Clinical Optometry Practice: Tonometry

features glaucoma Normal range of IOP notes

Objective measurement Silent thief of sight Average: 15.5 mmHg Simple applanation devices
of intraocular pressure • First introduced in 1867
(IOP) Most common form is Normal range: 10-22 • Based on principle that two
• Based most painless and insidious mmHg (Moses, 1975) spheres in contact with one
commonly on the in its destruction of another share a flat surface only
force required to visual field IOP is not constant within if the internal pressures of the
flatten the cornea an individual spheres are identical
• Degree of corneal Defined by triad of: • Arterial pulse: 2-3 o Flatten a small area of the
indentation produced • High IOP mmHg central cornea and measure
by a fixed force • Optic nerve • Erect or supine the amount of force required
Has been performed damage position of px: 2-4
since the latter part of the • Loss of visual mmHg Impression/Indentation Tonometers
19th century field • Time of day: 5 • Involves a weighted free-
mmHg moving plunger that indents
Used to assist in the Early detection by rather than flattens the cornea
diagnosis of glaucoma tonometry • Data is then translated into IOP
readings
Can be divided into those • Perfected by Schiotz in 1905
instruments that • Elevated the IOP significantly
applanate (flatten) and and are influenced by scleral
those that indent the rigidity
cornea o Via weights and a
nomogram, a reasonably
accurate determination of
IOP can be done
• Time consuming compared with
applanation tonometers that are
internally calibrated and easier
for the patient and clinician
Goldmann Applanating Device
Contemporary standard for applanation tonometry
features procedure interpretation
Based on Imbert-Fick Law Fluorescein + local anesthetic is applied to the eye Tonometer is too low
• A perfect sphere has its topically
internal pressure equally • Anesthetic maintains patient comfort
distributed and that the • Patient is in primary gaze
external force needed to • Dial is preset between 1 and 2
flatten a known area of
that sphere is directly Fluorescein spreads into the tear film and forms a Tonometer is too close
proportional to the meniscus surrounding the area of contact between the
internal pressure of the probe tip and corneal surface
sphere
• Intraocular pressure is Tangential to the probe is the light source, with a cobalt Too much fluorescein
equal to the tonometer blue filter in place
weight divided by the
applanated area Clinician views the illuminated probe through the
microscope
assumes that the eye is a
perfect sphere A circular field shows two faint white arcs that indicate
proximity to the patient’s cornea Too little fluorescein
Area of contact between the • Grossly center these two arcs
tip of the tonometer and the
cornea is constant When the probe tip touches the cornea
• Two yellow-green glowing semicircles are seen
Force required to maintain • Semicircles represents the doubled image of the
the contact area is converted circular applanated area Advantages
into millimeters of mercury Clinician adjusts the force applied to the globe 1. Gold standard for IOP
(mmHg) • Inner limit of the fluorescent meniscus has been measurement
doubled by the fixed prism 2. Accurate & precise
Measures the force needed • Diameter of the contact area is at 3.06mm
to flatten a 3.06mm Disadvantages
diameter circular area of the Fluorescence is visualized by using cobalt-filtered 1. Only provides valid
cornea to provide a measure illumination of the flat end of the Goldmann probe as it measurements for
of the pressure in the eye rests against the corneal surface corneas with near
o Diameter chosen average thickness
because it was found Tension dial is adjusted so that the inner edges of the - Thick corneas, IOP
that at such a diameter, semicircles become coincident overestimated
the surface tension • Thickness of each semicircle should be - Thin corneas, IOP
