ORIGINAL STUDY
Corneal Biomechanical Changes After Trabeculectomy
and the Impact on Intraocular Pressure Measurement
Karin R. Pillunat, MD, Eberhard Spoerl, PhD, Naim Terai, MD,
and Lutz E. Pillunat, MD, PhD
Purpose: To evaluate corneal biomechanical changes induced by
trabeculectomy and their impact on intraocular pressure (IOP)
measurements.
Materials and Methods: In total, 35 eyes of 35 consecutive glau-
coma patients undergoing first-time trabeculectomy with mitomy-
cin C were enrolled in this prospective interventional case series.
Goldmann applanation tonometry (GAT) IOP, central corneal
thickness, axial length, and Ocular Response Analyzer measure-
ments [Goldmann-correlated IOP (IOPg), corneal-compensated
IOP (IOPcc), corneal hysteresis (CH), and corneal resistance factor
(CRF)] were assessed before and 6 months after uncomplicated
trabeculectomy. Linear mixed models were used to compare the
parameters before and after surgery.
Results: IOP, central corneal thickness, and axial length showed a
strong correlation with CH and CRF preoperatively and post-
operatively. After adjusting for these influencing factors, CH
changed from 7.75 ± 1.46 to 7.62 ± 1.66 mm Hg (P = 0.720) and
CRF from 8.67 ± 1.18 to 8.52 ± 1.35 mm Hg (P = 0.640) after
trabeculectomy, but these changes were not statistically significant.
IOP decreased statistically significantly with all IOP measurements
(P = 0.001). IOPcc was statistically significantly higher than GAT
(4.82 ± 5.24 mm Hg; P = 0.001) and IOPg (2.92 ± 1.74 mm Hg;
P = 0.001) preoperatively and postoperatively (GAT,
3.29 ± 3.36 mm Hg; P = 0.001; IOPg, 3.35 ± 1.81 mm Hg;
P = 0.001). The difference between IOPcc and GAT (P = 0.5) and
IOPcc and IOPg (P = 0.06) did not change significantly before or
after trabeculectomy.
Conclusions: Despite a marked IOP reduction and a possible
weakening of the ocular walls after trabeculectomy, corneal
structural tissue properties are not altered, and therefore, the
accuracy of IOP measurements is not changed postoperatively. It
seems likely, however, that Goldmann-correlated IOP measure-
ments are underestimated in glaucoma patients before and after
surgery.
Key Words: trabeculectomy, corneal hysteresis, corneal resistance
factor, intraocular pressure, tonometry, corneal biomechanics
(J Glaucoma 2017;26:278–282)
Received for publication July 4, 2016; accepted October 25, 2016.
From the Department of Ophthalmology, Medical Faculty Carl Gustav
Carus, University of Technology, Dresden, Germany.
Clinical trial registration: NCT02287545.
Disclosure: The authors declare no conflict of interest.
Reprints: Karin R. Pillunat, MD, Department of Ophthalmology,
Medical Faculty Carl Gustav Carus, University of Technology,
Dresden, Germany, Fetscherstrasse 74, 01307 Dresden, Germany
(e-mail: karin.pillunat@uniklinikum-dresden.de).
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/IJG.0000000000000595
278 | www.glaucomajournal.com J Glaucoma  Volume 26, Number 3, March 2017
Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.
A ccurate measurements of intraocular pressure (IOP) are
important because IOP is crucial for the evaluation and
follow-up of patients with glaucoma.
Goldmann applanation tonometry (GAT) is the gold
standard for clinical IOP measurements, although it is
known that the accuracy of this technique may be affected
by corneal properties.1–3
The Ocular Response Analyzer (ORA; AMETEK Inc.
and Reichert Inc., Depew, NY), a noncontact tonometer,
has been designed to make up for the corneal effects on IOP
measurement and to improve IOP assessment.4 Moreover,
it generates 2 corneal biomechanical parameters: corneal
hysteresis (CH), which characterizes viscoelasticity, and
corneal resistance factor (CRF), a measure of the whole
viscoelastic resistance.
There is evidence that CH and CRF are significantly
lower in eyes with glaucoma compared with normal eyes,
even when the influence of IOP is taken into consid-
eration.5–10 This is probably an effect caused by the glau-
comatous disease itself. It seems possible that a lower CH
and CRF is a sign of accelerated aging11 and part of the
complex multifactorial pathogenesis of glaucoma.
