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Presented by Dr. Ranjani K J 1st year PG student Department of Ophthalmology St.Johns Medical College
TONOMETRY
INSTRUMENT USED TO MEASURE INTRA OCULAR PRESSURE CONTACT INDENTATION APPLANATION NON-CONTACT
HISTORY
VON GRAFFE- 1865 Maklakov instrument- late 19th century
Schiotz- indentation tonometer , first two- thirds 20th century Goldmann applanation tonometer, 1950
PRINCIPLE OF OPERATION
CONTACT
Deforming the globe and correlating the force responsible for the deformation to the pressure within the eye
NON CONTACT
Time required to deform the corneal surface in force produced by jet of air
INDENTATION TONOMETRY
Scale
SCHIOTZ TONOMETER
Needle
Weight Holder
Plunger Footplate
OPERATING TECHNIQUE
DISINFECTION
Disassembled, barrel cleaned with two pipe cleaners, first soaked in alcohol and second dry. Footplate: alcohol swab Disposable covers
APPLANATION TONOMETRY
IMBERT FICKS LAW:
PRESSURE INSIDE = A SPHERE [P] VARIABLE FORCE TONOMETRY Goldmann tonometer Perkin tonometer Draeger tonometer Macky Marg tonometer Tonopen Cat ioo tonometer Keta tonometer Pneumatic tonometer FORCE REQUIRED TO FLATTEN SURFACE [W] AREA OF FLATTENING [A]
GOLDMANNS TONOMETRY
Thick lines
Thin lines
Settings magnification- 10x max light beam Cobalt blue filter used Illumination arm and microscope-60 measuring drum-10
POTENTIAL ERRORS
Thickness of cornea
Thin- low iop Thick increased collagen fibrils- high iop stromal or epithelial edema- low iop
Curvature of cornea 1mm hg- every 3D increase in corneal power With the rule astigmatism- iop is under estimated 1mm hg for every 4D Against the rule of astigmatism- over estimated
STERLIZATION
Swabbing the tonometer tip with an alcohol pre pad and allowing it for drying for 10 min wiping and soaking the tip in 3%hydrogen peroxide for 5 min disposable sleeves
PERKINS TONOMETER
Uses Goldmann prisms adapted small light source ADVANTAGE Portable Performed in any position of patient
DRAEGER TONOMETER
Uses different set of prisms and operates with a motor adjusting the force on these prisms
MACKY-MARG TONOMETER
Consists of plunger, movement of which is electronically monitored by transducer and recorded on paper strip
CREST : IOP and force required to deform cornea TROUGH : IOP MAXIMUM : Artificially elevated iop
TONO PEN
Hand held, self contained battery powered, portable. Probe tip has transducermeasures the applied force and micro processor analyses force/time curve generated by transducer on corneal indentation to calculate iop ADVANTAGE Portable Measure iop in distorted and edematous cornea Through bandage contact lens
PNEUMATO TONOMETER
Four major components
1. Sensing unit: nozzle covered with sialistic diaphragm 2. Transducer: converts pneumatic signal to electrical signal 3. Amplifier and recording unit: processes signal and provides visual read out 4. Air supply unit: provides compressed air
ADVANTAGES Eyes with scarred, edematous, irregular corneas Continuous intra ocular pressure monitoring Soft contact lens
MAKLAKOV TONOMETER
(Constant force applanation tonometer)
Principle: iop estimated by measuring the diameter of corneal area flattened by fixed weight Dumbell shaped metal cylinder with end plates of polished glass, on which thin layer of dye is spread. Instrument is allowed to make contact with anaesthetised cornea. Tono end is pressed on to special paper circle of dye produced, diameter of which is measured and using conversion tables iop is measured
ADVANTAGES No corneal abrasions, reaction to topical anesthetic, transmission of infectious agents Mass screening DISADVANTAGES In abnormal corneas- sub epithelial bubbles
DIATON TONOMETER
The patient is positioned so that the tip of the device and lid are overlying sclera.
Principle: The Diaton tonometer calculates pressure by measuring the response of a free falling rod from constant height interaction with eye through eyelid. Device has a position sensor and rod movement is remembered by built in processor.
F [eye elasticity force influencing the rod]
P =
S [area of eye and rod interaction] According to Newtons second law, F= m a, m= mass of rod, a= acceleration of the rod P= directly proportional to acceleration of the rod
ADVANTAGES Does not involve contact with the cornea No sterilization of the device No topical anaesthetic.
DISADVANTAGES Only moderate correlation with those provided by applanation tonometry More affected by the corneal thickness than Goldmann tonometry.
