ORIGINAL STUDY
The Clinical Utility of Dynamic Contour Tonometry
and Ocular Pulse Amplitude
Jennifer S. Weizer, MD,*w Sanjay Asrani, MD,* Sandra S. Stinnett, DrPH,*
and Leon W. Herndon, MD*
Purpose: To determine if ocular pulse amplitude (OPA) as
measured by dynamic contour tonometry (DCT) is related to
severity of glaucoma, and if intraocular pressure (IOP) as
measured by DCT is related to central corneal thickness (CCT).
Methods: Patients were selected from the Duke Eye Center
glaucoma clinic. Fifty-five eyes of 32 patients were included;
right and left eyes were analyzed separately. CCT, OPA, DCT
IOP, Goldmann applanation tonometry (GAT), Tonopen
applanation tonometry (TAT), and systemic blood pressure
were measured. Advanced Glaucoma Intervention Study score
and mean deviation of visual field, and vertical and horizontal
cup-disc ratios were recorded in a masked manner. Descriptive
statistics were obtained, and OPA, DCT IOP, GAT, and TAT
underwent univariate analyses to assess for relationships with
predictor variables.
Results: OPA, DCT IOP, GAT, and TAT were positively
associated with CCT and with having no surgical intervention
for right and left eyes, and were negatively associated with
vertical and horizontal cup-disc ratios.
Conclusions: Increased OPA seems to correlate with less severe
glaucoma and with increased CCT. DCT IOP seems to be
affected by CCT along with GAT and TAT.
Key Words: ocular pulse amplitude, dynamic contour tonome-
try, central corneal thickness, intraocular pressure
(J Glaucoma 2007;16:700–703)
D ynamic contour tonometry (DCT) is a novel
technique for measuring intraocular pressure (IOP)
without applanation. The DCT instrument contains a
contoured tip designed to fit the corneal surface and
compensate for any corneal forces while measuring IOP
with its pressure sensor.1 A few recent studies have
suggested that DCT IOP is not affected by central corneal
Received for publication September 26, 2006; accepted April 7, 2007.
From the *Duke University Eye Center, Durham, NC; and wKellogg
Eye Center, Ann Arbor, MI.
None of the authors has a proprietary interest in this manuscript.
The dynamic contour tonometer instrument was borrowed for the
purposes of this study from SMT Swiss Microtechnology AG.
Reprints: Jennifer S. Weizer, MD, Kellogg Eye Center, 1000 Wall Street,
Ann Arbor, MI 48105 (e-mail: jweizer@umich.edu).
Copyright r 2007 by Lippincott Williams & Wilkins
700
thickness (CCT), unlike other applanation methods such
as Goldmann applanation tonometry (GAT).2–8 The
DCT instrument also measures ocular pulse amplitude
(OPA), which is a measure of the difference between IOP
at systole and at diastole during the cardiac cycle.9
Our purpose was to determine if OPA is related to
ocular examination parameters and severity of glaucoma
and also to determine if DCT IOP is affected by
CCT compared with GAT and Tonopen applanation
tonometry (TAT).
METHODS
In this prospective descriptive case series, subjects
were recruited from the Duke Eye Center glaucoma clinic.
The study and data accumulation were carried out with
approval from the Duke University Medical Center
Institutional Review Board, informed consent was
obtained from all subjects, and the study was in accord
with HIPAA regulations. Fifty-five eyes of 32 patients
were included; right and left eyes were analyzed sepa-
rately. Inclusion criteria were diagnosis of normal, ocular
hypertension (OHT), glaucoma suspect, or primary
open-angle glaucoma (POAG). Ocular hypertension was
defined by IOP >21 without glaucomatous optic nerve
head or nerve fiber layer changes. Glaucoma suspect was
defined by suspicious but not definite optic nerve head,
nerve fiber layer, or visual field abnormalities suggesting
glaucoma. POAG was defined by definitely glaucomatous
optic nerve head or nerve fiber layer abnormalities, with
or without visual field defects. Exclusion criteria were
secondary glaucoma, contact lens wear, or any eye
surgery within the previous 3 months, or any previous
corneal surgery. Age and systemic blood pressure were
recorded per patient, and diagnosis and any surgical
glaucoma interventions performed were recorded per eye.
Subjects underwent ocular examination including best
corrected Snellen visual acuity, spherical equivalent by
autorefraction, automated keratometry, GAT, TAT,
ultrasonic pachymetry, and DCT (IOP and OPA).
