Pediatr Nephrol

DOI 10.1007/s00467-014-2848-x

ORIGINAL ARTICLE

Early and frequent development of ocular hypertension

in children with nephrotic syndrome
Emi Kawaguchi & Kenji Ishikura & Riku Hamada & Yoshinobu Nagaoka &
Yoshihiko Morikawa & Tomoyuki Sakai & Yuko Hamasaki & Hiroshi Hataya &
Eiichiro Noda & Masaru Miura & Takashi Ando & Masataka Honda

Received: 20 September 2013 / Revised: 24 April 2014 / Accepted: 1 May 2014

# IPNA 2014

Abstract Methods In this retrospective cohort study, children with ne-

Background Prednisolone, the first-line treatment for children
with nephrotic syndrome, causes severe side effects. One of
these side effects is ocular hypertension, which can result in
severe and permanent visual disturbance. However, the exact
prevalence, severity and timing of development of ocular
hypertension have yet to be fully explored in this pediatric
patient group.
E. Kawaguchi
Division of General Pediatrics, Tokyo Metropolitan Children’s
Medical Center, Tokyo, Japan
E. Kawaguchi : K. Ishikura (*) : R. Hamada : H. Hataya :
M. Honda
Department of Nephrology, Tokyo Metropolitan Children’s Medical
Center, 2-8-29 Musashidai Fuchu, Tokyo 183-8561, Japan
e-mail: kenzo@ii.e-mansion.com
E. Kawaguchi : Y. Morikawa : M. Miura
Clinical Research Support Center, Tokyo Metropolitan Children’s
Medical Center, Tokyo, Japan
Y. Nagaoka
Department of Pediatrics, National Hospital Organization Hokkaido
Medical Center, Sapporo, Japan
phrotic syndrome treated with prednisolone for their first
episode were analyzed. Intraocular pressure was screened
with an iCare® tonometer and confirmed with Goldmann
applanation tonometry before the initiation of prednisolone
treatment and at 1 and 4 weeks thereafter.
Results A total of 26 children with nephrotic syndrome were
included in this study, of whom eight (30.8 %) required
treatment with eye drops for ocular hypertension. The median
time interval between the diagnosis of ocular hypertension
and start of treatment was 9 (range 5–31) days. At relapse of
nephrotic syndrome, all children who had undergone treat-
ment for ocular hypertension in their first episode again re-
quired treatment for ocular hypertension.
Conclusions Routine ophthalmologic examination should be
conducted from the early phase after the start of prednisolone
treatment. In addition, children with episodes of ocular hyper-
tension may be at greater risk of its reappearance with relapse
of the nephrotic syndrome.
Keywords Intraocular pressure . Children . Prednisolone .
Nephrotic syndrome . iCare tonometer . Goldmann
applanation tonometry . Side effect

T. Sakai
Department of Pediatrics, Shiga University of Medical Science,
Ōtsu, Japan Introduction

Y. Hamasaki Corticosteroid medications, such as prednisolone, play a fun-

Department of Pediatric Nephrology, Toho University Faculty of
damental role in the treatment of children with idiopathic
Medicine, Tokyo, Japan
nephrotic syndrome. Approximately 80–90 % of children re-
E. Noda spond to prednisolone [1], and its introduction has dramatically
Division of Ophthalmology, Tokyo Metropolitan Children’s Medical reduced mortality rates [2]. However, about 30 % of children
Center, Tokyo, Japan
experience frequent relapses [3–5], and they may also develop
T. Ando severe side effects to prednisolone, including Cushing’s dis-
Japan Clinical Research Support Unit, Tokyo, Japan ease, growth failure, hypertension, gastrointestinal effects,