TONOMETRY IN CHILDREN
1. Under general anesthesia, use tono pen or perkins hand held tonometer Effect of anesthetising agents on iop: except ketamine and trichloroethylene, other general anaesthestics reduce iop Depolarizing muscle relaxants- sudden elevation of iop Non depolarizing muscle relaxants prevent rise in iop EXCEPT d- tubocurarine, gallamine Increased Pco2- rise in iop, Increased Po2- decrease in iop 2. Non contact tonometer
Tonography
Grant- 1950
Procedure: electronic schiotz tonometr has electrical analog of pointer position is used. Electrical output signal from this instrument, to drive a chart recorder, creating a continous graphic record of pressure changes. as tonometer rests on eye, increased amounts of aqueous humor leave eye and eye softens. as this occurs, corneal indentation increases , scleral distension decreases. combined volume change with driving force and duration of test- to derive co-efficient of aqueous humour outflow-C
Grants equation C= V
T( Ptav- Po)
v - change in vol(microlitres) T- duration of test Ptav- average pressure elevation Po- baseline pressure
Potential errors sudden eye movements or eyelid contractions frequent coughing, sneezing, breath holding Abnormal scleral rigidity
GONIOSCOPY
Gonioscopy is a clinical technique used to examine structures in the anterior chamber angle.
In 1907, Trantas, using indentation in an eye with keratoglobus, first visualized the anterior chamber angle in a living eye and coined the term gonioscopy.
DIRECT GONIOSCOPES
Curve of contact lens is such that critical angle is not reached and light rays are refracted at contact lens- air interface Eg:Koeppe goniolens, Huskins Barkans lens, Swan jacobs lens,Richardson-Shaffers lens
INDIRECT GONIOSCOPES
Light rays are reflected by a mirror in contact lens[gonio prism] and leave lens nearly at right angle to the contact lens- air interface. Eg: Goldmann single, and three mirror lenses, Ziess four mirror lenses, posner and susmann four mirror lenses, Thorpe four mirror, Ritch trabeculoplasty lens
DIRECT GONIOSCOPY
space b/w inner surface of lens and cornea is filled with saline or viscous solution. Angle is viewed through binocular magnifier held with one hand, while eye is illuminated by hand held light.
Koeppe lens
ADVANTAGES Straight on view more panoramic angle recession- comparison DISADVANTAGES Difficulty of learning the technique. Instrumentation expensive and difficult to obtain. Less magnification. USES: Goniotomy for infantile glaucoma
INDIRECT GONIOSCOPY
Operating technique
GOLDMANN LENS
ZEISS LENS
Goldmann 3- mirror gonio prism semicircular mirror- 59, used for gonioscopy 2 rectangular mirrors , inclined 67examine pars plana area of ciliary body another inclined 73 - examine ora serrata area of peripheral fundus Zeiss gonio lens 4 identical mirrors angled at 64
General guidelines: Use magnification- 10 to 25x Short and narrow beam [2-3mm] Use a dark room since pupillary constriction makes narrower angle appear more open
Schwalbes line- best identified by locating corneal wedge . Trabecular meshworkant- non pigmented trabecular meshwork post-pigmented Scleral spur-thin white or grey band Ciliary body- dark brown band
SCHEIE SYSTEM:
Grade 0 - Entire angle visible as far posterior as a wide ciliary body band Grade I - Last roll of iris obscures part of the ciliary body Grade II - Nothing posterior to trabecular meshwork visible Grade III - Posterior portion of trabecular meshwork hidden Grade IV - No structures posterior to Schwalbes line visible Based upon the most posterior structure visible in the angle
INDENTATION GONIOSCOPY
1. Helps to distinguish narrow from closed angle 2. Determine whether closed portions of circumference of angle- reversible apposition of iris to mesh work or by peripheral anterior synechiae 3. Identifies plateau iris configuration 4. Identifies lens induced angle closure
Synechial closure
Appositional closure
Angle closure
Abnormal structures:
1. Peripheral anterior synechiae 2. Neovascularisation 3. Abnormal pigmentation
NEO VASCULARISATION
Abnormal pigmentation Exfoliation syndrome- segmental Pigmentary glaucoma- diffuse, darker brown / black
Clinical uses
Diagnostic uses:
Diagnose and provide prognosis for congenital glaucoma
Diagnose secondary glaucoma ,especially subtle angle recession, uvietic glaucoma, neovasculirisation,irido corneal endothelial syndromes. Differentiate between POAG and PACG
Black pigment balls- characterstic of resolved hyphema, s/o past trauma Diagnose- tumours of anterior segment, intra ocular foreign body, early detection of KF ring Unusual causes of glaucoma, eg. haptic of pciol protruding through peripheral iridectomy and resting in angle of anterior chamber.
Therapeutic uses:
Perform laser trabeculoplasty, iridoplasty,cryo photocoagulation, Congenital glaucoma- goniotomy Indentation gonioscopy- to break an attack of angle closure glaucoma
Limitations of gonioscopy
Cannot be formed in painful inflamed eyes Patients who are on mydriatics- as they obscure angle by bunching up of iris
Disinfection
Concave contact area- wiped with alcohol sponge Lenses - cleaned with 2% glutraldehyde Glass lenses - autoclaved
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