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Intraocular Pressure (IOP)

TONOMETRY AND • The fluid pressure inside the eye

PACHYMETRY • The pressure created by the continual renewal of fluids

(aqueous humor) within the eye
Caroline Pate, OD • Maintains shape of eye
• Provides nutrients to ocular tissues
Associate Professor
• Carries away metabolic waste products
UAB School of Optometry
• Helps defend against ocular pathogens
Birmingham, AL

• Measured clinically via tonometry

• Recorded in mmHg

Aqueous Secretion Aqueous Drainage (via two main pathways)

• Secreted by non-
1. Conventional Route (Trabecular
pigmented epithelial Meshwork Route)
cells of the ciliary body • Through trabecular meshwork
(TM), into lumen of Schlemm’s
canal, ending in the episcleral
• Flows into the posterior venous circulation
chamber, around the
lens, and through the 2. Unconventional Route
(Uveoscleral Route)
pupil into the anterior • Across iris root, uveal
chamber. meshwork, ciliary muscle,
suprachoroidal space, and out
through the sclera

Image from Kaufman PL, Wiedman T, Robinson JR: Cholinergics. In Sears ML [ed]: Pharmacology of the eye: handbook of experimental Image from Kaufman PL, Wiedman T, Robinson JR: Cholinergics. In Sears ML [ed]: Pharmacology of the eye: handbook of experimental
pharmacology, Berlin, 1984, Springer-Verlag. pharmacology, Berlin, 1984, Springer-Verlag.

Aqueous Humor Dynamics ‘Normal’ Intraocular Pressure (IOP)

• Mean IOP is about 15.5 mmHg +/- 2.6

• The entire aqueous turns over in about 100 • Distribution is skewed toward high end
• ‘Normal’ Range = 10 - 21 mmHg
• Production must equal drainage rate • Pressure which does not lead to glaucomatous
• Overproduction or decreased draining increased IOP damage to the optic nerve head
Terms related to Intraocular Pressure (IOP) Factors Influencing IOP
• Ocular Hypertension = IOP ABOVE normal • Time of day = Diurnal • Voluntarily widening
• IOP is greater than 21 mmHg but there is no sign of Variation fissure
glaucomatous optic nerve head damage • Generally less than 5-6 • Forced blink
• Normal optic nerve head mmHg
• Exercise
• No glaucomatous visual field damage • > 10 mmHg pathologic
• Pregnancy
• Respiration
• Hypotony = IOP BELOW normal • Age/Race
• Heartbeat
• IOP ≤5mm Hg • Medications
• Valsalva (increases 4-
• Can lead to corneal decompensation, accelerated
cataract formation, discomfort, retinal changes 5mmHg)
• Posture (2-3 mmHg

Why do we check IOP? Key Points

• Never consider IOP’s in isolation!
• Part of “routine” ophthalmic exam
• “There is no IOP below which optic nerve damage will
• Post-operative examinations never occur, nor is there any IOP above which damage
will always occur.”
• Evaluation and management for glaucoma
• Although IOP is not the sole component of glaucoma, it is one
component of the disease we can manage

• Tonometer
• instrument used to measure tension or pressure

• Tonometry

TONOMETRY- METHODS AND • test that measures the pressure inside the eyes, intraocular

CLINICAL PROCEDURE • Performed on every patient capable of being tested

• Performed after refractive procedures but before dilation
Types of Tonometry Indentation Tonometry
• Mechanical
1. Indentation • Schiotz
• indents the corneal surface • Uses a plunger and weights to indent
• direct pressure on the eyeball the anesthetized cornea
• determines pressure by calculating how much weight is required to • Pt must be lying down
flatten, or indent, an area of the cornea • Compare indentation based on weight
• must account for ocular rigidity used to a chart to determine IOP
• OUCH!!!
2. Rebound
o estimates intraocular pressure by bouncing a small plastic tipped
metal probe against the cornea and measures the induction current
that is created

3. Applanation
• involves slight flattening of the cornea
• intraocular pressure is measured by calculating the force required
to flatten or applanate an area of the cornea
• Imbert-Fick Law

Rebound Tonometry Keep an eye on the display monitor

• Icare Tonometer P_ : standard deviation of
measurements is
• Hand held, portable
slightly greater than
• Does not use anesthetic or dyes!! normal but unlikely to
• Great to use with children, scarred have affected results;
corneas, those with disabilities no need to repeat
• Uses disposable probes measurement

P- : greater than normal;

repeat measurement
if IOP >19mmHg

P¯ : much greater than

normal; repeat

Error messages – “double beep” Applanation Tonometry

• Non-contact
• E01: Probe did not move • Estimates intraocular pressure
• E02: Probe did not touch eye; too far away by measuring the force of the
air it takes to applanate an
• E03: Probe speed too slow; too far away or tilted area of the cornea.
upwards • Does not touch cornea no
• E04: Probe speed too fast; tilted downwards anesthetic needed
• E05: Contact with eye too soft; eyelid in way or patient • Good for screenings

blinked • Portable or stationary

• E06: Contact with eye too hard

• E07: “Bad hit”; positioning/centralization on cornea wrong
or probe inserted incorrectly
• E08: “Bad data” Sight Gags by Scott Lee, OD
Applanation Tonometry
• Non-contact • Electronic
• Diaton • Tono-Pen
• Measures IOP through the eyelid • Uses applanation and indentation
(transpalpebral tonometry) principles
• No anesthetic required • Small size and easily portable
• Can be used with patient in seated or • Good for scarred corneas, patients
reclined position with disabilities, and young children
• Patient’s gaze at approximately 45 • Most accurate tonometer if scarred or
degrees, clinician holds tonometer edematous cornea
vertical and gently presses down on • Uses a latex cover over the tip
tonometer to obtain reading • Requires anesthetic
• Correlates closely with Goldmann

