Tonometry

Click to edit Master subtitle style Chapter 4 Lecturer : Dr. Genalin Ang O.D.

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What is tonometer?

This is a clinical technique that provides a measurement of the Internal pressure of the eye Called IOP ( Intra ocular pressure, ocular Tension )

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What is IOP ( Intraocular Pressure)

High

intraocular pressure causes damage to the optic nerve, which can lead to glaucoma. But what is it? What makes it happen? What can you do about it?

First,

let's dissect the term. Intra is the Latin word for within or inside. Ocular refers to the eye. Pressureis the result of applying a force onto a surface.
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Small reductions or increases in ball pressure would mean that the bounce potential would change and influence three key dimensions of the game: height of return after the ball strikes the floor, bounce off the backboard, and bounce off the rim of the basket.

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HOW DOES THIS APPLY TO THE EYE?

The aqueous humor is confined to a small space in the front part of the eye. The remainder of the eye is filled with vitreous humor.

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 When

we talk about intraocular pressure, we are referring to the pressure exerted by these two fluids on the walls of the eye and on the structures inside. Similar to the basketball, the materials of the eye that contain the aqueous and vitreous humors in a closed space have limited flexibility and expansion capabilities. This means that additional aqueous humor introduced into the eye increases the pressure inside the eye.
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Theoretical Principle of Tonometery

There

is three different principles :

APPLANATION IDENTATION MANOMETRY

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Applanation
Is

the most commonly used technique to measure IOP IOP= force/ area Meaning in physics + force applied as well as the size of the area of the eye on which this force applied

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APPLANATION
GOLDMANN PERKINS NON-CONTACT

( NCT ) TONOMETERS

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Goldmann Tonometer

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Applanation
Goldmann

tonometer the "gold standard" instrument attached to the slit lamp biomicroscope used in all eye doctors' offices It requires a cobalt blue light source and a small droplet of fluorescein on the ocular surface.

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Applantion
A

tiny pressure sensor attached to a springloaded arm is gently placed against the tear film, and the doctor or technician reads the pressure through the microscope under the blue light.

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 Maklokov

Tonometer Is a method of applanation that applies a constant force to the cornea

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Indentation
Schiotz

tonometer

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Schiotz tonometer
Disadvatages More

invasive It is affected corneal rigidity Repeated measurement may be misleading due to aqueous humour being evacuated at each reading

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Manometry
Is

the most direct and accurate method to measure IOP Its not use due to invasive nature of the procedure

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Common Techniques
Goldmann

Tonometer

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Goldmann Tonometer
Goldmann

applanation tonometry is considered the Gold Standard based on its accuracy and repeatability of results. A hand-held version called the Perkins tonometer

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Excessive pressure reading on the eye distorts the mires Turning the reading drum

Figure 4.4 a) Move Slit lamp up b) Move slit lamp right c) Move slit lamp up and left

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Insufficient presurre on the eye on indenting the probe

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Perkins Tonometer
Advantage

you can use in different position

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Using Perkins tonometer

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Tonopen
Uses

both Applanation and Identation priciple Portable, penshape hand held devices handheld device and calibrates digitally with the push of a button. It requires a disposable sterile cover for each patient. The sterile device tip is gently placed against the tear film by the doctor or technician, and the pressure reading appears on

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Tonopen

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Tips of Tonopen
Advisable

in Children , un cooperative patients or patient unable to be positioned behind the lamp or long enough to perform Perkins or NCT Contraindicated in patients with known allergies to latex.

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Non Contact Tonometry

Which

generally requires no anesthetic drop, is widely used in doctor's offices, clinics, and screening facilities. It is very safe due to the "no touch" technology,

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Non Contact tonometer

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Generally, most NCT instruments use the following elements and steps:
A

video monitoring system to view the image of the eye - Some sort of visible mires in the viewer (reflections off the cornea) Mires must be focused and aligned - A button on the joystick is pressed (or an automatic mechanism is triggered) and the instrument shoots its puff of air - The reading is visible in the viewer (can also be printed on some models) Table4/28/12