As recent studies have shown,12–16 adjusting CH and
CRF values for their influencing factors [IOP, central cor-
neal thickness (CCT), axial length, and age] is very
important to analyze and interpret these parameters. Not
correcting for these variables leads to wrong conclusions.15
Some studies have shown an increase in CH and a
decrease in CRF after glaucoma surgery, suggesting a
partial recovery of CH and CRF and altered corneal bio-
mechanics after IOP reduction.17–20
The purpose of this study was to investigate the effect
of a functioning trabeculectomy on ocular biomechanical
properties, taking the influencing factors on these meas-
urements into account, and evaluating the impact on IOP
measurements.
MATERIALS AND METHODS
In total, 35 eyes of 35 consecutive white patients with
open-angle glaucoma undergoing first-time uncomplicated
trabeculectomy with mitomycin C (MMC) were included in
this prospective interventional case series.
All trabeculectomies were performed by 2 surgeons
(K.R.P. and L.E.P.) using the same technique. After the
preparation of a fornix-based conjunctival flap, two
9 4 mm Merocel sponges soaked with 0.2 mg/mL of MMC
(0.02%) were applied below the conjunctiva for 3 minutes.
The anterior free margin of the conjunctival flap was spared
from exposure to MMC. The area exposed to MMC was
irrigated with 5 mL of balanced salt solution. A 3 3 mm
partial-thickness scleral flap was dissected at the 12-o’clock
position. After preparing a paracentesis at the 10-o’clock
J Glaucoma  Volume 26, Number 3, March 2017
position, the anterior chamber was filled with Healon GV
(Abbott Laboratories inc. Abbott Park, IL). The scle-
rostomy was performed with the Kelly punch after an
incision of the cornea, anterior to the scleral spur with a
diamond knife. A peripheral iridectomy was performed.
The scleral flap was sutured with two 10-0 nylon sutures
and the conjunctiva was sutured with 2 to 3 single-knot 10-
0 nylon sutures. After forming the filtering bleb by the
application of balanced salt solution into the anterior
chamber, also monitoring for bleb-leaks, a 10-0 nylon
mattress suture was set at the limbus.
Postoperatively, patients received preservative-free topical
steroids (dexamethasone; Dexa EDO, Dr. Mann Pharma
GmbH, Germany) 5 times a day for 4 weeks, with gradual
tapering. Furthermore, preservative-free topical antibiotics
(ofloxacin; Floxal EDO, Dr. Mann Pharma GmbH) were
obtained 3 times a day for a week and a preservative-free
mydriatic (cyclopentolat; Zyklolat EDO, Dr. Mann Pharma
GmbH) twice a day for a week. Laser suturolysis, if necessary,
was performed during the first 4 weeks of follow-up.
Exclusion criteria were as follows: use of contact
lenses, any corneal disease, previous refractive surgery,
prior incisional glaucoma surgery, diagnosis of angle clo-
sure glaucoma, age below 18 years.
GAT-IOP was measured on the day of surgery (Haag-
Streit, Koeniz, Switzerland). The mean of 3 measurements was
used. After informed consent to the study, participants
underwent ORA (AMETEK Inc. and Reichert Inc.) meas-
urements. The mode of action of this instrument has been
described previously.21 An air pulse, similar to that used in
noncontact airpuff tonometry, achieves a first applanation
state, which then returns from milliseconds of concavity into a
second applanation state, before returning to its normal convex
curvature. The average pressure of the inward and outward
applanation is the traditionally measured Goldmann-correlated
IOP (IOPg). The difference between the inward and outward
applanation pressure is the CH, which characterizes the cor-
nea’s viscoelastic response and energy absorption or damping
capacity. Two other parameters have been defined through
empirical investigations. Corneal-compensated IOP (IOPcc)
was designed to be free from the biomechanical effects of the
cornea and is calculated from IOPg and CH. CRF, a measure
of the whole viscoelastic resistance, was designed to have
maximum correlation with CCT.12 Each measurement con-
sisted of 4 air pulses and the one with the best-signal value was
chosen by the instrument (software 3.01) and used for analysis.