musculoskeletal effects, susceptibility to infections and oph-
thalmologic diseases [6].
The ophthalmologic side effects associated with corticoste-
roid use are particularly severe and sometimes cause perma-
nent visual dysfunction. Prednisolone induces an elevation of
intraocular pressure (IOP) via increased aqueous outflow re-
sistance owing to an accumulation of extracellular matrix in
the trabecular meshwork [7], and subsequent ocular hyperten-
sion affects visual function. Steroid-induced ocular hyperten-
sion and permanent visual disturbances have been reported in
children with nephrotic syndrome and other diseases [8, 9].
Prompt treatment prevents retinal nerve fiber layer damage
and visual acuity loss [10, 11], but the exact prevalence and
severity of this condition have yet to be fully explored in these
children. In addition, the precise time during the management
of nephrotic syndrome when there is a risk of progression to
increased IOP is unknown.
Here, we report the results of our retrospective cohort study
in which we investigated the prevalence and course of steroid-
induced ocular hypertension in children during their first
episode of nephrotic syndrome and its reappearance at relapse.
Materials and methods
Study design and participants
This was a retrospective cohort study of children (age range
1–18 years) with nephrotic syndrome who were managed in
Tokyo Metropolitan Children’s Medical Center during their
first episode between March 2010 and October 2012. The
criteria for and definitions of nephrotic syndrome and relapse
were in accordance with those of the International Study of
Kidney Disease in Children (ISKDC) [12]. Data pertaining to
the diagnosis, treatment regimen, ocular management and
other complications were analyzed based on the medical
records of each patient.
The study was conducted in accordance with the ethical
principles set out in the Declaration of Helsinki and with the
ethical guidelines for epidemiological studies issued by the
Ministry of Health, Labour and Welfare in Japan. The study
was approved by the ethics board of our institution (ID: H25-24).
Due to the retrospective nature of the study (data were collected
retrospectively from patient charts), informed consent was not
obtained in accordance with the above guidelines.
Management of nephrotic syndrome
At presentation of the first episode of nephrotic syndrome,
all children were admitted to the hospital for 5 weeks. The
patients received 60 mg/m2/day of prednisolone during
the first 4 weeks of hospitalization, concomitant with
blood analyses (complete blood cell count and blood
Pediatr Nephrol
chemistry) and urine tests (urinalysis and quantitative
proteinuria) weekly and daily, respectively, until remis-
sion; thereafter, blood analyses and urine tests were per-
formed monthly and weekly, respectively. Prednisolone
was administered to the patients with nephrotic syndrome
based on the following protocol [13]: for the initial epi-
sode of nephrotic syndrome, prednisolone was adminis-
tered for 4 weeks at a dose of 60 mg/m2/day (calculated
based on ideal weight; maximum dosage 80 mg/day)
divided into three doses, followed by 40 mg/m2/day on
alternate days for 4 weeks. With the occurrence of a
relapse, prednisolone at 60 mg/m2/day divided into three
doses was given until remission, followed by 60 mg/m2/
day on alternate days for 2 weeks, 30 mg/m2/day on
alternate days for 2 weeks and finally15 mg/m2/day on
alternate days for 2 weeks.
Ophthalmologic management
During an initial screening, the IOP of the children was
measured using an iCare® tonometer (Icare Finland Oy,
Helsinki, Finland). If the IOP as measured with the iCare
tonometer was above the normal level (≧30 mmHg), the
IOP was measured again by Goldmann applanation tonometry
(GAT). Treatment for ocular hypertension was started when
the IOP measured with the GAT exceeded 25 mmHg, based on
the decision of a pediatric ophthalmologist.
The IOP was measured in accordance with standard clini-
cal practice at three time-points: before treatment with pred-
nisolone when available and at 1 and 4 week post-treatment
initiation. If the IOP was elevated, the measurement was
repeated. Treatment with eye drops was discontinued when
the IOP decreased to a normal range, i.e. below 20 mmHg.
However, these criteria were modified based on the schedule
for reducing prednisolone use.
The first treatment of ocular hypertension consisted of eye
drops (Timoptol® Ophthalmic Solution; timolol maleate;
MSD, Tokyo, Japan) and Xalatan® Eye Drops (latanoprost;
Pfizer Japan Inc., Tokyo, Japan). If the IOP could not be
controlled, it was treated with oral medicine, such as
Diamox® (acetazolamide; Sanwa Kagaku Kenkyusho Co.,
Aichi, Japan) or surgery. IOP was measured when the patients
were at rest, and sedation was not used.
Statistical analyses
The background characteristics of the patients were analyzed
using the mean and standard deviation for the continuous var-
iables, and frequency distribution and percentages for categor-
ical variables. Regression analysis and a Bland–Altman analysis
were performed to investigate the linear relationship between
IOP measurements made with using iCare® tonometry and
GAT. The proportion of those who needed ophthalmologic
Pediatr Nephrol
treatment was calculated using the Kaplan–Meier method using
time from the start of prednisolone treatment until ophthalmo-
logic treatment as endpoints for curve generation.
A two-sided significance level was set at 0.05. Kaplan–
Meier analyses, Student’s t tests and chi-square tests were
performed using the IBM SPSS Statistics software package
for Windows, release 20.0.0 (IBM Corp.. Armonk, NY).
Results
Patients
A total of 26 patients (17 boys, 9 girls; mean age 6.8 years) who
had experienced their first episode of nephrotic syndrome were
included in our study. The background characteristics of the
patients, those treated with eye drops for ocular hypertension
and those untreated are shown in Table 1. In total, 25 patients
had steroid-sensitive nephrotic syndrome and one patient had
steroid-resistant nephrotic syndrome at the first episode.
Evaluation of IOP measurement
The IOP of the children was measured for screening using an
iCare® tonometer. The correlation between the iCare® mea-
surement results and those obtained by GAT are shown in
Fig. 1a, b. In Fig. 1a, all points but two were included in the
95 % confidence interval (CI), and the IOP values obtained
with the iCare® tonometer tended to be higher than those
measured with GAT. Bilateral IOP was measured in all pa-
tients, and the mean differences between right and left IOP are
shown in Fig. 2. Based on the good correlation between right
and left IOP measurements, we used the mean bilateral IOP
for further analyses in our study.
Increase of IOP at the initial stage
The initial ophthalmological treatment for ocular hypertension
in eight children (30.8 %, 6 boys, 2 girls) was eye drop treatment
Table 1 Characteristics of
patients Patient characteristicsa
Age (years)
Sex (male/female) (n)
SSNS/SRNS (n)
SSNS, Steroid-sensitive nephrotic Maximum IOP (mm Hg)
syndrome; SRNS, steroid-resis-
tant nephrotic syndrome; IOP, in- Serum albumin (g/dl)
traocular pressure Serum creatinine (mg/dl)
a
All data are presented as the Urine protein/creatinine (g/g)
mean ± standard deviation (SD) Days until remission
unless indicated otherwise
(Table 1). The initiation of treatment in all patients was based on
the IOP; all patients required bilateral treatment, and all were
asymptomatic at the first episode of nephrotic syndrome.
Timolol maleate and/or latanoprost were used in the eye drop
treatment. During their first episode of nephrotic syndrome, no
patient received surgical management for ocular hypertension.
The mean age of the treated and untreated patients was 5.5±
2.2 and 7.3±5.2 years, respectively (p=0.378). With the except
of maximum IOP, there were no significant differences between
the characteristics of patients treated and untreated with pred-
nisolone (i.e. age, sex, steroid-sensitive or -resistant, serum
albumin, serum creatinine, urine protein/creatinine).
The ophthalmological treatment-free period for all patients
is given in Fig. 3. Of the eight patients who received treatment
for ocular hypertension, treatment was initiated in seven of
these before day 15 from the start of steroid treatment. Among
those who needed ocular hypertension treatment, the median
time until start of treatment for ocular hypertension was 9
(range 5–31) days. The change of IOP during prednisolone
treatment is shown in Fig. 4. IOP increased after the start of
prednisolone treatment (days 1–28), then decreased during
dose reduction of prednisolone (days 29–56), and converging
on the normal range thereafter (Fig. 4).
The number of days until remission of the nephrotic syn-
drome was not significantly different (p=0.575) between the
two groups. Two patients had primary ophthalmological ill-
ness, namely myopia, before treatment.
Increase of IOP at relapse
Nine patients experienced relapse of nephrotic syndrome dur-
ing the observational period; of these, three had undergone
treatment for ocular hypertension at the first episode of ne-
phrotic syndrome, and all required treatment at relapse. The
remaining six patients, who did not have ocular hypertension
at the first episode did not need treatment at relapse (p=0.012,
Fisher’s exact test). One patient who developed frequently
relapsing nephrotic syndrome required surgical treatment at
his sixth relapse. He presented with headache and blurred
vision, and his maximum IOP was 46 and 19 mmHg in the
Total Treated Untreated
(n=26) (n=8) (n=18)
6.8±4.7 5.5±2.2 7.3±5.2
17/9 6/2 11/7
25/1 7/1 18/0
26.0±8.5 34.5±7.0 22.5±6.6
1.4±0.6 1.4±0.4 1.3±0.7
0.41±0.28 0.34±0.13 0.44±0.33
13.9±13.2 18.0±14.1 12.1±13.3
11.7±4.9 12.8±8.0 11.1±2.9

