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GLAUCOMA IS ONE of the worlds
leading causes of blindness. Intraocular
pressure (IOP) is an important criterion
for decision-making in both the screening
and management of this disease.
In practice, measurement of the IOP
is by tonometry. The force required to
applanate or flatten the outer coat of the
eye is the basis of applanation tonometry.
A true measure of IOP can only be
obtained using manometric methods
which require a probe to be inserted
directly into the anterior chamber.
Tonometry has evolved a long way
from the days of digital palpation and
the indentation tonometers, developed
in the late 1800s
1
(see Figure 1). Most
instruments now use the basic principle of
applanation tonometry, a method derived
from the Maklakov-Fick law, alternatively
known as the Imbert-Fick law.
IMBERT-FICK LAW
The Imbert-Fick law states that pressure
is equal to the force per unit area of
applanation for a spherical container,
assumed to be infinitely thin, dry and
perfectly elastic in form.
The cornea is, however, a rigid structure
which has an average thickness of 540m,
and a tear-moistened outer surface.
Nevertheless, by selecting a circular
zone 3.06mm in diameter the smallest
area of applanation (7.35mm
2
) is attained
while still giving accurate results,
introducing a relative error in IOP of only
2.5 per cent.
This is due to the balance between
the four forces acting on the cornea on
applanation:
Force of probe + Tear capillary action
= IOP + Ocular rigidity
Furthermore, once the density of
mercury (13.6g/cm
3
) is considered in the
final calculation, an easy conversion is
produced in which 1g of weight equates to
10mmHg of pressure.
Contact applanation
tonometry
Successful participation in each module
counts as one credit towards the GOC CET
scheme administered by Vantage and one
towards the AOIs scheme.
Priya Dabasia reviews the correct use of contact tonometers
and some modern contact and non-contact alternatives
(Module C3467, one standard point)
CONTACT APPLANATION
TONOMETRY
The two main contact applanation
tonometers used in the UK are the
Goldmann and the Perkins, which
use the basic principle of varying the
force applied to applanate a fixed area.
The basic instrumentation consists of a
flat applanating cone comprised of two
prisms with apices joined together. Its
main advantage over the first mechanical
indentation designs is the reduction
in induced aqueous outflow known as
ocular massage. Research has shown
there to be a maximum volume displace-
ment of 0.50mm
3
which has minimal
effects on the IOP.
Goldmann tonometry
This technique should only be performed
on completion of all other clinical tests
including refraction, as softening of
the cornea by anaesthesia in addition
to potential corneal abrasions can
cause blurred vision. Only dilation is
recommended post-Goldmann as the
softening action permits increased
absorption of the mydriatic across the
corneal surface.
1) The instrument should be calibrated
regularly depending on usage. The
Goldmann is mounted onto the slit lamp
with the cone in position. A calibration
key comprising a metal rod with three
grooves is inserted into the main body
of the instrument (Figure 2). The central
groove of the key is initially aligned with
the marking of the attaching device; in
this arrangement the tonometer cone
should rock forward at a weight of 0g.
The key is then moved towards the
Applanation
Indentation
(eg Schiotz)
Ocular
Response
Analyser (ORA)
Pascal DCT
Tonometers
Contact
Non-contact (eg
NT-3000, Pulsair)
Fixed weight, variable
area (eg Maklakoff)
Fixed area, variable
weight (Goldmann,
Perkins, Tonopen)
Dynamic Static
FIGURE 1. Summary of tonometer types
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practitioner aligning the second (2g) and
third (6g) groove, repeating the same
procedure in turn. The instrument must
be sent for re-calibration if any non-linear
error or a linear error outside +/- 2.5mmHg
is recorded.
4

2) Ascertain any contraindications to
contact tonometry such as previous adverse
reactions to anaesthetic drops. The practi-
tioner must wash their hands thoroughly
using antibacterial soap. Further prelimi-
nary checks include the assessment of
visual acuity and corneal integrity, using
the slit lamp biomicroscope. Initially, a
wide parallelopiped with moderate to high
magnification is used, followed by a more
detailed examination using fluorescein
under cobalt blue light. Contact tonometry
is inadvisable if any signs of infections or
abrasions are found, as direct contact with
the eye inevitably risks further damage
even when conducted by an experienced
practitioner.
