Goldmann Model T (removable)

Applanation Tonometry
(Adult)
Standard Operating Procedure
Practice Development Team
Professional Education & Development
May 2008

PD/051/1.0

Other documents related to

this:
• Trust competency
statement
• NHS KSF: Aug 2004
• Calibration of
Tonometers SOP
(Rev. 2008)
Version 1.0
September 2007
Version History 1.0

Version Date issued Brief summary Author

of change
1.0 May 2008 Practice
Development
Team

For more information Isabelle Hamilton Bower

on the status of this Lead Nurse – Practice Development
document, please Moorfields Eye Hospital NHS Foundation
contact: Trust
City road
London
EC1V 2PD

Email: isabelle.hamilton-
bower@moorfields.nhs.uk

Tel: 020 7566 2274

Author: Practice Development Team
Department: Professional Education & Development
Accountable Director: Director of Nursing
Date of Issue: May 2008
Reference Number: PD051/1.0
Last Updated
Next updated June 2010
Approved By: Interprofessional Practice Forum
Audience: Clinical Staff

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Introduction

This standard operating procedure is intended to inform good practice, it is not a

substitute for the practitioner’s own sound clinical judgement which they should
continue to exercise. The format follows the structure of the Knowledge and Skills
Framework. It will help inform the process of assessment of competence.

Tonometry is an objective measurement of Intra Ocular Pressure (IOP) based on the

force required to flatten the cornea (Imbert-Fick principle). Tonometry is a skilled
procedure requiring training, a period of supervised practice followed by an
assessment of competence before the practitioner carries out this investigation
independently. Accurate measurement of the IOP is a critical aspect of ophthalmic
patient assessment. It informs diagnosis and the monitoring of disease progression.

Goldmann Applanation Tonometry is the gold standard for measuring IOP.

Applanation tonometry relies upon the “application of an external force to cause a
deformity of the cornea (flattening) and relating the deformation to the eye’s internal
pressure”. (Doshi & Harvey, 2003).

The Goldmann Model T (removable) tonometer consists of a lever weight system with
an adjustable scale (calibrated in grams) and a feeler arm for insertion of the
tonometer probe. The probe consists of a cone with a flat end containing two prisms
mounted with their apices together. When the probe is in contact with the cornea, the
two prisms (split prism) are seen as two semicircles known as mires. The mires can
be moved into the optimum position by adjusting the measuring drum to either
increase or decrease the pressure being applied by the lever weight. The optimum
position is when the inner aspect of each mire is just touching. See figure 1.

Figure 1
Tear miniscus seen through the prism when the weight applied is
at the correct level for IOP measurement.

The measuring drum scale is calibrated in grammes. This measurement is expressed

clinically in millimetres of mercury (mmHg) i.e. 2-grammes = 20 mmHg.

The accepted method of writing results of tonometry measurement in the Trust is to

write the result for the right eye on the left side of the paper and visa versa. You may
indicate that the figures relate to IOP measurement either by placing the numbers

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either side of a capital letter A (applanation) or a capital letter T (tonometry) as
follows: -
18 T 20
(Right) (Left)

18 A 20
Potential errors in measurement occur when the practitioner accepts inappropriate
flourescein patterns (see table 1).
View seen Problem Solution
Mires too thick/wide Prism too moist or lids touching Wipe prism with clean tissue
prism
Mires too thin Tear film too scant Allow patient to blink several
times or consider tear film
substitute
Large incomplete Too much pressure applied to Careful repositioning.
mires cornea or incorrect positioning
i.e. too high or too low or not
central
Mires touching on Insufficient pressure being Increase pressure by turning
outer aspect applied by control weight the revolving knob on
measuring drum
Mires seen as Insufficient pressure being Increase pressure by turning
continuous S shape applied by control weight the revolving knob on
measuring drum
Table 1 Cause of abnormal tonometry flourescein mires and suggested solutions.

There are other sources of error for example; corneal pathology; previous refractive
surgery. As part of this procedure the practitioner should be aware of the patient’s
ophthalmic history in order to anticipate potential difficulties.

One other common source of IOP measurement error is through faulty equipment i.e.
tonometer calibration not checked. Please see Standard Operating Procedure of the
Calibration of Tonometers prior to commencement of this procedure to and check
daily calibration testing carried out on equipment being used.

Preparation

Wash your hands and clean the slit lamp as per Trust Infection Control Manual.
Rationale To prevent cross infection

Introduce self to patient, establish rapport and sit the patient safely at the slit lamp.
Rationale To treat patient with respect and dignity

Explain procedure to patient in a reassuring manner.

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Rationale To ensure patient understands the procedure and gives valid consent

Procedure

Instil anaesthetic and flourescein drop/s as per Trust PGD for tonometry and allow the
patient time to recover from stinging sensation.
Rationale To anaesthetise and stain the patient’s tear film for patient comfort and
to ensure clear view of mires.