Ultrasonic pachymetry was performed (using the DGH
550 Pachette 2; DGH Technology, Exton, PA) immedi-
ately after GAT and TAT and immediately before DCT;
the average of 5 CCT readings was recorded. The quality
level (Q) of each DCT reading was recorded (ranging
from 1 to 5, 1 being optimal and 5 least optimal); only
readings with Q levels of 1, 2, or 3 were included in the
J Glaucoma  Volume 16, Number 8, December 2007
J Glaucoma  Volume 16, Number 8, December 2007 Dynamic Contour Tonometry and Ocular Pulse Amplitude

statistical analysis. Dilation of the pupil was deferred Descriptive statistics per eye are listed in Table 1.
until all study readings were obtained. All the above AGIS score and mean deviation of visual field were
parameters were collected during a single visit for each reported for 42 eyes, and vertical and horizontal cup-disc
patient. ratios were reported for 53 eyes.
POAG [including normal tension glaucoma Twenty eyes (36%) had undergone previous inci-
(NTG)], glaucoma suspect, or OHT patients with reliable sional glaucoma surgery. Of these, 16 eyes (29%) had
Humphrey automated 24-2 (Humphrey Systems, Dublin, undergone trabeculectomy with mitomycin-C and 4
CA) Swedish Interactive Thresholding Algorithm stan- (7%) had undergone Baerveldt 350 tube implant. One
dard perimetry performed within 2 years of their study of the trabeculectomy eyes underwent transscleral diode
visit had their visual field data included in the statistical cyclophotocoagulation subsequent to the trabeculectomy,
analysis. Visual field data included type of visual field and one of the Baerveldt eyes had undergone endocyclo-
analysis performed, Advanced Glaucoma Intervention photocoagulation before the tube implant.
Study (AGIS) score, mean deviation, fixation losses, and Mean DCT IOP was 17.6 mm Hg (SD 6.2) in right
false negative and false positive responses. Reliable eyes and 15.4 mm Hg (SD 4.8) in left eyes. Mean GAT
Humphrey automated perimetry was defined by having was 15.1 mm Hg (SD 4.9) in right eyes and 13.8 mm Hg
fewer than 2 of the following characteristics: fixation (SD 4.7) in left eyes. Mean TAT was 12.1 mm Hg (SD 4.2)
losses greater than 20%, false positive responses greater in right eyes and 11.2 mm Hg (SD 4.2) in left eyes. The
than 33%, or false negative responses greater than 33%. differences between all 3 measurement methods were
These reliability criteria were adapted from the AGIS statistically significant (P<0.001).
reliability ratings.10 The AGIS score has been described DCT quality readings were ‘‘1’’ in 10 right eyes
in detail previously.10 In brief, the visual fields are graded (40%) and 13 left eyes (43%), ‘‘2’’ in 11 right eyes (44%)
on a scale of 0 to 20 on the basis of the degree of damage and 10 left eyes (33%), ‘‘3’’ in 2 right eyes (8%) and 5 left
on the Total Deviation printout. A score of 0 represents a eyes (17%). Of note, 2 right eyes (8%) and 2 left eyes
normal visual field; 1 to 5 represents mild disease; 6 to 11, (8%) had quality readings of ‘‘4’’ despite repeated
moderate disease; 12 to 17, severe disease; and 18 to 20, measurements, so these OPA and DCT IOP measure-
end-stage glaucoma. Each Humphrey 24-2 visual field ments were not included in the statistical analysis.
was scored by one masked grader (J.S.W.) according to Univariate analysis revealed that increased OPA
the AGIS scoring system.10 was significantly associated with only the following
One masked grader (L.W.H.) determined vertical predictor variables: with having no previous incisional
and horizontal cup-disc ratios for each eye. Cup-disc glaucoma surgery in right (P = 0.020) and left (P =
ratios were judged using stereoscopic optic disc photo- 0.001) eyes, with increased mean CCT in right (P = 0.001,
graphs from each patient’s study visit when available, or R2 = 0.37) and left (P = 0.010, R2 = 0.21) eyes, with
by evaluating detailed chart drawings from each visit smaller mean vertical cup-disc ratios in right (P = 0.024,
when photographs were not available. R2 = 0.39) and left (P<0.001, R2 = 0.45) eyes, and with
Descriptive statistics were obtained for each vari- smaller horizontal cup-disc ratios in right (P = 0.009,
able. Then univariate analysis, using linear regression, R2 = 0.27) and left (P<0.001, R2 = 0.40) eyes.