3) Non-disposable tonometer cones
must be disinfected according to College
of Optometrists or ABDO guidelines to
prevent any risk of transmitting HIV,
vCJD or Hepatitis B. All have been
isolated in the tear film. It is advisable
to rinse the disinfected cone with saline,
before leaving it to air dry to prevent
any residual disinfectant causing a
toxic reaction. Alternatively, disposable
Tonosafe cones are available to use
with both the Goldmann and Perkins
tonometers, although at increased
expense (Figure 3).
4) The tonometer probe is inserted into
the main instrument body with prism
aligned horizontally, taking care not
to touch the sterile cone surface. This
can either be approximated visually, or
checked by aligning the white line of
the probe carrier with the 0/180 marking
of the body when using non-disposable
cones. However, if the corneal astigmatism
is 3DC or above, an elliptical applanation
area larger than 7.35mm
2
is produced,
leading to an IOP error of at least
1mmHg.
5
This is avoided by rotating the
prism 43 to the flattest corneal meridian.
Since the separation between white and
red markings of the probe carrier is 43,
the red marking simply needs to be
aligned with the prism for with the rule
or against the rule astigmatism.
5) One drop of anaesthetic (such as
benoxinate 0.4 per cent, or a combina-
tion such as proxymetacaine 0.5 per cent
with fluorescein) is instilled into the lower
conjunctival sac. Allow approximately 30
seconds for the drops to take effect, taking
this time to record the drug name, expiry
CONTACT APPLANATION TONOMETRY
FIGURE 2. Calibration rod
positioned such that
6g of force is needed
to move the probe
forward

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date, dose, batch number and time of
instillation on the record card. The
corneal sensitivity can be checked using
either a sterile wisp of tissue or preferably
a wetted fluoret strip at the limbal edge.
6) The Goldmann is mounted onto the slit
lamp via a foot plate with two grooves. The
procedure is conducted through only one
eyepiece depending on whether the left or
right groove is used. Setting the base into
the nasal groove is advised as it compen-
sates for convergence of the eye. Initially,
the force is set to an average reading
13mmHg,
6
as this reduces contact time
with the cornea and prevents vibration of
the probe. The slit lamp is set to maximise
the light illuminating the cone head:
Wide angle of illumination (60)
High illumination to account for light
absorbance through cobalt blue filter
Widest beam width and height
Low to moderate magnification (10-
16X).
7) Applanation is initially attempted
without manipulating the lids as the
patient stares at a fixation target straight
ahead. If this is unsuccessful, the practi-
tioners free hand is used to carefully
part the lids using the forefinger to hold
the upper lid against the superior orbital
ridge and the thumb to draw the lower
lid down, taking care not to press on the
globe and cause a change in IOP.
8) The slit lamp is carefully advanced to
bring the cone within 2-3mm of the central
cornea. Final contact is made using the
joystick for fine control. This will cause a
slight backward tip of the cone and create
FIGURE 3. Tonosafe
disposable cone in
position
FIGURE 4. Goldmann dial this should be
set as close to the expected measurement
as possible to minimise movement during
contact (in this case 1.6g)
CONTACT APPLANATION TONOMETRY
FIGURE 5. Schematic
representation
of a variety of
appearances of the
meniscus rings; (a)
the ideal alignment,
(b) more force
needed, (c) too much
force used, reduce
force, (d) move cone
upward, (e) move
cone downward (f)
wait for fluorescein
to drain
(a)
(b)
(c)
(d)
(e)
(f)
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ment) with cone in position. Initially,
calibration is checked with no weight in
place (0g), and then free weights of 2g
and 5g are placed in turn onto the cone
head. Correct calibration results in the
cone rocking forwards on reaching the
equivalent reading on the dial.