Check the slit lamp eyepieces are correctly focussed and set magnification X 10.

Adjust slit beam control to cobalt blue filter setting. Adjust the transformer to 6V for
medium light intensity and open the aperture to maximum.
Rationale To ensure the equipment is set up for maximum viewing potential.

Ask the patient to place their chin on the chinrest and press their forehead against the
head bar, looking straight ahead with eyes open.
Rationale To allow examination of the cornea

Examine both corneas with the illuminator arm at 45-degree temporal angle for each.
View cornea down the microscope with viewing arm at 90-degrees, broad beam
illumination and X10 magnification.
Rationale To provide a baseline corneal surface examination prior to contact
tonometry.

Mount disposable prism on to the disposable prism holder. Ensure the prism is
clicked into position and check the surface is level. Mount this holder and prism on to
the Goldmann model T (removable) tonometer. Inspect the prism to ensure it is
positioned such that a horizontal line divides the mires (You may prefer to do this
when the tonometer is mounted on the slit lamp).
Rationale To ensure optimal set up of equipment to facilitate safe and efficient
measurement.

Set the measuring drum at the graduation mark 1 (10mmHg equivalent)

Rationale Normal IOP is between 10 – 21 mmHg and by setting measuring drum
to lower setting within the range it helps to minimise contact time with
the cornea

Mount the tonometer onto the guide plate. There are two notches for the tonometer
on the guide plate. Position the tonometer so that the probe is directed slightly from
the nasal aspect (diagonally). You may need to make adjustments to the tonometer
position depending on the patient’s ability to fixate. The principle is that the
tonometer should be positioned such that the prism will lie flat against the centre of
the cornea.

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Rationale To allow the incidence to be on axis despite any slight convergence by
the patient.

Swing the slit lamp illuminator arm further temporally to an angle of 60 degrees (this
does not apply to other model tonometers).
Rationale To illuminate the tip of the prism so that the image is bright and free of
reflection

Remind patient to keep eyes still, open and if required use a fixation target. Remind
the patient to keep their head pressed against the bar.
Rationale to enable the head of the prism to touch and indent the central corneal
surface without interference from the lid margins.

Ask patient to blink

Rationale To ensure the cornea is well moistened with flourescein stained tear film

Slowly move the gliding plate forward until the prism is brought into contact with the
central cornea or pupillary area. Observe this movement with the naked eye from the
side opposite the illumination. On contact, the limbus shines with a blue light and no
further forward movement is desirable.
Rationale To ensure best positioning for accurate recording of IOP and prevent
inaccuracy through indentation

When in position, just touching the centre of the patient’s cornea, change to viewing
through the slit lamp using both eyes. Move the height adjustment lever until the
flattened area is seen as two equally sized semicircles (mires) in the middle of the
field of view. Adjust the revolving knob on the measuring drum of the tonometer until
the inner borders of the two flourescein-stained mires just touch each other on the
inner aspect.
Rationale To obtain an accurate measurement.

Withdraw the tonometer from the patient’s eye as soon as appropriate flourescein
pattern has been obtained. Minimum contact time is preferred however it is
recommended practice that you take a minimum of two readings per eye and repeat if
not within 1 mmHg of each other. Note reading from the graduations on the
measuring drum.
Rationale To obtain an accurate measurement

Repeat for the other eye.

On completion, examine both corneas with the illuminator arm at 45-degree temporal
angle for each. View cornea down the microscope with viewing arm at 90-degrees,
broad beam illumination and X10 magnification.
Rationale To ensure corneal surface has not been compromised by contact
tonometry.

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If experiencing difficulty achieving the desired flourescein pattern promptly, withdraw
from the patient’s cornea to try again and allow the patient to blink. Do not keep
prism in contact with the patient’s cornea for longer than 10 – 15 seconds between
attempts. Do not make repeated attempts if having difficulty. Disposable prisms are
single patient use only and should be disposed of into a clinical waste bag. The
prism holder may be used 20 times (i.e. one per tray) and then disposed. If prism
holder becomes contaminated prior to the 20th use, please dispose and obtain a new
one from another tray.

Wash your hands and clean the slit lamp as per Trust Infection Control manual.
Rationale To prevent cross infection

Record keeping

Record your findings in the patient’s clinical notes. Date, time, signature and
designation should be clearly recorded.

Rationale To facilitate communication within the team, to meet legal requirements

of practice and to enable monitoring over a time period

Appropriate action

Inform patient of your findings.

Rationale To facilitate good communication and a partnership approach to care

Inform appropriate person promptly if abnormal reading obtained.

Rationale To ensure patient receives appropriate and timely care as this may
indicate deterioration in a patient’s condition.