Intraexaminer and interexaminer reproducibility for all ORA
parameters have been shown to be high.22 Lam et al23 showed
that there is no difference between the mean of 3 or 4 meas-
urements and the best-signal value chosen by the instrument.
Measurements with waveform scores of r3.5 were excluded.23
AL was measured by means of partial optical coher-
ence interferometry with the IOLMaster (Carl Zeiss Med-
itec AG, Jena, Germany) and the CCT with the Pentacam
HR3 (Oculus, Wetzlar, Germany).
All measurements were repeated during a routine fol-
low-up, 6 months after surgery.
The study was approved by the ethics committee of the
Medical Faculty of the University of Technology, Dresden,
Germany, and followed the tenets of the Declaration of
Helsinki.
Data Analysis
Normally distributed variables were expressed as
mean ± SD and non-normally distributed variables as
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.
Corneal Biomechanical Changes After Trabeculectomy
median and interquartile range. A linear mixed model was
used to compare the parameters before and after trabecu-
lectomy. Because CH and CRF are IOP-dependent, CCT-
dependent and AL-dependent, IOP (IOPg or IOPcc), CCT,
and AL were included as covariates and the adjusted mean
values were calculated. The adjustment for multiple tests
was chosen according to Sidak. Expecting a difference of
1 mm Hg in CH with a SD of 1.7 (a = 0.05,  = 0.8), a
sample size of 25 was calculated with the G*Power 3.1.9.2
Sample size software. SPSS 22 (IBM Corp., Armonk, NY)
served as the statistical software. A P < 0.05 was consid-
ered statistically significant.
RESULTS
Patient demographics and ocular parameters are
shown in Table 1.
All IOP measurements (GAT-IOP, IOPg, and IOPcc)
were significantly lower 6 months after surgery (Table 2).
The difference between Goldmann-correlated IOPg and
GAT-IOP was not statistically significantly different before
(P = 0.180) or after surgery (P = 0.699), whereas IOPcc
was statistically significantly higher than IOPg (P = 0.001)
as well as GAT-IOP (P = 0.001) before and after surgery
(Fig.1).
The difference between IOPg and GAT, IOPcc and
GAT, as well as IOPcc and IOPg did not change sig-
nificantly after trabeculectomy (P = 0.081, P = 0.192,
P = 0.224, respectively) compared with preoperative values
(Table 2).
CH increased from 7.22 ± 2.08 to 8.54 ± 1.78 mm Hg
(P = 0.005) (Fig. 2) and CRF decreased from 9.86 ± 2.76 to
6.98 ± 1.62 mm Hg (P = 0.001) (Fig. 3). There was a strong
correlation between IOPg (CH: r = 0.687; P < 0.001; CRF:
r = 0.886; P < 0.001) as well as IOPcc (CH: r = 0.778;
P < 0.001; CRF: r = 0.817; P < 0.001), CCT (CH: r = 0.185;
P = 0.150; CRF: r = 0.433; P < 0.001) and AL (CH:
r = 0.479; P < 0.001; CRF: r = 0.157; P = 0.276) with CH
and CRF. Therefore, these factors were taken into account as
covariates in a linear mixed model. With IOPg, CCT, and AL
as covariates, CH changed from 7.75 ± 1.46 to
7.62 ± 1.66 mm Hg, which was no longer statistically sig-
nificantly different (P = 0.720) and CRF from 8.67 ± 1.18 to
TABLE 1. Patient Demographics and Ocular Parameters
Age (y) 70.1 ± 8.1
Sex (male/female) 21/14
BCVA in logMAR 0.169 ± 0.226
SE (D) 0.96 ± 2.30
Phakic/pseudophakic 26/9
CCT (mm) 515.6 ± 34.6
Type of glaucoma 23 HPG/8 NPG/4PEG
Known duration of glaucoma (y) 12.0 ± 8.6
No. glaucoma medications 3.9 ± 0.9
Preoperative GAT-IOP (mm Hg) 20.4 ± 9.0
MD (dB) 10.1 ( 16.9, 4.6)
PSD (dB) 8.6 (4.9, 12.1)
Means and SD, numbers, median, and interquartile range (MD and
PSD).
