The Thuringia preventional campaign 2017 offers an effective simple screening approach based on intravaginal pH measurement.

Blood Pressure Self-Measurement.

Blood pressure self-measurement has been used extensively as part of several clinical processes including in the home monitoring setting for mitigating white coat effect and gaining more detailed insights into the blood pressure variability of patients over time. Self-measurement of BP is also being used as part of telemonitoring and telemedicine processes, as well as in the waiting rooms and self-measurement rooms of general practice clinics, specialized hospital department's outpatient clinics, and in other types of care facilitates and institutions.The aim of this review is to provide an overview of where, when, and how blood pressure self-measurement is being used, which official clinical guidelines and procedures are available for its implementation, as well as the opportunities and challenges that are related to its use.

[Effect of a fixed-dose combination of perindopril arginine/amlodipine on the level and variability of blood pressure according to its office visit-to-visit measurements and self-measurements at home: A subanalysis of the PREVOSHODSTVO (SUPERIORITY) program]. / Vliianie fiksirovannoi kombinatsii perindoprila arginin/amlodipin na uroven' i variabel'nost' arterial'nogo davleniia po dannym izmereniia na prieme u vracha i samokontrolia: cubanaliz programmy PREVOSKhODSTVO.

AIM: To study the effect of a fixed-dose combination of perindopril arginine/amlodipine (prestans) on the goal levels and variability of blood pressure (BP) according to its office visit-to-visit measurements and self-measurement (OVVM and SM) in a subgroup of 483 people from the population of the Russian observational SUPERIORITY program, most cases of whom are given the combination replacing the previously ineffective mono- and combination antihypertensive therapy (AHT). SUBJECTS AND METHODS: The subanalysis included data on 483 patients (34% men) aged 57.9±10.8 years with uncontrolled hypertension, who were both untreated and treated with antihypertensive mono- or combination therapy using a free or fixed-dose combination of 2-3 antihypertensive drugs and in whom the physicians decided to use prestans to correct AHT. The follow-up period was 24 weeks. RESULTS: At the end of the investigation, the patients received prestans in the following doses: 5/5 mg (34% of the patients), 10/5 mg (39.5%), 5/10 mg (3.9%), and 10/10 mg (22%). In the analyzed patient group, the baseline BP was 160.8±8.8/92.6±7.4 mm Hg and dropped to 125.9±7.9/77.8±5.0 mm Hg at 24 weeks (p<0.001). According to SM, the morning BP significantly decreased from 147.0±13.3/85.6±7.2 to 127.5±8.3/78,9±5.6 mm Hg at 24 weeks (p<0.001). The evening BP readings showed the similar trends. Target BP was achieved in 93 and 78% of the patients, as shown by OVVM and SM, respectively. According to SCM, the day-to-day variability of BP significantly decreased from 5.1±3.2/3.4±2.3 Hg mm at Visit 2 to 2.7±2/0/2,3±1/5 mm Hg at Visit 5 (p<0.001). CONCLUSION: The use of the fixed-dose combination of perindopril arginine/amlodipine in hypertensive patients just at the beginning of treatment, by switching from insufficiently effective mono- or combination AHT to the fixed-dose combination of perindopril arginine/amlodipine, is an effective way to optimize AHT in clinical practice, which lowers the BP level and variability, as evidenced by both OVVM and SM.

Intra-rater reliability when using a tympanic thermometer under different self-measurement conditions.

[Purpose] This study investigated intra-rater reliability when using a tympanic thermometer under different self-measurement conditions. [Subjects and Methods] Ten males participated. Intra-rater reliability was assessed by comparing the values under three conditions of measurement using a tympanic thermometer. Intraclass correlation coefficients were used to assess intra-rater reliability. [Results] According to the intraclass correlation coefficient analysis, reliability could be ranked according to the conditions of measurement. [Conclusion] The results showed that self-measurement of body temperature is more precise when combined with common sense and basic education about the anatomy of the eardrum.

Effects of using a device for self-measurement of cervical ROM on neck pain of computer user.

