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Schiotz Tonometer

Schiotz Tonometer

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Schiotz Tonometer

In spite of the limitations of indentation tonometry, Schiotz tonometer is still in use in the primary eye care set up in developing countries. The methods for sterilzation of such tonometers include: 1. 1. Heating the base of the instrument with the flame of a spirit lamp for 10 seconds and allowing sufficient time for cooling before use. Repeated heating may, however, distort the curvature of the foot plate and plunger, resulting in erroneous readings. 2. 2. Cleaning the foot plate with ether or alcohol swab (allowing sufficient time for drying of chemical). 3. 3. Ultraviolet rays. 4. 4. Soaking the assembled foot plate in a bowl with 1:1000 merthiolate solution. 5. 5. Use of tonofilm. All these methods of sterlisation may be unsatisfactory because sterility is not achieved in all parts of the tonometer. Recommendations An ideal method for sterilisation of Schiotz tonometer is: 1. 1. Disassemble the tonometer between each use. Clean the barrel by inserting a white pipe cleaner saturated with alcohol, pulling back and forth several times and then inserting a second dry pipe cleaner. 2. 2. Then clean the foot plate and plunger with alcohol. 3. 3. Clean the test cornea with alcohol swab. 4. 4. Reassemble the instrument and wait for atleast 60 seconds (after cleaning with alcohol) before placing the instrument on the cornea.

A more practical approach would involve keeping the base of the tonometer continuously dipped in a solution of 1:1000 merthiolate solution (Figure). Prior to use, the footplate can be rinsed in saline/distilled water. After usage it should be replaced in the merthiolate solution.

You will need (Figure 1)
     

Schiötz tonometer, weights, and scale card local anaesthetic drops clean cotton wool or gauze swabs isopropyl alcohol 70 per cent (methylated spirit) or impregnated ‗Mediswabs‘. Test the tonometer using the spherical mould in the box and the 5.5 g weight. The pointer should immediately reach the ‗O‘ marking (see Figure 2). Clean the plunger and disc of the tonometer with a gauze swab (or cotton wool) and the methylated spirit (or a Mediswab). Wipe dry with a clean dry gauze swab (or cotton wool).

replace the 5 g weight with the 7.the anaesthetic will last for about five minutes. its use and characteristics are described in greatest detail. gently hold open the patient's eyelids. Tell the patient not to rub the eye . With the footplate resting on the stand. Lie the patient flat with his or her head supported on a pillow. Following calibration. If the scale reading is ‗2‘ or less. remove the tonometer. Note the scale reading. taking care not to put any pressure on the eye (see Figure 5). . with your hands level with the patient's head. the Schiotz tonometer needs to be calibrated and sterilized. Most primary-care physicians use the Schiotz tonometer because of its ease of use and relative low cost. Position yourself correctly: stand upright. hold the tonometer (with the 5. Note the scale reading again and remove the tonometer. Note the health worker's good posture in Figure 3 and the awkward position of the health worker in Figure 4. and repeat the procedure. With the thumb and index finger of one hand. Calibration can be simply done by placing the footplate of the instrument on the rounded metal stand (the artificial cornea) provided with the storage case.5 g weight. Ask the patient to look at a fixed object (the patient's own thumb or finger held directly in front of his or her eyes may work) and to keep absolutely still.5 g weight) between the thumb and index finger and place the plunger on the central cornea (see Figure 5). a correctly calibrated instrument will have a scale reading of zero. behind the head of the patient. or ether. Clean and dry the tonometer again and store it safely in the box. therefore. the footplate can be sterilized with a flame. Before measuring the intraocular pressure.  Using the scale card. Clean and dry the tonometer head. Method               Wash and dry your hands. Repeat the whole procedure for the other eye. With the other hand. Bad posture can affect the tonometry reading. Allow the disc to lower gently onto the corneal surface. convert the noted scale readings and record the IOP in the patient's records. alcohol. Instil local anaesthetic eye drops and wait about 30 seconds.

