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 Glaucoma is a disease characterized
by functional or structural anomalies
of the eye in which at least one
characteristic change in the optic disc
or visual field is present and in which
the progression of optic nerve
damage can ordinarily be alleviated
or halted by lowering intraocular
pressure.
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Úiurnal variation 3-
3-5 mmHg ,
more in untreated glaucoma

Maximum between 8-
8-11am
Minimum between midnight & 2am

This is dependent on sleep cycle than


daylight cycle
 
The wearing of CL before tonometry is
performed may lead to an artifactually
raised IOP as measured by GAT.
CL wearing patients should have
tonometry performed after having
been awake, without CL, for at least 2
hrs for CL-
CL- induced and diurnal
corneal edema to resolve.
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 ^alsalva maneuvers, or breath holding by
the patient, must be avoided.
 The semicircles should be clear with
distinct margins.
 Wider, blurred semicircles result in false-
false-
high readings as does vertical
misalignment.
|
 Measurements without the use of
fluorescein underestimate the true
IOP
 Corneal astigmatism may result in
false pressure readings. The error
has been calculated at 1 mm for
every 4 diopters (underestimated for
with--the
with the--rule; overestimates for
against--the-
against the-rule
|
 IOP increases temporarily because of
wearing tight neckties, caffeine intake,
yoga positions and isometric exercises.

 The unanswered D  is whether


these intermittent bursts of elevated
eye pressure lead to pathological
problems?

Neurol Res. 1999;


1999;21:
21:243-
243-6
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 CONCLUSIONS ( 
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 Large amounts of corneal edema


produce an underestimation of IOP
when measured by applanation
tonometry.
 Small amounts of corneal edema (as
induced by contact lens wear)
probably cause an overestimation
of IOP.
 ! 
 eratoconic and Fuchs¶ subjects
measure unusually low IOP on GAT.
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 %)5V $6 ( eye can manifest clinically as


%)
decreased ^A, myopic shift in refraction,
stromal edema or interface fluid on slit
lamp exam, increase in pachymetry
measurements, steepening of corneal
topography, or inappropriately low IOP
measurements
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 Interface fluid syndrome is associated


with falsely low IOP measurements
due to cushioning by the fluid-
fluid-filled
pocket. A more accurate IOP reading
can be obtained by applying the
Goldmann or Tono-
Tono-Pen tonometer
peripheral to the LASI flap
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Pathophysiology:
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 IOP measurement
inaccuracies arise
because applanation
tonometry reflects the
pressure of the interface
fluid pocket and not the
true IOP
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 Interface fluid syndrome are


associated with steroid-
steroid-induced
ocular hypertension; they do not
respond to topical corticosteroids,
and they typically resolve with
discontinuation of topical
corticosteroids and application of
IOP--lowering medications.
IOP

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According to the V$ study,


reducing IOP in glaucoma patients
limits disease progression and slows
visual field loss. R

According to the ' study, for


every 1 mm drop in IOP, a 10%
reduction in risk of glaucomatous
progression was observed.
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As Goldmann
applanation tonometry is
the most reproducible, it
is recommended for IOP
measurement in patients
with healthy corneas

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Under ideal circumstances for measurement,


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:: 2.5 mmHg
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two readings by the same observer will be
within this figure for 95% of subjects.
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::  4 mmHg
(95% confidence limits either side of
mean difference between observers)
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 Approximately 90%
90% and 30%
30% of
tonometers were outside the
tolerance ranges of 0.5 and 2.5
mmHg,respectively.

 For achieving more accurate IOP


measurement regular checking of
GAT tonometers for calibration

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 non-contact tonometry
non-
or air-
air-puff tonometry:
 This type of tonometer uses a
rapid air pulse to applanate
the cornea. Intraocular
pressure is estimated by
detecting the force of the air
jet at the instance of
applanation.
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 Tono-pen - is a portable electronic,
Tono-
digital pen-
pen-like instrument that
determines IOP by making contact with
the cornea, after use of topical
anesthetic eye drops.
 In Children
 Supine Position
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Consideration can be given to finger
tonometry to estimate IOP as very low,
normal, or very high in certain situations
(e.g., eyes with flat anterior chambers
[lens--cornea touch], eyes with
[lens
keratoprosthesis)

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 Corneal thickness,curvature &


hydration can affect IOP

 Biomechanical properties of the


cornea (hyteresis) can influence IOP

 These differences should be


considered between indeviduals & in
same person
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Physiological variations
Measurement errors
Corneal thickness,Hysteresis
Individual suscebility
State & rate of progression
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A³target´ pressure should be set as a


goal of long term therapy: it should
be chosen on an individual basis,
weighing potential benefits and risks
of treatment for each patient.

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The goal of the clinician while treating


patients with glaucoma should be to
lower the IOP to a level that is
† ? for that particular eye.

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Target IOP may be defined as a


pressure, rather a range of IOP levels
within which the progression of
glaucoma and visual field loss will be
delayed or halted

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 IOP level at which optic nerve
damage occurred
 Extent and rate of progression of
glaucomatous damage,
 Presence of other risk factors
 Patient¶s age
 Expected life span & Medical history
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Target IOP = ³Maximum IOP ± Maximum IOP% -

Z is an optic nerve damage severity factor.
0 Normal disc and Normal ^F

1 Abnormal Úisc and Normal ^F

2 ^F loss not threatening


fixation
3 ^F loss threatening or
involving fixation

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An eye with a maximum IOP of 30


mmHg, optic nerve damage and
visual field loss not threatening
fixation would have a target set at
19 mmHg (30 (30--30%
30%-2)

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 Recommended to record and


highlight the target pressure in the
chart of a patient
 Úraw an IOP curve for each
glaucomatous patient and to
highlight the target pressure on the
curve

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