attraction of the probe approximately 1/10 of the diameter underestimated
was equal and opposite • Too thick semicircles, IOP is overestimated 2. Cornea is anesthesized
to the force required to • Too thin, IOP is underestimated 3. Needs a slit lamp but a
counteract corneal handheld version has
• Calibrated in grams, with each gram of force
rigidity for an average been developed
equivalent to 10mmHg IOP
thickness cornea
notes disinfection Potential errors
Corneal curvature may Wipe the probe clean and Inappropriate fluorescein pattern
influence the reading soak the tip in • Resulting from excessive fluorescein will make the
• Measurement of IOP • 1:10 dilution of semicircles too thick and the radius too small
in eyes with corneal household bleach • Insufficient fluorescein will make the semicircles too
astigmatism exceeding • 3% hydrogen peroxide thin and the radius too large
4D should be made • 70% ethanol or Pressure on the globe
approximately 45 isopropanol • By the examiner or the patient squeezing the eyelids,
degrees from the • Accomplishes high- and restricted EOM may result in an artificially high
flattest meridian level disinfection reading
• Alcohol soaks cause
rapid damage to the Cornea edema
probe • May result in artificially low IOP by as much as 10
mmHg compared with the true pressure
Reducing the risk of cross
infection
• Avoiding tonometry in
individuals with overt
infection
• Using a disposable
sleeve which covers the
tip of the tonometer
• Swabbing the tonometer
tip thoroughly with an
alcohol prep pad and
allowing it to dry for
approximately 10
minutes
features
Local anesthetic is used
Patient’s head is reclined
Practitioner applies the
tonometer to the corneal
apex
• Simple mechanical
device that employs
weight to press a
freely moving plunger
against the cornea,
indenting it
Reading taken has a scale
value that is translated into
an IOP reading using a
nomogram
• Calculated on the
basis of average
scleral rigidity
• Readings obtained
using standard 5.5g
weight
Three readings taken for
more accurate measurement
• Hydrogen peroxide is
less destructive than Corneal thickness
diluted bleach • If the cornea is thinner, underestimation of IOP may
• Most wipe with alcohol result and if thicker, an overestimation
swab • Individuals with ocular hypertension tend to have
corneas thicker than normal; normal-tension
glaucoma tend to have thinner corneas
Incorrect calibration
• Can result in an incorrect reading
• Check the calibration at regular intervals
Other factors
• Tight collar, which obstructs venous return and
causes IOP to rise
• Anxiety
Schiotz (indentation) tonometer
procedure Advantages n dis notes
1. Patient must be reclined Advantages Cleaning
2. Drop of anesthetic 1. Portability • Entire instrument
instilled to both eyes 2. Reduced cost must be cleaned to
3. Instruct patient to open compared to Goldmann avoid spread of
both eyes and look at tonometer infection
the ceiling (inexpensive) o Isoprophyl
4. Hold gently the patients 3. Autoclavable alcohol
eye lids apart anchoring instrument o Steam
them against the orbital sterilization
rim Disadvantages o Noncorrosive
5. Gently lower the 1. Cornea is anesthetized chemical
tonometer on the 2. Accurate data is disinfection
patient's eye (foot plate difficult to obtain • Disassemble prior to
rest on the center of the 3. Due to repeated cleaning
cornea) indentation of the • Dry thoroughly on a
6. Take the reading 3 times cornea sterile pad
and get the average - Clarity may be • Reassemble in reverse
disrupted order
4. Supine position of the
patient may influence Calibration
IOP • Checked by resting
5. Indentation of the the tonometer
cornea forces aqueous perpendicularly on the
from the anterior test block
chamber • Needle should
- Underestimation of indicate zero
IOP with successive
readings
 • If it does not, a small
screw at the base of
the needle can be
loosened to rezero the
needle. Don’t bend the
needle

