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Tonometer
Tonometry refers to the indirect estimation of intraocular pressure by measuring
resistance of the eye to indentation by an applied force. A tonometer is an
instrument that exploits the physical properties of the eye to permit non-invasive
measurement of pressure without the need to cannulate the eye. At the crudest level,
palpation of the eyeball with the fingertips and estimating turgidity is a form of
tonometry. More accurately, and more safely, intraocular pressure is estimated with
a variety of instruments that mechanically deform the globe and relate intraocular
pressure to either the force required to deform the eye or the area of eye deformed
by the force.

Classification of most tonometers is according to how the eyeball is deformed:

indented or flattened. The prototype of the indentation tonometer is the familiar
Schiotz instrument, whereas tonometers that measure intraocular pressure by
flattening the cornea are known as applanation tonometers. Several applanation
tonometers are commercially available, but the recognized "gold standard" is the
Goldmann apparatus used by most American ophthalmologists. Represented in
neither of these classifications are the noncontact tonometers. These instruments
produce a jet of air that deforms the cornea, and the intraocular pressure is estimated
by the amount of time necessary to indent the eye.

History of Tonometer-

The link between ocular pressure and what was later identified as glaucoma seems
to have been recognised as far back as the 10th century AD by Al-Tabari an Arabian
surgeon. By 1622 Bannister was discussing the use of the fingers by the practitioner
to feel for the pressure. This is called palpation or (confusingly, given the other
modern meaning of the word) 'digital' tonometry.

Observation of the optic disc, via ophthalmoscopy, and the prospect of a surgical
‘cure’ by iridectomy, encouraged those who sought a means more effective than
palpation to test for glaucoma. Space does not permit an outline of all the various
diagnostic techniques developed in the late nineteenth and twentieth centuries but
we might say that from the 1880s Jannik Bjerrum was foremost in documenting the
defects in the visual field that are characteristic of glaucoma and can be detected
with the perimeter. Other techniques include gonioscopy (1918), by virtue of which
glaucoma came first to be defined in open and closed angle varieties, dynamometry
and the 1950s technique of tonography. The principal technique however has proved
to be tonometry.

In 1862 Von Graefe, a professor in Berlin, was the first to design an indentation
tonometer for testing the pressure of a seated patient’s eyeball and reading it off a

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scale. The instrument recorded the depth of indentation caused on the eye by a
known weight.

In 1865 Donders designed the first tonometer intended for use against the sclera, the
white part of the eye, and Priestley Smith would independently come up with
something similar in 1884.

Ernst Pflüger was a Bern ophthalmologist whose clinical work in the 1880s
concentrated on glaucoma. The incidence of glaucoma specialists is a notable
development. Pflüger’s thesis of 1871 had already dealt with tonometry, which can
thus be seen to have established itself as a primary technique. That said, even large
university clinics often lacked a tonometer and the tension of the eye was still most
often measured by pressing a finger onto it, with all the consequent risks of
infection.

Clinical Significance of Tonometry –

Glaucoma, characterized by elevated intraocular pressure, optic disk cupping and

atrophy, and loss of vision, is one of the three leading causes of acquired blindness
in the Western world. Tonometry is the fundamental screening test for detecting
elevated intraocular pressure. Prevalence figures for elevated intraocular pressure
vary with the screening level used, but all studies demonstrate increasing frequency
with each decade of life after the age of 40. Using a generally accepted screening
level of 21.9 mm Hg, the prevalence of intraocular hypertension exceeds 10% by the
sixth decade.

Intraocular pressure is a function of aqueous humor drainage from the eye. Formed
by the ciliary body located slightly behind and lateral to the lens, aqueous humor
flows between the iris and lens, through the pupil into the anterior chamber, and
drains out via the trabecular network and canal of Schlemm into the extraocular
veins at the rate of 2 to 3 μl/min. Resistance to free drainage is the primary
responsible mechanism maintaining aqueous humor volume and pressure. Studies
in normal individuals reveal that the mean intraocular pressure is 15.5 ± 2.5 mm Hg.
Unfortunately, for the sake of simplified risk assignment, the frequency distribution
of intraocular pressures is not Gaussian, but slightly skewed to the right so that the
95% confidence level extends to 28 mm Hg. However, 3.5% of patients with
intraocular pressures between 21 and 30 mm Hg have demonstrated visual field
losses within 5 years, and above 30 mm Hg, the frequency of visual field loss rapidly
increases. Thus, while the risk of glaucoma rises with increasing intraocular
pressure, individual eyes vary considerably in their ability to tolerate elevated
intraocular pressure, and glaucomatous vision loss is not necessarily associated with
even high levels of intraocular pressure.