2) Follow Steps 2, 3 and 5 as for
Goldmann procedure. Perkins can be
conducted with the patient supine or
seated upright. Extend the instrument
headrest setting it firmly on the patients
forehead using the two middle fingers of
your free hand. Use the thumb of this
hand to lift the patients upper lid as
required (Figure 6).
3) Advance the cone carefully towards the
eye, with the patient fixating a target just
above the straight ahead position. Ensure
the rings are the correct thickness and
equal in size, making any minor adjust-
ments off the cornea, before reaching the
final endpoint using the same principles
as Goldmann (see Step 8).
4) Follow post-applanation Steps 9 and
10 as with Goldmann.
NON-CONTACT TONOMETRY
Although Goldmann tonometry
is considered the gold standard
tonometer, most general practices in the
CONTACT APPLANATION TONOMETRY

a circumferential fluorescein limbal glow.

An image of two horizontally separated
semicircular rings should now be seen
through the eyepiece. The ideal thickness
of each ring is 1/10th of the arc diameter; if
the rings are too thin or thick, the pressure
can be underestimated or overestimated
respectively. The cone position may also
need to be altered to ensure that the rings
are equal in size, always moving the cone
towards the larger ring, with the cone
slightly off the cornea to avoid trauma for
large movements.
The practitioner should ensure they
have located the dial on the Goldmann
base unit which alters the force applied
prior to applanation (Figure 4). This force
is varied to alter the ring separation until a
final endpoint is reached, where the inner
rings just touch (Figure 5). If the rings
are separated too far, the force must be
increased and vice versa.
The fluorescein rings can commonly
be seen to pulsate with the venous pulse.
In such cases, the force is either adjusted
so pulsation occurs equally either side
of the endpoint, or an average reading of
the highest and lowest point of the pulse
is taken.
9) Retract the cone off the cornea and
gently release the lids. Record the final
result along with the time, instrument
name and eye applanated. Only one
accurate reading is required per eye
as the increased corneal contact time
accounts for any variation of IOP with the
cardiac cycle.
10) Re-check the corneal integrity.
Assess the severity of any staining and
manage accordingly by rinsing the
fluorescein from the eye using sterile
saline minims, and advising prophylactic
antibiotics/ocular lubricants as necessary.
Ideally, the patient should not leave the
practice until corneal sensitivity has been
sufficiently regained. Advise the patient
to avoid rubbing the eyes and protect
from foreign bodies for at least another
half hour. A written sheet of information
of potential side effects and subsequent
action to take should ideally be given to
the patient.
PERKINS TONOMETRY
The Perkins tonometer is essentially
a handheld version of the Goldmann.
It has an internal illumination system
making it perfectly portable and ideal
for domiciliary visits, or patients with
mobility difficulties.
1) Calibration should be checked
regularly depending on usage, employing
a similar procedure to Goldmann (see
Step 1). The instrument (with battery
pack removed) is set horizontally on
a metal rest (supplied with the instru-
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UK use non-contact tonometry (NCT).
While initial costs of NCTs are high,
they are quick, easy to use and less
invasive, and can therefore be delegated
to non-optometric members of staff
who have received adequate training.
Multiple readings are, however, required
to average out variations of IOP with the
cardiac cycle. The vast array of models
available commercially is so great that
it is impossible to cover them all in this
article. Nonetheless a summary of three
widely known NCTs can be seen in
Table 1.
All three NCTs employ the same basic
principle in which a jet of air is used to
applanate the central cornea. The point
of applanation is assessed using an infra-
red, electro-optical system in which a
collimated beam of light is directed at the
cornea from an oblique angle. Complete
applanation is reached when maximum
reflected light is received by a photore-
ceptor diode:
1) Once the patient has been seated
comfortably, check instrument calibration
while demonstrating the air puff on the
patients hand. This also clears any dust
particles from the nozzle.
2) Ask the patient to close their eyes
while the instrument is locked into
position 1cm from the upper lid using
the stopper safety device.
3) Ask the patient to blink between
readings to re-moisten the anterior surface.
Record the individual and final average
IOPs, time of day and instrument name.
Take care to avoid hitting the patients nose
when moving between eyes by pulling the
instrument back sufficiently.