BCVA indicates best-corrected visual acuity; CCT, central corneal
thickness; GAT-IOP, Goldmann applanation tonometry intraocular pres-
sure; HPG, high-pressure glaucoma; MD, mean deviation; NPG, normal
pressure glaucoma; PEG, pseudoexfoliation-glaucoma; PSD, pattern SD;
SE, spherical equivalent.
www.glaucomajournal.com | 279
Pillunat et al J Glaucoma  Volume 26, Number 3, March 2017

preoperatively, whereas only 1 patient (2.9%) received pros-

TABLE 2. Change in Intraocular Pressure (mm Hg) and Corneal taglandins postoperatively; therefore, prostaglandins were not
Biomechanical Parameters (mm Hg) After TE
included in a multivariate model.
Parameters Before TE After TE P
GAT-IOP 20.4 ± 9.0 9.2 ± 2.7 0.0001
IOPg 22.7 ± 11.7 9.3 ± 4.3 0.0001 DISCUSSION
IOPcc 25.6 ± 11.6 12.7 ± 4.7 0.0001 In the current study, a functioning trabeculectomy
IOPg-GAT 1.89 ± 5.25 0.06 ± 2.92 0.081 serves as a model to compare corneal biomechanical
IOPcc-GAT 4.82 ± 5.24 3.29 ± 3.36 0.192 response to an airpuff after a marked IOP reduction and an
IOPcc-IOPg 2.92 ± 1.74 3.35 ± 1.81 0.224 excision of limbal tissue containing trabecular meshwork,
CCT (mm) 515.6 ± 34.6 529.1 ± 36.1 0.001
sclera, and the adjacent basal iris, ie, after a possible
AL (mm) 24.1 ± 1.4 23.9 ± 1.2 0.036
CH 7.22 ± 2.08 8.54 ± 1.78 0.005 weakening of the ocular walls. A functioning trabeculec-
CH(IOPg adj.) 7.93 ± 1.72 7.64 ± 1.73 0.469 tomy, ie, IOP <15 mm Hg, and a working bleb implicate
CH(IOPg + CCT adj.) 7.75 ± 1.75 7.77 ± 1.66 0.956 that the sclerotomy must be open and not scarred.
CH(IOPg + CCT + AL adj.) 7.75 ± 1.46 7.62 ± 1.66 0.720 This study could not find any alteration in the struc-
CH(IOPcc adj.) 8.04 ± 1.47 7.53 ± 1.46 0.149 tural tissue properties of the cornea 6 months post-
CH(IOPcc + CCT adj.) 7.87 ± 1.50 7.66 ± 1.40 0.563 operatively, once the confounding effects of IOP, CCT, and
CH(IOPcc + CCT + AL adj.) 7.82 ± 1.26 7.55 ± 1.35 0.410 AL on biomechanical measurements were considered.
CRF 9.86 ± 2.76 6.98 ± 1.62 0.0001 At present, it is not possible to measure biomechanical
CRF(IOPg adj.) 8.64 ± 1.45 8.36 ± 1.47 0.413
parameters of the peripapillary sclera and of the lamina
CRF(IOPg + CCT adj.) 8.55 ± 1.79 8.54 ± 1.79 0.977
CRF(IOPg + CCT + AL adj.) 8.67 ± 1.18 8.52 ± 1.35 0.640 cribrosa directly. There are, however, presumptions that
CRF(IOPcc adj.) 8.83 ± 1.48 8.36 ± 1.41 0.413 CH and CRF, which can easily be measured in vivo, reflect
CRF(IOPcc + CCT adj.) 8.70 ± 1.82 8.39 ± 1.71 0.502 the biomechanical properties of this area.24 If ORA meas-
CRF(IOPcc + CCT + AL adj.) 8.77 ± 1.51 8.40 ± 1.65 0.349 urements were to reflect ocular biomechanics in general and
not only corneal properties, one would expect weaker bio-
Means and SD. mechanical parameters after the excision of ocular tissues,
Adj indicates adjusted; AL, axial length; CCT, central corneal thickness; CH,
corneal hysteresis; CRF, orneal resistance factor; GAT-IOP, Goldmann appla- involved in penetrating glaucoma surgery. This assumption
nation tonometry intraocular pressure; IOPcc, corneal-compensated intraocular is not supported by the current data, although there seems
pressure; IOPg, Goldmann-correlated intraocular pressure; TE, trabeculectomy. to be a relationship between hysteresis and optic nerve
surface compliance.24,25 We therefore hypothesize that the
parameters measured with the ORA might represent
properties of only the cornea but not of other anatomic
8.52 ± 1.35 mm Hg, which did not reach statistical significance structures of the eye.