[Purpose] The purpose of this study was to investigate the effects of using a device for the self-measurement of cervical range of motion on neck pain experienced by a computer user. [Subject] A 39-year-old male subject with neck pain caused by working on a computer was selected for the study. [Methods] The instrument was developed for the study, and that the instrument is used to self-measure cervical range of movement. The subject was trained in self-measurement procedures and a self-exercise program for two months, and pain was controlled through self-assessment and a program. The pressure pain threshold for the upper trapezius muscle, and cervical ranges of motion were measured prior to and after the 2-month period of pain control. [Results] At the conclusion of self-measurement and the self-exercise program, the pressure pain threshold was higher than the initial pressure pain threshold, and all cervical ranges of motion increased compared to the initial cervical ranges of motion. [Conclusion] This result shows that the self-management device for cervical ROM is an effective tool for pain management for computer users with cervical pain.

Diagnosis and treatment of resistant hypertension.

Hypertension resistant to lifestyle interventions and antihypertensive medications is a common problem encountered by physicians in everyday practice. It is most often defined as a blood pressure remaining ≥ 140/90 mmHg despite the regular intake of at least three drugs lowering blood pressure by different mechanisms, one of them being a diuretic. It now appears justified to include, unless contraindicated or not tolerated, a blocker of the renin-angiotensin system and a calcium channel blocker in this drug regimen, not only to gain antihypertensive efficacy, but also to prevent or regress target organ damage and delay the development of cardiorenal complications. A non-negligible fraction of treatment-resistant hypertension have normal "out of office" blood pressures. Ambulatory blood pressure monitoring and/or home blood pressure recording should therefore be routinely performed to identify patients with true resistant hypertension, i.e. patients who are more likely to benefit from treatment intensification.

Patient practices, perceptions, and barriers to self-measurement of blood pressure in a rural health system.

BACKGROUND: Self-measurement of blood pressure (SMBP) is endorsed by current guidelines for diagnosing and managing hypertension (HTN). We surveyed individuals in a rural healthcare system on practices and attitudes related to SMBP that could guide future practice. METHODS: : Survey questions were sent via an online patient portal to a random sample of 56,275 patients with either BP >140/90 mmHg or cardiovascular care in the system. Questions addressed home blood pressure (BP) monitor ownership, use, willingness to purchase, desire to share data with providers, perceptions of patient education, and patient-centeredness of care. Multivariable logistic regression was used to examine patient characteristics associated with SMBP behaviors. RESULTS: The overall response rate was 12%, and 8.4% completed all questions. Most respondents, 60.9%, owned a BP monitor, while 51.5% reported checking their BP at home the month prior. Among device owners, 45.1% reported receiving instructions on SMBP technique, frequency, and readings interpretation. Only 29.2% reported sharing readings with providers in the last six months, whereas 57.9% said they would be willing to do so regularly. Older age, female sex, and higher income were associated with a higher likelihood of device ownership. Younger age, lower income, and Medicaid insurance were associated with a greater willingness to share SMBP results with providers regularly. CONCLUSIONS: While a significant proportion of respondents performed SMBP regularly, many reported insufficient education on SMBP, and few shared their home BP readings with providers. Patient-centered interventions and telemedicine-based care are opportunities that emerged in our survey that could enhance future HTN care.

Feasibility of self-measurement telemonitoring using a handheld heart sound recorder in patients with heart failure - SELPH multicenter pilot study.