Different types of NCT

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Tips fro NCT

When

applicable, the chin and headrest of the instrument must be disinfected Demonstration the small air puff onto the patients fingers By convention, the right eye is usually tested first If applicable, a safety lock usually allows the instrument to stop at a safe distance from the eye

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readings or more are taken and averaged (to account for ocular pulse) NCT readings are often imprecise and are best used as screening tools or if corneal contact is not possible. Goldmann or Perkins tonometry should be performed whenever possible, and each time an NCT measurement is abnormal or suspicious

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Schiotz tonometer

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 The

patient is placed in a supine position for the procedure. A constant known weight is applied to the cornea and the depth of the area depressed is measured and converted to IOP by using a graph. Readings are placed on a calibration scale from which the IOP is determined The measurement is then corrected for error induced by corneal rigidity on a graph.
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Tips
For

high IOP measurements, it is necessary to use more weight to perform Schiotz because there is more resistance to indentation. The additional weight is needed to indent the cornea and obtain an accurate reading. The disadvantages of the Schiotz include: high risk of corneal abrasion, supine position of patient, influence of technique on results, assembly and disassembly of instrument, aqueous displacement affecting repeat readings, and patient 4/28/12 apprehension to procedure. Since there are

Finger Tension ( Digital IOP )

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Finger tension IOP

Finger

tension IOP is a crude method to grossly assess IOP used in situations where no other more precise method is available or possible (e.g. Non-cooperative patients). One can only approximate whether the eye is soft, normal or hard and compare both eyes for a notable difference.

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Recording
The

IOP value for each eye Type of anesthetic and instrument used The time that tonometry was performed. Repeated measurements and their time (if performed) Patient position (if pertinent)

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Interpretation of Results
Normals The

IOP

mean IOP in the normal population is 16mmHg +/- 2.5mmHg

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FACTORS INFLUENCING IOP

Physical

factors Physiological factors

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Physical factors
Pressure Applying

on the globe

pressure on the globe tends to elevate the IOP. This is important because during the procedure it may become necessary to control the patients lids

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 Patient

blinking also results in an increase in IOP. Forceful blinking or blepharospasm can significantly elevate the IOP due to lid muscle compression on the globe. It is therefore necessary to instruct patients to blink gently to avoid an artificially elevated measurement.

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Trauma / inflammation
Trauma

or inflammation of the eye can either decrease or increase the IOP. trauma affects the ciliary body, aqueous production may be reduced which would decrease the IOP while if the trauma affects the anterior chamber angle structures, aqueous outflow may be reduced which would increase the IOP.

If

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 If

a patient has an intraocular inflammation such as uveitis, the ciliary body may become inflamed and decrease aqueous production therefore decreasing IOP.

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Medication
Certain

IOP Long-term use of corticosteroids (especially topical and oral) has proven to induce increased IOP. Certain blood pressure medications such as Beta-blockers when taken orally can reduce IOP. The use of substances such as marijuana and alcohol temporarily reduce the IOP.
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medications may elevate or reduce

Physiological factors
Diurnal

variation Integrity

Vascular

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Diurnal Variations
The

IOP tends to vary throughout the day being generally highest during the morning and lowest in the evening. The average diurnal variation is 4mmHg. Persons with glaucoma tend to have a greater diurnal variation. Diurnal variation exceeding 8mmHg is a risk factor for POAG. To measure diurnal variation in IOP several measurements may be taken at various times of the day in order to make a definitive assessment.
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Vascular Integrity
Impaired

venous drainage in the head-neck region can result in a decrease of aqueous outflow and subsequently an increase in IOP up to 4-5mmHg. This can be brought on by a tight collar or when the patient holds their breath during tonometry.

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 If

there is poor circulation to the ciliary body, then aqueous production is reduced and IOP is decreased. This may occur in persons with cardiovascular conditions, including carotid occlusive disease. When there is carotid artery

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Patient Position Movement

When

the patient is in a supine position or if the head is below the heart, IOP is increased. The IOP is measured tobe 2-3mmHg higher lying down than when the patient is sitting upright. The increase in IOP can be attributed decrease the aqueous outflow.

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Thank You
The

most pathetic person in the world is someone who has sight, but has no vision. Helen Keller

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