Fig. 1 Correlation between intraocular pressure (IOP) measured with the
iCare® tonometer and by Goldmann applanation tonometry (GAT). a
Bland–Altman plot showing the differences between IOP measurements
with iCare® and those with GAT. The 95 % confidence interval (solid
horizontal lines) of the differences was 0.27–14.33. b A scattered plot of
the results of iCare® and GAT measurements. The linear regression
between iCare® and GAT is shown
right and left eye, respectively (measured by GAT). This
patient underwent trabeculotomy, and the IOP was success-
fully controlled without visual disturbance thereafter.
Including this patient no children had nearsightedness or
glaucomatous changes of the optic disk at the last ophthalmo-
logic examination.
Discussion
In this retrospective cohort study of children who received
prednisolone for their first episode of nephrotic syndrome, we
Pediatr Nephrol
Fig. 2 Difference in intraocular pressure (IOP) between the right and left
eyes. Mean difference in IOP between the right and left eyes was
−0.05 mmHg (±2.59 standard deviation; range −13 to 7 mmHg). The
Pearson product–moment correlation coefficient was 0.934
found that IOP increased in about one-third of children during
steroid treatment. Furthermore, most of the children with
ocular hypertension were treated within 2 weeks from the start
of prednisolone treatment. To our knowledge, this is the first
cohort study to identify the frequency and timing of ocular
hypertension in children with nephrotic syndrome treated with
prednisolone.
Among our patient cohort, approximately 30 % of the
children with nephrotic syndrome who received prednisolone
for their first episode required treatment for ocular hyperten-
sion. Ocular hypertension is known as an important side effect
of prednisolone, which ultimately results in visual distur-
bance. Ophthalmalgia, headache, blurred vision and visual
field defect are known symptoms of ocular hypertension, but
sometimes no symptoms appear at all [14, 15], as was also
noted in our study. Once the visual functions are impaired,
they never recover [14, 16]. The Japan Glaucoma Society
recommends early intervention because delay of treatment
may result in greater visual impairment [14]. Therefore, to
detect ocular hypertension and provide early treatment, rou-
tine ophthalmologic examination for children with nephrotic
syndrome is strongly recommended.
Among the patients enrolled in our study, approximately
75 % of those with ocular hypertension were treated within
2 weeks from the start of prednisolone treatment, which is
earlier than has been reported in previous studies [17–19].
Early evaluation with the iCare® tonometer, a suitable modality
for routine use in children, may have resulted in early detection
in our study: the median duration from start of prednisolone
Pediatr Nephrol