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Elevated intraocular pressure produces blindness by its

effect on the optic nerve at the point where the nerve
bends to pass from the retina into the nerve head.
Nerve damage may be mediated through obstruction of
axoplasmic flow, but whether mechanical or vascular
factors are primarily responsible for the obstruction is
not known. Early recognition of optic nerve loss is
enhanced by knowing that the upper and lower
temporal areas of the optic disk are damaged first, and
loss of these axons can be clinically recognized as an
increase in the physiologic cupping of the optic disk.
Physiologic cupping is detected as a pale and depressed
area on the temporal side of the optic disk that is
attributable to an area devoid of nerve fibers. Loss of
axons secondary to glaucoma increases the vertical
Enlargement of the physiologic cup
length of the cup (Figure on right) and frequently
interiorly from the original cup margin.
results in asymmetry between the vertical length of
the cup between the two eyes. Additional clues to the presence of axonal loss are
pallor of the optic nerve head and disappearance of normal pink neuronal tissue
completely encircling the optic cup.

Two major dichotomous classifications of glaucoma are useful to the primary-care

physician: primary versus secondary glaucoma and open-angle versus closed-angle
glaucoma. Primary glaucomas occur without previous ocular or systemic disease.
Secondary glaucomas are the result of other conditions that can be considered
causative, such as ocular inflammation, trauma, diabetic neovascular formation,
corticosteroids, and occasionally tumors. Patients with secondary glaucoma are often
already established with an ophthalmologist and rarely pose a diagnostic problem to
primary physicians.

Primary glaucomas can be further classified as either open-angle or closed-angle,

referring to the angle that the iris assumes in relation to the cornea and trabecular
network (Figure below left). Primary open-angle glaucoma is the single type most
likely to be encountered by the primary-care physician, accounting for
approximately 90% of all glaucoma cases. Also known as chronic simple glaucoma,
primary open-angle glaucoma has a heritable tendency, and is probably due to
degenerative changes in the trabecular network that reduce the flow of aqueous
humor from the eye.

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The anatomy of the eye, comparing normal with A bedside technique for closed-angle glaucoma.
closed-angle glaucoma.

Closed-angle glaucomas are characterized by a shallow anterior chamber that forces

the root of the mid-dilated iris forward against the trabecular network, obstructing
the drainage of aqueous humor and thereby increasing the intraocular pressure. The
shallow anterior chamber is the anatomical clue to the presence of closed-angle
glaucoma. It can frequently be suspected by shining a light obliquely across the face
of the iris, which will illuminate most of the normal iris but only the proximal half of
the iris that is abnormally bowed forward (Figure above right). The diagnosis of
closed-angle glaucoma can be confirmed by an ophthalmologist using the technique
of gonioscopy, whereby a contact lens is placed on the cornea to help visualize and
measure the angle between the iris and cornea.

Types of Tonometers -
Tonometers can be broadly classified into:

1. Indentation tonometers:

Schiotz tonometer: IOP measurement is based on volume change before and after
placement. The schiotz tonometer was calibrated by Friedenwald, based on in-vitro
& in-vivo manometric studies in 1948. The scale readings are converted into IOP
values from the Friendenwald nomogram.

It is easier to use during mass screenings, less accurate and

variables like ocular rigidity, corneal thickness, variable
expulsion of intraocular blood etc. affect the reading.

 Schiotz tonometer:

Most primary-care physicians use the Schiotz tonometer

because of its ease of use and relative low cost; therefore, its
use and characteristics are described in greatest detail.

Before measuring the intraocular pressure, the Schiotz

tonometer needs to be calibrated and sterilized. Calibration
can be simply done by placing the footplate of the instrument

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on the rounded metal stand (the artificial cornea) provided with

the storage case. With the footplate resting on the stand, a
correctly calibrated instrument will have a scale reading of zero.
Following calibration, the footplate can be sterilized with a
flame, alcohol, or ether. Care must be taken to ensure that the
footplate is cool and dry before placing on the cornea.

Following preparation of the instrument, the patient should be

prepared. After a thorough explanation of the procedure, the
patient is asked to lie on the examining table with eyes fixed
upward on the ceiling. After applying a topical anesthetic to the cornea, such as 0.5%
proparacaine, the examiner gently separates the eyelids with the thumb and index
finger and applies the tonometer footplate directly on the cornea (Figure right). The
instrument must be held perpendicular to the eye to allow the plunger to move
freely, indenting the cornea. The degree of indentation is measured by movement of
a needle on a scale. Fine oscillations of the needle represent ocular pulsations,
indicating free movement of the plunger and good technique. The midpoint of the
needle excursion is taken as the pressure measurement.

The standard force on the plunger producing corneal indentation is a 5.5 g weight.
Globes with elevated intraocular pressure will be resistant to denting by the plunger,
resulting in inaccurate measurements. Three larger plunger weights are provided
with the instrument and, when added to the standard 5.5 g weight, increase the total
plunger weight to 7.5, 10, or 15 g. The extra weights should be used whenever the
pressure reading on the instrument scale is 4 or less.