In patients with known or suspected ocular infection. estimated from large screening programs to be less than 1 %. the patient is asked to lie on the examining table with eyes fixed upward on the ceiling.D. indicating free movement of the plunger and good technique. Following preparation of the instrument. resulting in inaccurate measurements. Studies have shown that the 1948 table more closely approximates pressures obtained with Goldmann applanation tonometry. The degree of indentation is measured by movement of a needle on a scale. After a thorough explanation of the procedure. After applying a topical anesthetic to the cornea. indenting the cornea. Placing the Schiotz tonometer on a patient's eye. a standardized format for recording the data is strongly recommended. The magnitude. O. Globes with elevated intraocular pressure will be resistant to denting by the plunger. the examiner gently separates the eyelids with the thumb and index finger and applies the tonometer footplate directly on the cornea (Figure 118. and eye measured. interinstrument and interexaminer errors.5. Corneal disease and past ocular operations alter the resistance to indentation and are an additional source of measurement error. Fine oscillations of the needle represent ocular pulsations. or known sensitivity to the topical anesthetic. trauma. because of the increased risk of corneal abrasion. Three larger plunger weights are provided with the instrument and. published in 1948 and 1955. 10. Since the Schiotz tonometer does not measure pressure directly. For example. the patient should be prepared. however. such as 0. conversion table.5 g weight. Once the pressure readings have been taken. unpredictable direction of these measurement errors indicate that caution should be used when interpreting results. tonometer weight.5% proparacaine. refractive errors including hyperopia and myopia increase and decrease scleral rigidity respectively. The actual complication rate of tonometry is quite small.5 g weight. supplied with the instrument. Even with the experienced user. Factors external to the instrument can be responsible for similarly large errors and are due to the force needed to overcome the natural resistance of the sclera independent of ocular pressure.Care must be taken to ensure that the footplate is cool and dry before placing on the cornea. increase the total plunger weight to 7. when added to the standard 5. Schiotz tonometry should not be performed by a primary-care physician. and at times. are possible. It . which includes the scale reading. The instrument must be held perpendicular to the eye to allow the plunger to move freely. and includes corneal abrasions.5 = 12 mm Hg (1955). Although technicians can be trained to use the Schiotz instrument. conversion tables. or 15 g. are used to translate scale readings into estimates of intra-ocular pressure.1). A typical measurement would be recorded as follows: 7/5. infections. and drug sensitivity. intraocular pressure. The extra weights should be used whenever the pressure reading on the instrument scale is 4 or less. The midpoint of the needle excursion is taken as the pressure measurement. The standard force on the plunger producing corneal indentation is a 5. each of a magnitude of 2 mm Hg. The procedure is further contraindicated in patients who cannot inhibit their blinking. user inexperience is a considerable source of measurement error. Two conversion tables are available.

Before each measurement. 10. The plunger rides inside a metal cylinder attached to a footplate curved to match the average human corneal curvature (Fig.05 mm of plunger movement.1 In the Schiøtz tonometer.05 mm that the plunger sinks below the level of the footplate. the lower the intraocular pressure. Schiøtz Tonometer Schiøtz developed an excellent tonometer in 1905 and continued to refine it through 1927. which should result in no plunger depression and a scale reading of zero. The top of the plunger rides along a curved lever that attaches to a pointer. Thus. the tonometer is placed on a solid steel block. Each scale marking indicates 0. the pointer moves up 1 scale unit. The tonometer has been modified only slightly since Schiøtz's time. Schiøtz tonometer. . reliability. it is the only indentation tonometer in widespread use today. gravity provides a known force on a weighted metal plunger. Fig.may be prudent to assume that the Schiotz tonometer will indicate a probable range of intraocular pressures and. Scale readings can be converted to millimeters of mercury by conversion tables. which in turn rides along a scale. and relative accuracy. For each 0. Arrow points to scale. the farther into the cornea the plunger sinks and the higher the scale reading. His refined tonometer became the most widely used in the world and because of its simplicity. based on the amount of weight placed on the plunger. is not sufficient in itself to make the diagnosis of glaucoma. 10). as with other tonometry measurements.

2 17. it is not possible to get an accurate pressure reading other than to know that the pressure is elevated above the ―normal‖ range.4 35.4 49.8 15.0 3.6 13.2 15.6 81.5 7.8 37. The scale . The heavier weights cause the plunger to sink deeper for a given intraocular pressure and to give a higher scale reading.0 18.6 30.6 14. Hetherington J Jr: Becker-Shaffer's Diagnosis and Therapy of the Glaucomas.6 (Kolker AE.5.1 19. respectively. In effect.5 9.4 Therefore.2 18.) Conversion tables to obtain Po (resting intraocular pressure) from Pt (pressure with the tonometer on the eye) were developed from studies done on cadaver eyes by Friedenwald.2 20.5 8.5.0 7.2 9.6 23.0 18.0 32. Schiøtz Scale Readings: Intraocular Pressure (PO) Conversion Table (from 1955 revision): Assumes Average Ocular Rigidity (PO in mmHg) Plunger Load Scale Reading 5.3 21.2.4 43.9 16. and 15 g.4 8.5 g 7.0 10.0 9.4 57. and 9.0 8. so that the higher intraocular pressures are compressed toward the lower end of the scale.The scale measuring the amount of indentation is linear.3 25.0 4.3 38. additional weights of 2. the heavier weights expand the lower end of the scale (Table 3).6 34. may be added to the plunger to give effective plunger weights of 7.0 40. 4.2 66. 10.2 10.2 61.8 7.1 14.2 17.152 These values were basically confirmed by McBain153.4 20.5 7. Louis: CV Mosby.4 33.5 29.5 g.9 31.154 in studies using an adjustable manometer.8 22.6 12.0 5.5 6.0 25.5 g 10 g 15 g 3.1 13.8 50.9 28.0 6.8 34.5 10.6 21. The relation between the amount of indentation and intraocular pressure is not linear but about logarithmic.9 76.1 29. respectively.5 4.152 Below the scale reading of 3.0 46. 4th ed.5 11. St.4 71.1 43.1 40.9 12.5 5.2 46. 1976.0 24.8 53.9 23.5 27. TABLE 7-3.