either (P = 0.640) (Table 2, Figs. 2, 3). Taking IOPcc, CCT, Corneal biomechanical parameters do not recover
and AL as covariates, CH changed from 7.82 ± 1.26 to after surgical IOP lowering, as some studies have
7.55 ± 1.35 mm Hg, which again was not statistically sig- shown.17–20 The reason for this conclusion might be that
nificantly different (P = 0.410) and CRF from 8.77 ± 1.51 to they did not take the impact of IOP and other influencing
8.40 ± 1.65 mm Hg (P = 0.349) (Table 2). Age, another factors on the measurement of these parameters into
influencing factor on corneal biomechanical parameters, did account. The measured changes of CH and CRF after
not change significantly within the 6 months to be considered surgery can mainly be explained by IOP reduction and are
in the adjustment of the corneal biomechanical parameters. not a result of structural tissue changes such as in dia-
The severity of glaucoma did not change preoperativly or betes,26,27 aging,28 or glaucoma.5–7,29
postoperatively and showed no influence on the change of CH In contrast to a finding by Martinez-de-la-Casa et al,30
(P = 0.654) and CRF (P = 0.730). the current study did not find a difference of ORA IOPg
Topical IOP-lowering substances were significantly and GAT values at higher IOP levels before surgery or at
reduced from 3.91 ± 0.93 to 0.12 ± 0.5 6 months after trabe- quite low IOP levels after surgery. Kirwan et al31 reported
culectomy. All patients (100%) received prostaglandins findings similar to ours’ in nonglaucomatous and

FIGURE 1. IOP values before and after trabeculectomy. Error bars represent SD. *Statistically significantly different to IOPg and GAT-
IOP. IOP indicates intraocular pressure; IOPcc, corneal-compensated intraocular pressure; IOPg, Goldmann-correlated intraocular
pressure; GAT-IOP, Goldmann applanation tonometry intraocular pressure.

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Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.
J Glaucoma  Volume 26, Number 3, March 2017
FIGURE 2. Unadjusted corneal hysteresis and measurements
adjusted for central corneal thickness + Goldmann-correlated
intraocular pressure + axial length before and 6 months after
trabeculectomy. Error bars represent SD. CH indicates corneal
hysteresis; Preop, preoperative.
glaucomatous children, and Ehrlich et al32 reported similar
findings in 260 glaucoma patients.
The difference between IOPcc and GAT as well as
IOPg was statistically significant before and after surgery.
IOPcc, which integrates corneal biomechanical data,
measures IOP 3 to 4 mm Hg higher than the Goldmann-
correlated IOPs before trabeculectomy; therefore, IOP
in glaucoma patients might be underestimated using
GAT.4,29,33,34 This difference was first described by
Sullivan-Mee et al29 as the individual eye’s cornea-induced
measurement error. This measurement error did not change
significantly after surgery, which strengthens the hypothesis
that this might be characteristic for the individual eye and
relatively independent of the absolute level of IOP.29 IOP is
probably also underestimated by 3 to 4 mm Hg after tra-
beculectomy using GAT. IOPcc is statistically significantly
higher in the cohort of this study, which, however, only
included eyes with glaucoma. This is in accordance with the
findings of others.29,33 Sullivan-Mee et al29 described that
this difference was capable of discriminating between indi-
viduals with and without glaucoma. The fact that this dif-
ference did not change in the comparison of the timepoints
before and after surgery might indicate that corneal tissue
structures did not change after surgery. This might be
indirect proof that corneal biomechanical measurements
have to be adjusted for their influencing factors as men-
tioned above.
FIGURE 3. Unadjusted corneal resistance factor and measure-
ments adjusted for central corneal thickness + Goldmann-corre-
lated intraocular pressure + axial length before and 6 months
after trabeculectomy. Error bars represent SD. CRF indicates
corneal resistance factor; Preop, preoperative.
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.