was carried out to assess the significance of the relation- Univariate analysis also showed that increased DCT
ship between OPA, DCT IOP, GAT, and TAT and each IOP was significantly associated with only the following
predictor variable. Predictor variables were age, spherical predictor variables: with having no previous incisional
equivalent, keratometry, CCT, systemic blood pressure, glaucoma surgery in right (P<0.001) and left (P<0.001)
mean deviation of visual field, AGIS score, and vertical eyes, with increased CCT in right (P = 0.021, R2 = 0.23)
and horizontal cup-disc ratios. The significance of the
difference between those with and without surgical
intervention was assessed using the Wilcoxon rank TABLE 1. Descriptive Statistics
sum test. Multivariate analysis results were not included Mean (Standard Mean (Standard
due to several missing data points. Separate analyses were Deviation) Deviation)
Right Eyes Left Eyes
performed for right and left eyes. N = 25 N = 30
Best corrected visual 0.255 (0.46) 0.339 (0.58)
acuity LogMar or 20/36 LogMar or 20/44
RESULTS Snellen equivalent Snellen equivalent
Of the 55 eyes included in the study, 17 right eyes Average keratometry (D) 43.82 (1.74) 43.73 (1.44)
and 20 left eyes (67%) had the diagnosis of POAG, 4 right Spherical equivalent (D) 0.39 (2.19) 0.04 (2.23)
eyes and 4 left eyes (15%) had NTG, 2 right eyes and 2 AGIS score of 0.5 (Median) 1.5 (Median)
visual field Range 0 to 20 Range 0 to 20
left eyes (7%) were glaucoma suspect eyes, 2 right eyes Mean deviation of 5.44 (7.65) 7.15 (9.81)
and 2 left eyes (7%) had OHT, and 2 left eyes (4%) were visual field (dB)
normal. Mean age was 68.2 years [standard deviation Vertical cup-disc ratio 0.78 (0.17) 0.76 (0.22)
(SD) 12.8 y]. Mean systolic blood pressure was 137.4 mm Horizontal cup-disc ratio 0.75 (0.18) 0.73 (0.21)
OPA (mm Hg) 2.70 (1.70) 2.44 (1.73)
Hg (SD 14.7) and mean diastolic blood pressure was 80.4 CCT (mm) 535 (50.5) 538 (46.7)
(SD 13.6).

r 2007 Lippincott Williams & Wilkins 701

Weizer et al
and left (P = 0.030, R2 = 0.17) eyes, with smaller mean
vertical cup-disc ratios in right (P = 0.008, R2 = 0.30)
and left (P<0.001, R2 = 0.45) eyes, and with smaller
mean horizontal cup-disc ratios in right (P = 0.004,
R2 = 0.34) and left (P<0.001, R2 = 0.47) eyes.
Only the following predictor variables were sig-
nificantly associated with increased GAT: having no
previous incisional glaucoma surgery in right (P = 0.004)
and left (P<0.001) eyes, increased mean CCT in right
(P = 0.023, R2 = 0.21) and left (P = 0.017, R2 = 0.19)
eyes, smaller mean vertical cup-disc ratios in right
(P = 0.007, R2 = 0.29) and left (P<0.001, R2 = 0.37)
eyes, and smaller mean horizontal cup-disc ratios in right
(P = 0.006, R2 = 0.29) and left (P<0.001, R2 = 0.42)
eyes.
Increased TAT was significantly associated with
only these predictor variables: with having no previous
incisional glaucoma surgery in right (P = 0.006) and left
(P<0.001) eyes, with increased mean CCT in left eyes
(P = 0.028, R2 = 0.16), with smaller mean vertical cup-
disc ratios in right (P = 0.009, R2 = 0.27) and left
(P<0.001, R2 = 0.37) eyes, and with smaller mean
horizontal cup-disc ratios in right (P = 0.006,
R2 = 0.29) and left (P<0.001, R2 = 0.39) eyes. The
relationship between increased TAT and increased mean
CCT in right eyes approached but did not achieve
statistical significance (P = 0.060, R2 = 0.15).
DISCUSSION
Our study demonstrates that increased OPA is
related to decreased severity of glaucoma as measured
by smaller vertical and horizontal cup-disc ratios and
increased CCT. Also, DCT IOP seems to be correlated
with CCT and tends to measure IOP as higher than GAT
or TAT.
To our knowledge, our study is the first to link OPA
to severity of glaucoma. Kaufmann et al found that the
relationship between OPA and CCT approached but did
not achieve statistical significance in healthy subjects
(P = 0.08). Although the Kaufmann study reported a
significant association between OPA and axial length, we
found no parallel relationship between OPA and spherical
equivalent. In agreement with the Kaufmann study,
however, we also found no links between OPA and age
or between OPA and keratometry.11
Blood flow to both the optic nerve head and the
choroid is supplied by the short posterior ciliary arteries.