• Approach cornea perpendicularly and applanate with

gentle tapping motion Applanation Tonometry
• Chirping sound for individual readings, beep once measurement
complete • Perkins
• Uses the Goldmann applanating prism
• Record IOP along with confidence interval of the reading
• Requires anesthetic and fluorescein dye
• Portable (illumination built into instrument)
• Repeat if >20%
• No restrictions on patient positioning
• Great to use in patients who can’t be positioned in SL

Applanation Tonometry Goldmann Tonometry

• Goldmann
• The “Gold Standard” by which
all other methods are
• The illuminated 3.06mm
Goldmann probe
applanates a 3.06 mm
diameter circle on the
GoldmannTonometry Goldmann Preparation
• Alignment of Probe Disinfection
• Clean head & chin rest of slit lamp with alcohol prep, tissue dry

• Side view of • Probe tip requires high-level disinfection since it comes in contact with a
mucous membrane
probe in holder
• Note axis scale
from 0 – 180
• If corneal cyl <3D,
align with 180
• If corneal cyl >3D,
align minus cyl
axis with red mark

CDC, Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008

High-level disinfection
• Clean probe
• CDC recommendations: (HIV, HBV, HCV, HSV, • High level disinfection
Adenovirus) with soak in 3% H2O2 or
• Wipe instrument clean, followed by: 1:10 bleach
• 10 minute soak in 3% H2O2 • Do not leave in solution
• 15 minute soak in 1:10 bleach dilution for > 1 hour!
• 20 minute soak in 2% glutaraldehyde
• Rinse thoroughly
• Rinse well with sterile saline, air dry
• Dry and store

Tonometer probes

Traditional vs. Disposable Tonometer Tips Patient preparation

• Explain purpose of the test to the patient
• Instill anesthetic + fluorescein dye
• Pre-combined drops available (Fluress, Flurox) or can use
Proparacaine + NaFl strip
• Educate patient about possible sting
• Wait about 30 seconds for anesthetic to take effect

• Check corneal integrity before/after procedure

Tonosafe Disposable Prism

Patient Preparation

• Position patient properly in slit

lamp, ensuring canthus
• Illuminate probe with cobalt
blue filter, light housing
positioned temporally
• Set pressure dial 10-20 mmHg

Holding lids Goldmann Technique – Proper endpoint

•Mires are
centered and

•Mire thickness
is satisfactory.

Goldmann Technique Goldmann Technique

•One semi-circle •Mires are

is larger than overlapping too
the other one. much.

•Move the probe •Indicates

toward the there’s too much
larger one. force dialed in.
Goldmann Technique Goldmann Technique
•Mires overlap
•Mires are not well but they’re
overlapping. too thick.

•Indicates •This will result

there’s not in IOP over-
enough force on estimation.
the probe.
•Blot the eye &
make sure lids
are not touching
the probe.

Goldmann Technique Goldmann Technique

•Mires overlap •Mires that are
well but they’re significantly
too thin. separated and don’t
move much even
with changes in the
•This will result dial.
in IOP under-
estimation. •Too much probe
pressure is being
applied forward
•Re-instill a drop with the joystick—
of Fluress. need to pull back to
release some of the

Video of Goldmann Applanation


WHAT Recording tonometry results

SHOULD • Actual measurements of right and left eyes (in mmHg)
WE DO? • Time of day
• Apprehension level (low, moderate, high)
• Type of tonometry performed

• Example:

T 19
2:15pm, low apprehension

Clinical Pearls for tonometry
• Must be QUICK and accurate
• Must be ready to hold eyelids if you’ve got a
“blinker”….be careful not to push on globe
• Don’t be afraid to maneuver probe on the Calibration set at 20mmHg

Calibration set at 60mmHg

Set at

For Haag
Streit-style SL

What does corneal thickness have to do

Pachymetry – Billing and Coding
with IOP??
• CPT 76514 • Billing frequency
• PACHYMETRY can be a useful tool • Unilateral or bilateral • Once per lifetime per
to better understand a patient’s IOP • Ultrasound technique provider
reading • Includes interpretation • Glaucoma

report • Annually
• Corneal graft
• Ocular Hypertension Treatment • ~$12.00 reimbursement
• Keratoconic
Study (2002) • Aphakic contact lens
• Greater than annually
• Thicker corneas (>555μm) give falsely
• Corneal graft rejection
high IOP readings patients
• Thinner corneas (<555μm) give falsely • Corneal edema
low IOP readings

Corneal Hysteresis In Summary…

• Measures the • Tonometry is an important part of the optometric exam

biomechanical • Goldmann is the gold standard, but reliable alternative

methods are available
strength, or overall
• IOP’s should never be considered in isolation
resistance of the

Ocular Response Analyzer (Reichert)