Corneal Biomechanical Changes After Trabeculectomy
A strength of this study is that an uncomplicated,
functioning trabeculectomy serves as an in vivo model to
investigate biomechanical response parameters to an airpuff
after a marked IOP reduction and a possible weakening of
the ocular walls. Furthermore, it is a prospective study and
only 1 eye per patient was studied.
One of the limitations is that we cannot prove that the
ocular walls are actually weakened, although this might
seem logical. The degree of healing and scarring cannot be
determined.
Second, ORA measurements were not repeated at
other points in time after surgery. Therefore, the current
data contribute only to our understanding of CH and CRF
behavior 6 months after trabeculectomy.
In summary, corneal structural tissue properties (CH
and CRF) do not change after trabeculectomy once they
are adjusted for their influencing factors. Moreover, CH
and CRF probably do not represent biomechanical prop-
erties of other anatomic structures in the eye, besides the
cornea.
Goldmann IOP measurements might be altered in
glaucoma patients as a result of the lower corneal bio-
mechanical capacity caused by the disease process itself.
This could lead to a substantial misinterpretation and
possible mismanagement of glaucoma patients before and
after IOP-lowering surgery.
REFERENCES
1. Goldmann H, Schmidt T. Applanation tonometry. Ophthal-
mologica. 1957;134:221–242.
2. Whitacre MM, Stein RA, Hassanein K. The effect of corneal
thickness on applanation tonometry. Am J Ophthalmol.
1993;115:592–596.
3. Kohlhaas M, Boehm AG, Spoerl E, et al. Effect of central
corneal thickness, corneal curvature, and axial length on
applanation tonometry. Arch Ophthalmol. 2006;124:471–476.
4. Medeiros FA, Weinreb RN. Evaluation of the influence of
corneal biomechanical properties on intraocular pressure
measurements using the ocular response analyzer. J Glaucoma.
2006;15:364–370.
5. Congdon NG, Broman AT, Bandeen-Roche K, et al. Central
corneal thickness and corneal hysteresis associated with
glaucoma damage. Am J Ophthalmol. 2006;141:868–875.
6. Medeiros FA, Meira-Freitas D, Lisboa R, et al. Corneal
hysteresis as a risk factor for glaucoma progression: a prospective
longitudinal study. Ophthalmology. 2013;120:1533–1540.
7. De Moraes CV, Hill V, Tello C, et al. Lower corneal hysteresis
is associated with more rapid glaucomatous visual field
progression. J Glaucoma. 2012;21:209–213.
8. Prata TS, Lima VC, Guedes LM, et al. Association between
corneal biomechanical properties and optic nerve head
morphology in newly diagnosed glaucoma patients. Clin Exp
Ophthalmol. 2012;40:682–688.
9. Pillunat KR, Hermann C, Spoerl E, et al. Analyzing
biomechanical parameters of the cornea with glaucoma
severity in open-angle glaucoma. Graefes Arch Clin Exp
Ophthalmol. 2016;254:1345–1351.
10. Deol M, Taylor DA, Radcliffe NM. Corneal hysteresis and its
relevance to glaucoma. Curr Opin Ophthalmol. 2015;26:96–102.
11. Ishii K, Saito K, Kameda T, et al. Elastic hysteresis in human
eyes is an age-dependent value. Clin Exp Ophthalmol.
2013;41:6–11.
12. Roberts CJ. Concepts and misconceptions in corneal bio-
mechanics. J Cataract Refract Surg. 2014;40:862–869.
13. Bao F, Deng M, Wang Q, et al. Evaluation of the relationship
of corneal biomechanical metrics with physical intraocular
pressure and central corneal thickness in ex vivo rabbit eye
globes. Exp Eye Res. 2015;137:11–17.
www.glaucomajournal.com | 281
Pillunat et al
14. Alhamad TA, Meek KM. Comparison of factors that influence
the measurement of corneal hysteresis in vivo and in vitro. Acta
Ophthalmol. 2011;89:e443–e450.
15. Spoerl E, Pillunat KR, Kuhlisch E, et al. Concept for analyzing
biomechanical parameters in clinical studies. Cont Lens
Anterior Eye. 2015;38:389.
16. Roberts CJ. Importance of accurately assessing biomechanics
of the cornea. Curr Opin Ophthalmol. 2016;27:285–291.