BACKGROUND: Multi-parametric assessment, including heart sounds in addition to conventional parameters, may enhance the efficacy of noninvasive telemonitoring for heart failure (HF). We sought to assess the feasibility of self-telemonitoring with multiple devices including a handheld heart sound recorder and its association with clinical events in patients with HF. METHODS: Ambulatory HF patients recorded their own heart sounds, mono­lead electrocardiograms, oxygen saturation, body weight, and vital signs using multiple devices every morning for six months. RESULTS: In the 77 patients enrolled (63 ±â€¯13 years old, 84 % male), daily measurements were feasible with a self-measurement rate of >70 % of days in 75 % of patients. Younger age and higher Minnesota Living with Heart Failure Questionnaire scores were independently associated with lower adherence (p = 0.002 and 0.027, respectively). A usability questionnaire showed that 87 % of patients felt self-telemonitoring was helpful, and 96 % could use the devices without routine cohabitant support. Six patients experienced ten HF events of re-hospitalization and/or unplanned hospital visits due to HF. In patients who experienced HF events, a significant increase in heart rate and diastolic blood pressure and a decrease in the time interval from Q wave onset to the second heart sound were observed 7 days before the events compared with those without HF events. CONCLUSIONS: Self-telemonitoring with multiple devices including a handheld heart sound recorder was feasible even in elderly patients with HF. This intervention may confer a sense of relief to patients and enable monitoring of physiological parameters that could be valuable in detecting the deterioration of HF.

Reliability of self-measurement of visual acuity in AMD patients with two electronic devices based on the ETDRS chart: A randomized study.

INTRODUCTION: Age-related macular degeneration (AMD) requires continuous visual acuity (VA) monitoring, increasing the burden on the health care system. Self-measurement VA tests are available on various devices. However, none of them have been based on an internationally validated benchmark chart, such as that of the Early Treatment Diabetic Retinopathy Study (ETDRS). The goal of this study was to assess the reliability of two digitized ETDRS charts adapted to two electronic devices for self-measurement of VA. MATERIAL AND METHODS: A prospective, single-center, 1:1 randomized, two-arm, parallel group trial was conducted. The main objective was to compare VA variation as conventionally measured on a 4-m ETDRS chart versus self-measured with digitized ETDRS charts in patients treated for AMD. At each visit, conventional measurement and patient self-measurement, either on a computer at 80-cm (arm 1) or on a tablet at 40-cm (arm 2), were performed. RESULTS: Eighty patients were included (25 men, 55 women, mean age 81.3±7.4 years). No significant differences were observed between VA variation, conventionally measured and self-measured on a computer (arm 1; P=0.914) or tablet (arm 2; P=0.913). CONCLUSION: These results confirm the reliability of these two methods for self-measurement of VA, and will lead to the development of a wider "telemedicine" project extended to self-measurement of VA in various pathologies.

Advances in Canaloplasty-Modified Techniques Yield Strong Pressure Reduction with Low Risk Profile.

For decades, trabeculectomy (TE) was considered the gold standard for surgical treatment of open-angle glaucoma owing to its powerful intraocular pressure (IOP)-lowering potency. However, owing to the invasive nature and high-risk profile of TE, this standard is changing, and minimally invasive procedures are becoming more preferable. In particular, canaloplasty (CP) has been established as a much gentler alternative in everyday life and is under development as a full-fledged replacement. This technique involves probing Schlemm's canal with a microcatheter and inserting a pouch suture that places the trabecular meshwork under permanent tension. It aims to restore the natural outflow pathways of the aqueous humor and is independent of external wound healing. This physiological approach results in a significantly lower complication rate and allows considerably simplified perioperative management. There is now extensive evidence that canaloplasty achieves sufficient pressure reduction as well as a significant reduction in postoperative glaucoma medications. Unlike MIGS procedures, the indication is not only mild to moderate glaucoma; today, even advanced glaucoma benefits from the very low hypotony rate, which largely avoids a wipeout phenomenon. However, approximately half of patients are not completely medication-free after canaloplasty. As a consequence, a number of canaloplasty modifications have been developed with the goal of further enhancing the IOP-lowering effect while avoiding the risk of serious complications. By combining canaloplasty with the newly developed suprachoroidal drainage procedure, the individual improvements in trabecular facility and uveoscleral outflow facility appear to have an additive effect. Thus, for the first time, an IOP-lowering effect comparable to a successful trabeculectomy can be achieved. Other implant modifications also enhance the potential of canaloplasty or offer additional benefits such as the possibility of telemetric IOP self-measurement by the patient. This article reviews the modifications of canaloplasty, which has the potential to become a new gold standard in glaucoma surgery via stepwise refinement.