Once the pressure readings have been taken, a standardized format for recording the
data is strongly recommended, which includes the scale reading, tonometer weight,
intraocular pressure, conversion table, and eye measured. A typical measurement
would be recorded as follows: 7/5.5 = 12 mm Hg (1955), O.D.

2. Applanation tonometers:

The Imbert-Fick principle: When a plane surface is applied to a flexible

sphere with a force (F) causing an area (A) to be flattened, the pressure
inside the sphere, Pt = F/A.

There are generally 2 types: Variable force & Variable area.

A. Variable force type (Constant area) applanation tonometers -

Contact Type:

o Goldmann Applation tonometer (GAT): It is considered to

be the gold standard and calibrated for 550µCCT.

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o Perkins tonometer: Hand held. Similar to Goldmann

tonometer
o Draeger tonometer: Hand held, Similar to Perkins. It uses an
optical element, a biprism. It needs flourescien staining. CCT
correction to be made to measured IOP.
 Mackay-Marg tonometer:
Electronically controlled plunger measures IOP; traced on a paper strip.
No optical element. Tonometers based on Mackay-Marg:

o Tonopen: portable, hand held. electronic strain gauge

readings converted into IOP values.
o Pneumotonometer: Pneumatically controlled sensing head.
No plunger.
Mackay-Marg type tonometers are less affected by corneal
irregularities, as they don’t have an optical element.
o Both are useful in corneal edema & scarring.
o Can also measure over soft / bandage contact lens.
o Can also measure on peripheral corneas.
B. Variable force type (Constant area) applanation tonometers -
Non-Contact Type
o Air-puff tonometer (Invented by Grolman): Optoelectronic
sensor measures light reflected from cornea, applanated by a
collimated jet of air. The time lag between various stages of
applanation is converted into IOP readings. Eg: Pulsair.
Advantages: No risk infection, no anaesthetic, can be used in
children and for mass screening
o Ocular Response Analyser (ORA): This air-puff tonometer. It
can measure the Cornea Compensated IOP (Independant of
corneal thickness), Goldmann Correlated IOP, Corneal
Rigidity Factor (Correlates well with corneal CCT) and
Corneal Hysterisis (Viscous damping property of
cornea). Eyes with low Corneal Hysterisis are more
susceptible to ONH damage from IOP fluctuations, due
to poor damping.

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C. Variable area (Constant force) type applanation tonometers – Contact Type:

o Maklakov tonometer: The area of cornea applanated by a known force is
measured. Dumbbell- shaped metal cylinders of different weights are
used. The diameter of the applanated area can be measured from the
imprint created by the contact with instrument. IOP read from a
conversion table. Displaces a large volume of fluid, affected by ocular
rigidity. less accurate but portable.

3. Non-applanating type, Contact tonometers:

o Dynamic Contour Tonometer: Measuring head matches the contour of

cornea. Hence, minimal or zero applanation. The appostional force of 1gm
is constant. It electronically measures IOP via a piezo-resistive sensor built
into measuring head. Not affected by corneal rigidity. Capable of
continuous IOP measurement. Slitlamp mounted instrument.

o Rebound tonometer: The rebound characteristics of a probe after its

momentary contact with cornea, like, deceleration, contact time etc. are
analysed through complex algorithms by a software to measure the IOP.
No topical aneasthesia required. Its calibrated for average CCT’s like the
Goldmann tonometer, hence affected of CCT. Handheld device. Can be
used in children and uncooperative adults.

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About Author:

Piyush Vrijlal Patel

Assistant Professor,

Biomedical Engineering,

Government Engineering College,

Sector-28, Gandhinagar-382028, Gujarat.

Biography:

Mr Piyush Vrijlal Patel was born in Gujarat, India in the year 1988. He received his
Bachelor of Engineering degree in Biomedical Engineering from Government
Engineering College, Sector-28, Gandhinagar, Gujarat, India (2009). He has
completed Masters of Engineering in Biomedical Engineering with Gold Medal from
Government Engineering College, Sector-28, Gandhinagar affiliated to Gujarat
Technological University, Ahmedabad. He has carried out his dissertation work on
‚Continuous Blood Pressure Monitoring system: A Non-Invasive Approach‛ based
on combination of Pulse Transit Time (PTT) and Vascular Unloading Technique
(VUT). He has successfully monitored continuous systolic, diastolic and mean
arterial blood pressure signals using minimal sensors; i.e. finger pressure cuff and
plethysmography sensor; on two fingers; and also statistically validated the results
showing correlation between SBP-PTT and DBP-PTT. He is currently doing his Ph.D.
under Dr. Utpal Pandya, HOD IC Dept., SCET, Surat at Gujarat Technological
University.
Mr Piyush has joined Biomedical Department, Govt. Engg. College, Gandhinagar in
the year 2010 as Assistant Professor, Class-II Gazetted Officer. He has published 9
research papers in International Journals and Conferences. He has attended more
than 12 Faculty Development Programmes of 1-2 week at various State and National
Institutes.

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