Fig. 3 Timing of start of treatment for ocular hypertension Follow-up phase was 60 days, and the last day of consultation was determined as the censored case

treatment to ocular hypertension was 9 days, and the earliest
case was detected on the day 5. These findings suggest that IOP
should be measured at the very least by approximately 1 week
after the start of prednisolone treatment and that measurements
should be repeated if the IOP tends to be high.
Our findings show a relationship between IOP increase and
prednisolone treatment in children with nephrotic syndrome.
To exclude the effect of treatment with eye drops, we also
conducted a mixed model analysis and found that the degree
of increase in IOP was significantly related to prednisolone
dose (data not shown). Furthermore, none of the factors,
including age, gender and hypoalbuminemia, were signifi-
cantly associated with ocular hypertension in the multiple
logistic analyses (data not shown). These findings also support
the routine examination of IOP in all children with nephrotic
syndrome who receive prednisolone. As mentioned above,
treatment with systemic steroids is a risk factor for ocular
hypertension and, therefore, other inflammatory diseases that
are treated with prednisolone, such as Kawasaki disease,
ulcerative colitis and juvenile rheumatoid arthritis, may pre-
dispose to ocular hypertension during the early stages of
treatment.
All of the children in our study who were treated for ocular
hypertension during their first episode were treated again
during relapse. Approximately 30–40 % of the general popu-
lation are considered to be potential “steroid responders” (i.e.