Fig. Schiøtz tonometer on cornea. hyperopes and patients with scarred corneas have higher scleral rigidity. 11. 12). compared with an eye with average scleral rigidity at the same intraocular pressure (Table 4). resulting in overestimation of their intraocular pressures. The relative resistance an eye offers to expansion for a given rise in intraocular pressure is known as scleral rigidity. These observations were recorded and plotted on a logarithmic scale to yield the Friedenwald nomogram (Fig. Fig. which raises intraocular pressure to Pt. The scale reading will be higher and the intraocular pressure will be underestimated. Scleral rigidity from Friedenwald nomogram. Effect of Scleral Rigidity on Intraocular Pressure Measurement by Schiøtz Tonometry and Outflow Facility* . and the volume of the eye expands slightly. displacing a volume of aqueous humor until the elasticity of the cornea and the intraocular pressure (P) push back with enough force to prevent further sinking of the plunger. scleral rigidity is 0.022. In this case. Theoretically. and the Schiøtz plunger sinks deeper into the cornea. the corneal and scleral coats are distended. Footplate (A) rests on corneal surface supporting weight of tonometer. 11).155 In myopic eyes.reading of the tonometer with each plunger weight was recorded. which can be obtained directly from nomogram by drawing parallel line through 20 on the pressure scale (dotted line B to scleral rigidity scale on top of nomogram). Conversely. Solid line (A) joins Po (determined by applanation tonometry) and Pt1 (Schiøtz scale reading with 5. the same line could be obtained by joining scale readings with any two Schiøtz weights indicated by dots. The plunger (B) sinks into the cornea (C). scleral rigidity is lower than average.5-g weight). A diagnosis of glaucoma may be missed. The volume of aqueous humor displaced by the weight of the tonometer was also measured. Friedenwald's tables for conversion of Schiøtz scale readings to intraocular pressure are calculated based on an average scleral rigidity. the intraocular pressure is raised. Slope of line is scleral rigidity. blood is squeezed out of internal blood vessels.155 TABLE 7-4. Scleral rigidity varies from individual to individual. SCLERAL RIGIDITY When a significant external force is applied to the eye (Fig. 12. The reciprocal of rigidity is elasticity.

5 19.) Scleral rigidity can be calculated from the Friedenwald nomogram as follows (see Fig.38 15. If tears inside the barrel are allowed to dry. A cornea that is scarred. Dirty tonometers are also potentially inaccurate. Hetherington J Jr: Becker-Shaffer's Diagnosis and Therapy of Glaucomas. The opposite is true for a patient with high ocular rigidity. This introduces significant errors and makes dependence on Schiøtz tonometry hazardous. (Kolker AE. If the tonometer is not placed perpendicular to the corneal surface.5 15.A Low rigidity (0. Note that if the patient has a low ocular rigidity. causing the plunger to stick. The American Academy of Ophthalmology has established a Committee on Tonometer Standardization.0 0.5 23.5 g. A more accurate method is to use the applanation tonometry value as Po and one Schiøtz reading as Pt. or of abnormal curvature gives inaccurate readings with the Schiøtz.5 indicated in column A. . edematous. 11): Two different weights are used to obtain two tonometer scale readings (two different values for Pt).0135) High rigidity (0. In clinical practice. The secretions in the barrel harden. a scale reading of 4. Louis.2 Poor attention to detail in manufacture can make a tonometer totally unreliable. which has set rigid criteria for Schiøtz tonometers. PO = intraocular pressure by Schi<aso>tz corrected for ocular rigidity at scale reading of 4. the friction between the barrel and plunger is increased. using the 1955 revised conversion table (see Table 3). and the total instrument must be the correct weight for the Friedenwald tables and nomogram to apply. other errors may arise. A tonometer certified by this committee or by a laboratory committed to the same standards can be expected to perform reliably.11 *Using a weight of 5. Errors of Schiøtz Tonometry In addition to the potentially large error that an abnormal scleral rigidity can produce in Schiøtz tonometry.18 23. scleral rigidity measurements are not made as often as they should be. CV Mosby.0 0. St. This table assumes an average ocular rigidity.0315) PO C Average rigidity (0. C = outflow facility corrected for ocular rigidity with final Schi<aso>tz scale reading 6. additional friction is produced between plunger and barrel. A common error is to autoclave the tonometer without first carefully cleaning it.0 0. An even larger error in outflow facility is seen with changes in the scleral (ocular) rigidity.5 (mmHg). A = applanation reading (mmHg).5 on the Schi<aso>tz tonometer would indicate a pressure of 19 mmHg. 4th ed. 1976. The slope of the line formed by joining these two points gives the scleral rigidity (mmHg change in pressure per cubic mm change in volume).0215) 19.5. the figure of 19 mmHg significantly underestimates the true intraocular pressure of 23. The footplate must be the right curvature and size.

