Tonometry

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

4/28/12

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 )

4/28/12

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.  Pressure is the result of applying a force onto a surface.
4/28/12

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.

4/28/12

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.

4/28/12

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. When we talk about intraocular pressure.  4/28/12 . 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.

Theoretical Principle of Tonometery  There is three different principles :  APPLANATION  IDENTATION  MANOMETRY 4/28/12 .

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 4/28/12 .

APPLANATION  GOLDMANN  PERKINS  NON-CONTACT ( NCT ) TONOMETERS 4/28/12 .

Goldmann Tonometer 4/28/12 .

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. 4/28/12 .

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. 4/28/12 .

 Maklokov Tonometer  Is a method of applanation that applies a constant force to the cornea 4/28/12 .

Indentation  Schiotz tonometer 4/28/12 .

Schiotz tonometer  Disadvatages  More invasive  It is affected corneal rigidity  Repeated measurement may be misleading – due to aqueous humour being evacuated at each reading 4/28/12 .

Manometry  Is the most direct and accurate method to measure IOP  Its not use due to invasive nature of the procedure 4/28/12 .

Common Techniques  Goldmann Tonometer 4/28/12 .

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 4/28/12 .

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 4/28/12 .

Insufficient presurre on the eye on indenting the probe 4/28/12 .

Perkins Tonometer  Advantage you can use in different position 4/28/12 .

Using Perkins tonometer 4/28/12 .

and the pressure reading appears on  4/28/12 . penshape hand held devices  handheld device and calibrates digitally with the push of a button. It requires a disposable sterile cover for each patient.Tonopen  Uses both Applanation and Identation priciple  Portable. The sterile device tip is gently placed against the tear film by the doctor or technician.

Tonopen 4/28/12 .

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. 4/28/12 .Tips of Tonopen  Advisable in Children .

It is very safe due to the "no touch" technology. is widely used in doctor's offices.Non Contact Tonometry  Which generally requires no anesthetic drop. and screening facilities.  4/28/12 . clinics.

Non Contact tonometer 4/28/12 .

The reading is visible in the viewer (can also be printed on some models)  Table4/28/12 .A button on the joystick is pressed (or an automatic mechanism is triggered) and the instrument shoots its puff of  air  . 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  .Generally.

Different types of NCT 4/28/12 .

the chin and headrest of the instrument must be disinfected   Demonstration the small air puff onto the patient’s fingers  By convention.Tips fro NCT  When applicable. a safety lock usually allows the instrument to stop at a safe distance from the eye 4/28/12 . the right eye is usually tested first   If applicable.

and each time an NCT measurement is  abnormal or suspicious 4/28/12 .3 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.

Schiotz tonometer 4/28/12 .

4/28/12 . 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. The patient is placed in a supine position for the procedure.

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

Finger Tension ( Digital IOP ) 4/28/12 .

4/28/12 .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. One can only approximate whether the eye is soft. Non-cooperative patients).g. normal or hard  and compare both eyes for a notable difference.

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) 4/28/12 .

5mmHg 4/28/12 .2.Interpretation of Results  Normals  The IOP mean IOP in the normal population is 16mmHg +/.

FACTORS INFLUENCING IOP  Physical factors  Physiological factors 4/28/12 .

This is important because during the procedure it may become necessary to control the patient’s lids 4/28/12 .Physical factors  Pressure  Applying on the globe pressure on the globe tends to elevate the 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. Patient blinking also results in an increase in IOP. 4/28/12 .

aqueous production may be reduced which would decrease the IOP while if the trauma affects the anterior chamber angle structures.Trauma / inflammation  Trauma or inflammation of the eye can either decrease or increase the IOP. aqueous outflow may be reduced which would increase the IOP.  If 4/28/12 . trauma affects the ciliary body.

the ciliary body may become inflamed and decrease aqueous production therefore decreasing IOP. 4/28/12 . If a patient has an intraocular inflammation such as uveitis.

Medication  Certain IOP   Long-term use of corticosteroids (especially topical and oral) has proven to induce increased IOP.   The use of substances such as marijuana and alcohol temporarily reduce the IOP.   Certain blood pressure medications such as Beta-blockers when taken orally can reduce IOP. 4/28/12 medications may elevate or reduce .

Physiological factors  Diurnal variation Integrity  Vascular 4/28/12 .

Persons with glaucoma tend to have a greater diurnal variation. To measure diurnal variation in IOP several measurements  may be taken at various times of the day in order to make a definitive assessment. Diurnal  variation exceeding 8mmHg is a risk factor for POAG.Diurnal Variations  The IOP tends to vary throughout the day being generally highest during the morning and lowest in the evening. 4/28/12 .  The average diurnal variation is 4mmHg.

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. 4/28/12 . This can be brought on by a tight collar or when the patient holds their breath  during tonometry.

then aqueous production is reduced and IOP is decreased. When there is carotid artery 4/28/12 . including carotid occlusive disease. This may occur in persons with cardiovascular conditions. If there is poor circulation to the ciliary body.

4/28/12 .Patient Position Movement  When the patient is in a supine position or if the head is below the heart.  The IOP is measured tobe 2-3mmHg higher lying down than when the patient is sitting upright. IOP is increased. The increase in IOP can be attributed decrease the aqueous outflow.

Thank You  The most pathetic person in the world is someone who has sight.  – Helen Keller 4/28/12 . but has no vision.

903988993:579 %0 3.903983.3-0.803 !./8-04900..79  !83.70.70.6:04:84:914  .8090 .997-:90//0.8:70/94-0  22073 /439.8:53054894347190 0.70.303905.80/ %0 !820.< < 03905.

889 -:9.843 003007 .< %024895.834.909.50784339047/88420430 4.