Other tonometers
Non-contact tonometers
Features Advantages n dis interpretations
Based on the principle of applanation Advantages Too close to px
but instead of using a prism, the 1. No disinfection necessary
central part of the cornea is flattened 2. No topical anesthesia required
by a jet of air 3. Easier to perform

Time required to sufficiently flatten Disadvantages

the cornea relates directly to the level
of IOP
Instrument is easy to use and does not
require topical anesthesia
Main advantage is that it is accurate
only within the low to middle range
Jet of air can startle the patient both
with its apparent force and noise
1. More expensive and less portable Too far from the px
2. Accurate reading depends on precise
alignment of targets with patient’s eye
- Can be used for screening
- For high, unequal or increased IOP, use
GAT
3. Distance of device from corneal apex is
critical Focused
- Not for uncooperative patients
4. Can overestimate the IOP compared with
Goldmann technique

May be non-portable or portable

Features
Hand-held, self-contained
battery powered, portable
contact tonometer
Probe tip contains a
transducer that measures
the applied force
Microprocessor analyses
the force/time curve
generated by the transducer
during corneal indentation
to calculate IOP
Tono-pen
Calibrating procedure notes
1. Hold the instrument 1. Anesthetic in both eyes Common errors
with the tip down, the 2. Px is instructed to look • High IOP because of
black button is quickly straight ahead and keep patient apprehension
pressed twice both eyes open • Pressing on the globe
2. CAL will appear on the 3. Button is pressed once while holding the
window to activate the eyelids open
3. The button is depressed instrument. (beep • Too tight shirt collars
once, after a few sound) • Patient holding their
seconds, UP will appear 4. Tip is repeatedly breaths
4. Instrument is then touched to the cornea • Repeating the
inverted with the tip up. 5. Ask the patient not to applanation
GOOD or BAD will move their eyes o Reduces IOP due to
appear tonographic effect
5. Calibration check
should be done only at
Correlates well with
Goldmann tonometry day
although it slightly
overestimates a low IOP
and underestimates a high
IOP
Main advantage involves
the ability to measure IOP
in eyes with distorted or
edematous corneas as well
as through a bandage
contact lens
the beginning of each Advantages
1. Portable
2. Patient can be sitting
up or lying down
Disadvantages
1. Less stable than slit
lamp mounted
instrument
2. Does not allow for
examining the cornea
before and after the test

Other other tonometers

APPLANATION TONOMETER
Goldmann
• GAT Disadvantages
• Standard method for measuring IOP • High level of skill to operate
• Measurement of the force required to compress the • Inability to measure in supine patients
cornea over a given area • Need for topical anesthesia
• Topic anesthetic + Fluorescein dye + Cobalt blue • Decreased accuracy on an irregular or scarred
filter cornea
Perkins applanation tono
• Hand-held tonometer Disadvantages
• Same mechanism of applanation as the Goldmann • High level of skill to operate
• Portable • Decrease in stability with a handheld
• Useful in settings where a slit lamp is not instrument
feasible • Need for topical anesthesia
• Can be used in uptight or supine patient • Decreased accuracy on an irregular or
scarred cornea
Non-contact tonometer
• Also known as “air puff” tonometer Disadvantages
• Use a small puff of air directed at the cornea • Less accurate method than GAT
• Returning air from the surface of the cornea is
measured by a membrane that records the force,
converted to IOP
• No topical anesthesia needed
• Useful for children and adults unable to tolerate
contact methods
Ocular response analyer (ora)
• Non contact tonometer • Designed to improve IOP accuracy
• Utilizes a column of air as the applanating force to • Allows clinicians to account for the
deform the cornea variability in corneal biomechanical
• Based on the force of airflow and the rate of properties seen among patients
recovery from deformation • Disadvantage
• Corneal hysteresis • Cannot be used on supine patients
• Ability of the cornea to absorb and
dissipate applied forces based on its
viscoelastic properties
INDENTATION TONOMETER
Tono-pen indentation/applanation tonometer
• Electronic hand held device that uses a small Disadvantages
plunger to record the force needed to applanate the • Requires daily recalibration
cornea • Topical anesthesia required
• Averages multiple readings of this small force
converted to IOP
• Useful in portable screenings
• Ability to measure over soft CL, on an irregular
corneal surface
• Potential to measure at peripheral cornea
• Patient can be supine or upright
Pneumatonometer
• Uses a stream of air to indent the cornea with a Disadvantage
5mm diameter silicone tip • Hand held probe attached to a table
• Force of air that indents the cornea is recorded and mounted device
converted to IOP
• Can measure irregular cornea surfaces, over soft
CL, at the peripheral cornea
• Patient can be supine or upright
Schiotz tonometer
• Portable tonometer Disadvantages
• Consists of a weighted plunger attached to a • Patient must be supine
footplate positioned on a cornea • Topical anesthesia is required
• Weights are stacked onto the probe to cause
depression of the cornea
• Number of weights stacked onto the probe
correlates to a calibrated IOP
REBOUND TONOMETER
I-care tonometer
• Portable Disadvantages
• Simple to use hand held device using a small • Cannot be used on supine patients
probe that bounces off the cornea in the horizontal • Accuracy decreases in the setting of
plane corneal edema
• Deceleration of the probe produces a level of
voltage that is converted to IOP
• The faster the rate of deceleration against the
cornea, the higher the pressure
• No anesthesia required
• Patients who are not tolerant of contact methods
DYNAMIC CONTOUR TONOMETER (DCT)
 Pascale DCT
• Utilizes a contour-matched, piezoelectric sensor to Disadvantages
measure minuscule dynamic pulsations in IOP at • Requires topical anesthesia
the cornea • Less accurate on irregular corneas
• Allows measurement of IOP without deforming
the cornea
• Readings are independent of corneal thickness
• More accurate method on regularly shaped corneas