RECENT DEVELOPMENTS
The accuracy of Goldmann has been
called into question over recent years as
many studies have shown biomechanical
features of the cornea such as thickness,
rigidity and hydration to have a significant
effect on IOP readings.
Goldmann was originally calibrated
for an average corneal thickness of
545m,
8
but, in reality, thickness can
vary greatly in the normal population. A
thicker cornea requires a greater force to
applanate a given area, thereby producing
a higher IOP. Conversely, a thinner cornea
will produce an underestimation. The
importance of corneal thickness has been
highlighted by the recent increase in
refractive surgery procedures.
A study conducted by Ehlers in the
1970s revealed an underestimation of
7mmHg with every 100m reduction in
corneal thickness.
9
Thus, greater care
needs to be taken in patients following
refractive surgery correction of refractive
error of -3.00DS removes 30m of tissue,
underestimating the IOP by approxi-
mately 2mmHg.
10

So the question arises, Should
pachymetry be conducted in everyday
practice? The search for answers has
CONTACT APPLANATION TONOMETRY

TABLE 1. Summary of three well-known non-contact tonometers

7
Keeler Pulsair Nidek 3000 Reichert Mk II*
Range of IOP measured 4-59mmHg 0-60mmHg 0-99mmHg
Basic principle of IOP
measurement
Pressure of air puff on
complete applanation
Pressure of air on full
applanation
Time taken for full
applanation
Number of readings
required
4 3 3
Calibration reading 30 +/-1mmHg and 50
+/-1mmHg on pressing
demo switch
Pressure check OK
shown on CCTV
65mmHg when machine
is switched on and 50+/-
1mmHg on pressing demo
switch
Other features Reasonably portable;
can be conducted with
patient sitting upright or
supine
Ramped velocity
puff stops on complete
applanation
CCTV image of eye
APC (air puff control)
strength of puff is reduced
according to force of first
applanation
Auxillary lenses to ensure
good fixation
Poor patient comfort due
to strong puff (no APC)
* This has now been superceded by the Reichert AT555 NCT, or the hand-held Reichert PP100 both of which have a
0-99mmHg measurement range
FIGURE 6. Perkins being
positioned just prior to
applanation
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MULTIPLE-CHOICE QUESTIONS
Module C3467 To take part in this CET module go to www.opticianonline.net
and click on the Continuing Education section. Successful participation counts
as one credit towards the GOC CET scheme administered by Vantage and
one credit towards the Association of Optometrists Irelands scheme.
1 Which of the following may give an
apparently higher IOP reading for a
contact tonometer?
A Tear surface tension
B Lasik
C Ocular massage for one minute
D Thicker than average cornea

2 Which of the following statements is
correct?
A Contact tonometers cannot be used if
a linear error of 1.5mmHg is found on
calibration
B Air puff control is a new feature of NCTs in
which the air jet ceases on full applanation
C NCT readings are only considered reliable
in the low to moderate IOP range
D Ocular response analyser is a new
tonometer which requires corneal
anaesthetic
3 Which of the following could result in
a falsely high IOP reading when using
contact tonometry?
A Applying pressure to the superior orbital
ridge when lifting the patients upper lid
B Too much fluorescein in the eye on
applanation and corneal thickness of
540m
C Too little fluorescein in the eye on
applanation and corneal thickness of
520m
D Rotating the prism 43 degrees to the
flattest corneal meridian
4 Which of the following statements is
incorrect?
A Corneal hysteresis is an indication of
corneal elasticity
B The ICARE is a contact tonometer which
requires no corneal anaesthetic
C The Pascal is programmed to take 50
readings per second
D The ORA pushes the cornea flat twice per
reading cycle
5 Which of the following statements is
true about the Imbert-Fick law?
A It states that the pressure is directly
proportional to the force of applanation
per unit area
B It assumes an elliptical container is
applanated to be perfectly dry
C It assumes that the container applanated
has finite thickness
D It states that the force is inversely
proportional to the pressure per unit area
of applanation
6 Which of the following statements is
true about the Perkins tonometer?