Fig. 4 Change of intraocular pressure (IOP) after treatment with prednisolone Dots on solid smooth lines IOP measurements, dots on broken lines IOP
after eye drop treatment. Red lines Patients treated for ocular hypertension, purple lines untreated patients

more likely develop steroid-induced ocular hypertension) [20,
21]. Our results show that approximately 30 % of children in
our study required treatment for ocular hypertension and also
suggest that children are potential “steroid responders.” About
30 % of children with nephrotic syndrome experience fre-
quent relapse, and these patients are treated repeatedly with
prednisolone [3]. Therefore, they are exposed to the risk of
complications with prednisolone [3, 13], and the possibility of
ocular hypertension is also increased. The IOP of one patient in
our study increased continuously and could not be controlled
medicinally; consequently, this patient had to undergo surgical
treatment. Children who have experienced ocular hypertension
with prednisolone treatment may frequently require treatment
for ocular hypertension during relapse. Therefore, we suggest
that children who have previously undergone prednisolone
treatment should be carefully observed.
Although GAT is a standard means to measure IOP [22], in
our study we used the iCare® tonometer for the screening test
for IOP. In our dataset, the IOP measurements with the iCare®
tomometer were higher than those obtained with GAT, and the
correlation between the two modalities was only moderate
(R2 =0.477). However, compared to GAT, the iCare® tonom-
eter is painless, requires no drops or topical anesthetic before
examination and measurements are obtained in only a fraction
of a second [23, 24]. As the use of iCare® tonometer is easy
and simple, IOP can be measured frequently, without any
burden on children. Also, several studies have shown the
utility and good correlation between iCare® and GAT
[24–28]. Therefore, we consider the iCare® tonometer to be
suitable for use in screening for IOP in children.
Several limitations to our study warrant mention. First, the
duration of the observation period was confined to the time
period of prednisolone use. In our study, we therefore assessed
IOP until the end of prednisolone treatment. We suggest that the
long-term outcome of visual function should be evaluated in
other studies. Second, prednisolone was administered for
8 weeks (60 mg/m2/day for 4 weeks, followed by 40 mg/m2/
day on alternate days for 4 weeks) for the initial episode of
nephrotic syndrome, based on the ISKDC regimen [29].
Recently, however, several guidelines have been recommending
longer protocols [3, 12]; for example, in the Children’s
Nephrotic Syndrome Consensus, prednisolone was adminis-
tered for 12 weeks (2 mg/kg/day for 6 weeks, followed by
1.5 mg/kg/day for an additional 6 weeks). Children treated in
accordance with these protocols may have a higher risk of
ocular hypertension. Third, since our study was retrospectively
conducted, IOP measurements were performed based upon
current clinical practice. Consequently, the IOP was measured
before treatment with prednisolone whenever possible, and
when the measurements were not available, they were per-
formed as soon as possible after the initiation of treatment.
The time to increased IOP could have been biased because of
these limited measurements, and IOP may have increased earlier
Pediatr Nephrol
than we found. Moreover, we may have overlooked patients
who developed increased IOP after the early phase examination.
However, even patients who had a mild increase of IOP were
followed and examined repeatedly in order to maximize our
sensitivity of detection.
In conclusion, among our patient group the IOP increased
in approximately 30 % of the children with nephrotic syn-
drome treated with prednisolone, mostly within 2 weeks from
the start of administration. We recommend that routine oph-
thalmologic examination from the early phase should be con-
ducted in these children, since early intervention and treatment
of ocular hypertension improves outcome of visual function.
Acknowledgments
Financial declaration Kenji Ishikura has received lecture fees from
Novartis Pharma and Asahi Kasei Pharma. Yuko Hamasaki has received
research grants from Novartis Pharma, and lecture fee from Novartis
Pharma and Astellas Pharma. Hiroshi Hataya has received lecture fees
and travel expenses from Asahi Kasei Pharma, Astellas Pharma, Baxter,
JMS, and Meiji Seika Pharma Co. LTD. Masataka Honda has received
lecture fees from Novartis Pharma and Asahi Kasei Pharma.
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