17. Sun L, Shen M, Wang J, et al. Recovery of corneal hysteresis
after reduction of intraocular pressure in chronic primary
angle-closure glaucoma. Am J Ophthalmol. 2009;147:1061.e1-
2–1066.e1-2.
18. Shimmyo M. Recovery of corneal hysteresis after reduction of
intraocular pressure in chronic primary angle-closure glau-
coma. Am J Ophthalmol. 2009;148:623. Author reply 623.
19. Pakravan M, Afroozifar M, Yazdani S. Corneal biomechanical
changes following trabeculectomy, phaco-trabeculectomy,
Ahmed glaucoma valve implantation and phacoemulsification.
J Ophthalmic Vis Res. 2014;9:7–13.
20. Iordanidou V, Hamard P, Gendron G, et al. Modifications in
corneal biomechanics and intraocular pressure after deep
sclerectomy. J Glaucoma. 2010;19:252–256.
21. Luce DA. Determining in vivo biomechanical properties of the
cornea with an ocular response analyzer. J Cataract Refract
Surg. 2005;31:156–162.
22. Mandalos A, Anastasopoulos E, Makris L, et al. Inter-
examiner reproducibility of Ocular Response Analyzer using
the waveform score quality index in healthy subjects.
J Glaucoma. 2013;22:152–155.
23. Lam AK, Chen D, Tse J. The usefulness of waveform score from
the ocular response analyzer. Optom Vis Sci. 2010;87:195–199.
24. Wells AP, Garway-Heath DF, Poostchi A, et al. Corneal
hysteresis but not corneal thickness correlates with optic nerve
surface compliance in glaucoma patients. Invest Ophthalmol
Vis Sci. 2008;49:3262–3268.
25. Bochmann F, Ang GS, Azuara-Blanco A. Lower corneal
hysteresis in glaucoma patients with acquired pit of the optic
282 | www.glaucomajournal.com Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved.
J Glaucoma  Volume 26, Number 3, March 2017
nerve (APON). Graefes Arch Clin Exp Ophthalmol. 2008;246:
735–738.
26. Sahin A, Bayer A, Ozge G, et al. Corneal biomechanical
changes in diabetes mellitus and their influence on intraocular
pressure measurements. Invest Ophthalmol Vis Sci. 2009;50:
4597–4604.
27. Castro DP, Prata TS, Lima VC, et al. Corneal viscoelasticity
differences between diabetic and nondiabetic glaucomatous
patients. J Glaucoma. 2010;19:341–343.
28. Kotecha A, Elsheikh A, Roberts CR, et al. Corneal thickness-
and age-related biomechanical properties of the cornea
measured with the ocular response analyzer. Invest Ophthalmol
Vis Sci. 2006;47:5337–5347.
29. Sullivan-Mee M, Billingsley SC, Patel AD, et al. Ocular
Response Analyzer in subjects with and without glaucoma.
Optom Vis Sci. 2008;85:463–470.
30. Martinez-de-la-Casa JM, Garcia-Feijoo J, Fernandez-Vidal A,
et al. Ocular response analyzer versus Goldmann applanation
tonometry for intraocular pressure measurements. Invest
Ophthalmol Vis Sci. 2006;47:4410–4414.
31. Kirwan C, O’Keefe M, Lanigan B. Corneal hysteresis and
intraocular pressure measurement in children using the
reichert ocular response analyzer. Am J Ophthalmol. 2006;142:
990–992.
32. Ehrlich JR, Haseltine S, Shimmyo M, et al. Evaluation of
agreement between intraocular pressure measurements using
Goldmann applanation tonometry and Goldmann correlated
intraocular pressure by Reichert’s ocular response analyser.
Eye. 2010;24:1555–1560.
33. Morita T, Shoji N, Kamiya K, et al. Intraocular pressure
measured by dynamic contour tonometer and ocular response
analyzer in normal tension glaucoma. Graefes Arch Clin Exp
Ophthalmol. 2010;248:73–77.
34. Costin BR, Fleming GP, Weber PA, et al. Corneal bio-
mechanical properties affect Goldmann applanation tonom-
etry in primary open-angle glaucoma. J Glaucoma. 2014;23:
69–74.