A Uses the principle of variable area, fixed
weight applanation
B Is a form of static contact tonometry
C Uses the principle of contact indentation
tonometry
D Is a form of dynamic contact tonometry
The deadline for response is April 6
led to the development of a new genera-
tion of dynamic contact tonometers
which assess and compensate for corneal
biomechanics.
Tonopen
The Tonopen is a portable, electronic
contact tonometer with a stainless steel
probe transducer which measures the
force applied for full applanation.
Results correlate well with Goldmann,
with minor overestimations of lower
IOPs and under-estimations of higher
IOPs. Although Tonopen uses traditional
static applanation principles, studies
suggest that it gives a truer reading of IOP
when applied to the peripheral cornea in
eyes which have undergone refractive
surgery.
11
Ocular Response Analyser
The Ocular Response Analyser (ORA) is
a dynamic contact tonometer, which uses
a collimated air pulse to flatten the cornea
to full applanation and then beyond into
concavity, creating a second applanation
event once the air shuts off.
The force required for repeated
applanations is measured and displayed
in graphical form. The figures are used to
calculate the IOP, and give an indication
of corneal elasticity known as corneal
hysteresis.
12
ICARE
The ICARE is a portable contact
tonometer which also uses rebound
technology, but unlike the ORA it
requires no anaesthetic. The probe
momentarily touches the cornea, applying
such a light force that it barely elicits a
corneal reflex.
13
Pascal
The Pascal dynamic contour tonometer
is a slit-lamp-mounted device similar in
design to the Goldmann. Instead of a
flat cone, the Pascal has a curved head
to match the corneal contour, thereby
reducing distortion on applanation.
It compensates for ocular blood flow,
measuring IOP along the whole course
of the pulse amplitude, gathering 100
readings per second.
CONCLUSION
While NCT results correlate well with
Goldmann in the low to medium IOP
range, this relationship breaks down
with higher readings, particularly over
30mmHg. It is therefore advisable to
repeat any high or asymmetrical measure-
ments with Goldmann before making
final clinical decisions.
Although it is still early days for the
ORA and Pascal, their potential use
as clinical tools in decision making for
glaucoma referrals is substantial. Further-
more, the prevalence of glaucoma is
expected to increase with life expectancy,
placing heavy demands on our health
system, making quick and accurate
detection is essential.
References
1 www.medcompare.com/spotlight.asp?spotlight
id=185&headerid=0
2 Doshi S, Harvey W. Investigative Techniques and
Ocular examination, 2003; p64, (London: Butter-
worth-Heinmann).
3 Doshi S, Harvey W. Investigative Techniques and
Ocular examination, 2003; p64, (London: Butter-
worth-Heinmann).
4 www.evidence-based-eyecare.com/pt/re/ebeye/
abstract.00061198-200506000-00009.htm.
5 Elliot DB, Clinical Procedures in Primary
Eyecare, 1997; p259, (London, Butterworth-
Heinmann).
6 Elliot DB. Clinical Procedures in Primary
Eyecare, 1997, p 261, (London, Butterworth-
Heinmann).
7 NCT manuals for Pulsair, NT-3000 and AO
NCT.
8 www.opt.indiana.edu/Riley/HomePage/
new_Goldmann_tonometry/2Goldmann_
Tonometry.html
9 Kotecha A. Central corneal thickness and IOP,
OT, 2005; 22.
10 www.opt.indiana.edu/Riley/HomePage/
new_Goldmann_tonometry/2Goldmann_
Tonometry.html
11 Garzozi, HJ, Chung HS, Lang Y et al. Intraoc-
ular pressure and photorefractive keratectomy; a
comparison of three different tonometers. Cornea,
2005; 2001; 20, 33-36.
12 Pepose J, Sanderson JP, Qazi MA. How should
we measure IOP after LASIK? Cataract and
Refractive Surgery Today, 2005; 52-54.
13 www.tiolat.fi/tiolat.php?id=29
Priya Dabasia is a visiting clinician at
the Fight for Sight optometry clinic, City
University
CONTACT APPLANATION TONOMETRY