As the tonometer stays on the eye. aqueous is forced out of the eye. then a decrease. In tonography. An initial blink or avoidance reaction may occur as the patient sees the tonometer descending toward his or her eye. The Schiøtz tonometer must be used in the supine position or in the sitting position with the head back far enough to be horizontal.A corneal abrasion can be caused by the plunger if the eye or tonometer moves during measurement. TONOGRAPHY Tonography is based on the observation that pressing on the eye causes an initial increase in intraocular pressure. This process is similar to forcing air out of an air mattress. Pressing on the mattress indents and deforms the mattress. Compared with most other methods of tonometry. By measuring the decreasing pressure in the air mattress and knowing the volume displaced by pressing on the mattress. Patients and their families can be taught how to use it for home tonometry. The pressure inside the mattress is raised temporarily. The recording is usually made over 4 minutes. the intraocular pressure is raised from Po to Pt. The degree of pressure rise depends on the plunger weight. The pressure declines to final value (Pf) at the end of the 4 minutes (and would continue to decline at a decreasing rate until a steady state was reached). the Schiøtz tonometer still has a place in clinical practice. The average pressure during tonography (Ptav) is assumed to be . displacing some of the air. This increases the rate of air loss through the open valve of the air mattress. Although largely replaced in the United States by Goldmann or other types of tonometry. portable. it is possible to calculate the volume of air lost and more importantly. simple. it is inexpensive. the Schiøtz tonometer has been a remarkably useful instrument for the past 75 years.178 When the tonometer is placed on the eye. and easily sterilized. a period found to give repeatable readings. The Schiøtz tonometer is used both to cause the initial rise to Pt and to measure the subsequent fall in pressure. With a few assumptions and a formula. Despite the many potential sources of error. particularly if checked for accuracy against Goldmann tonometry in each patient. The rate of decline in intraocular pressure is a measure of the ease or difficulty with which fluid can be forced out of the eye by the weight of the tonometer. the outflow facility can be estimated. the pressure change is inferred from the Friedenwald relations. how easily the open valve allows air to escape. That intraocular pressure seems to decrease after repeated Schiøtz tonometry had been long known when Grant178 first described clinical tonography in 1950. Tonography quantifies the change in pressure over time and became clinically feasible by the development of a Schiøtz tonometer that records the position of the plunger electronically. the volume of fluid lost as the Schiøtz tonometer presses on the eye for a given time period is measured by how far the plunger sinks into the cornea.

or aqueous secretion rate.177–179 Although tables have been constructed that allow easy calculation of outflow facility. leading to the formula where ΔVS is the change in the distention of the ocular coats.It is assumed that the Ptav provides the pressure gradient that forces the fluid out of the eye. EVP. This can cause large errors in the value of C but no practical way has been found to measure this in the living human eye. . Note that the change in corneal indentation of the tonometer plunger gives both change in volume and—by reference to the Friedenwald data—change in pressure. but it is not known how variable this factor is from eye to eye. FtT the change in aqueous secretion (Ft) over the time (T) of the tonogram. and Pvt the EVP with the tonometer on the eye. and that the facility of outflow is not affected by the tonometer itself.180 EVP is raised an average of 1.25 mm with the tonometer on the eye. The intraocular blood volume changed when the tonometer rests on the eye and squeezes blood out of the eye.2 Tonographic tables contain a correction factor for this. A technique called constant-pressure tonography has been developed that eliminates the problem of scleral rigidity. these tables are based on the formula The assumptions inherent in this formula (none of which are true) are that the ocular rigidity is average. ΔVC the change in corneal indentation. The volume change (ΔV) is assumed to be equivalent to the increased indentation of the tonometer plunger during the measurement.5.181 A significant variation in ocular rigidity results in a dramatic error in calculated outflow facility (see Table 4). ΔVB the change in ocular blood volume. that placing the tonometer on the eye does not alter intraocular blood volume.2 This method appears to be reliable but remains largely a laboratory procedure. The true topographic outflow facility should consider these factors.

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