As 85% to 90% of intraocular blood flow is choroidal
and 70% of this choroidal blood flow is pulsatile in
nature,12,13 we hypothesize that the relationship between
OPA and severity of glaucoma demonstrated in our study
may shed some light on vascular factors affecting the
glaucomatous optic nerve head. As OPA varies not only
with the amount of blood transported to the eye during
systole but also depends on choroidal vascular rigidity
and scleral rigidity,25,28 we speculate that the relationship
between OPA and glaucoma severity in our study may
highlight the fact that OPA may serve as an indicator for
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J Glaucoma  Volume 16, Number 8, December 2007
the combined effect of ocular rigidity and the vascular
supply to the optic nerve head (because the same source
of blood flow supplies the optic nerve and choroid),
although it is also possible that the relationship between
OPA and glaucoma severity in our study could be a
paraphenomenon of no clinical or etiologic significance.
Previous studies have shown that pulsatile ocular blood
flow (POBF) as measured by the POBF tonometer is
decreased in POAG patients compared with ocular
hypertensives and normals.14,15 Agarwal et al16 noted
that POAG patients had increased POBF when their IOP
was better controlled. Several studies have noted that
NTG patients had lower POBF than normal patients,17–19
whereas Khan et al15 found that both NTG patients and
normal patients had similar POBF. POBF has also been
found to be decreased in patients with exudative age-
related macular degeneration,20 Graves ophthalmolopa-
thy,21 retinitis pigmentosa,22 and diabetic retinopathy
in some studies.12,23,24 Latanoprost25 and dorzolamide26
have been associated with increasing POBF whereas
timolol has not27; in the case of dorzolamide, the
increased POBF was independent of its IOP-lowering
effects.26
Phillips et al29 postulated that the choroid is a
piston and pulsatile blood flow a pump that drives
aqueous outflow and normalizes IOP. Similarly, Kerr
et al14 hypothesized that POAG is associated with
autonomic dysfunction in which parasympathetic under-
action leads to decreased choroidal blood flow and hence,
decreased blood flow at the lamina cribrosa. Our finding
that higher OPA correlates with less severe glaucoma may
be in concordance with these theories, although we found
no relationship between OPA and systemic blood
pressure in our study.
In this study, GAT, TAT, and DCT IOP were all
associated with CCT, in contrast to several other
studies.2–8,30 In a study by Ku et al,4 the relationship
between DCT IOP and CCT approached statistical
significance but did not achieve it (P = 0.073). Doyle
and Lachkar31 showed that DCT IOP is independent of
CCT in thinner corneas, but did not have any benefit
compared with GAT in thicker corneas, whereas Ku et al4
found that DCT IOP and GAT readings had the greatest
disparity in thicker corneas. These contradictory findings
in the literature concerning DCT IOP and CCT should
prompt further study of this relationship.
Our finding that DCT measures IOP as higher than
other applanation methods is in concordance with several
previous studies.2,4,5,7,8,32,33 DCT tends to measure IOP
as 1.0 to 4.0 mm Hg higher than GAT,3,4,32 which is
similar in our study. Kniestedt et al3 compared DCT IOP
and GAT with manometry in cadaver eyes and found that
DCT IOP was 0.36 to 0.50 mm Hg higher than mano-
metric pressures, whereas GAT was 3.14 to 3.48 mm Hg
lower than manometric pressures. DCT may also be less
variable than other applanation methods,3,5,11,33,34 espe-
cially since its readings are not subjective.
In this study, DCT IOP, GAT, and TAT were
positively associated with smaller vertical and horizontal
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J Glaucoma  Volume 16, Number 8, December 2007
cup-disc ratios, and also with having no previous
incisional glaucoma surgery. This may be because
patients with more severe disease were already being
treated more aggressively, both medically and surgically,
from a pressure-lowering standpoint.
One weakness of our study is that some patients
were receiving glaucoma treatment, and the contributions
of medical glaucoma treatment on OPA are not known.
Von Schulthess et al35 report that OPA may decrease
initially after successful trabeculectomy in POAG and
pseudoexfoliation glaucoma patients followed for 3
months postoperatively, so having had previous glauco-
ma surgery may have impacted our patients’ results.
Further study with longer follow-up among POAG
patients is needed to separate these possible confounding
factors.
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