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34
Tonometry

R Sidebottom

One of the first completely new skills that the new ophthalmic practitioner must
master is measurement of the intraocular pressure (IOP).

Principles
Most tonometers give an indirect measure of IOP using the Imbert–Fick
principle, which states that the pressure (P) inside an idealised sphere is equal
to the force (F) necessary to flatten the surface divided by the area (A) of
flattening (P = F/A). The eye is not an idealised sphere, primarily because
corneal rigidity resists the force and the capillary action of the tear film attracts
the tonometer prism. The design of the Goldmann tonometer exploits these two
opposing forces, as they approximately cancel each other when the applanated
area is of 3.06 mm diameter (the diameter of the tonometer prism).

Goldmann applanation tonometer

How to use it (Fig. 34.1)

• Remove the tonometer prism from the disinfectant solution (some units use
alcohol wipes), rinse and dry it.
• Insert the prism into the tonometer bracket holder, ensuring the 0° or 180°
markings line up with the white line on the bracket. The tonometer is then
placed on the slitlamp guide plate and locked there by inserting the peg
under the tonometer into one of the holes on the plate. Some tonometers are
mounted on a pivot permanently on the slitlamp; to move these into position
swing them round until they locate centrally in the measuring position.
• Increase the light source to maximum intensity with the blue filter in place
and the slit opened fully. It should illuminate the prism from the side at about
60°. If despite maximum power the tonometer head is not well-lit, then extra
light can occasionally be found by uncoupling the slitlamp illumination
column from the microscope (Ch. 12).
• Instil a drop of anaesthetic/fluorescein mixture into the eyes. Alternatively,
separate local anaesthetic drops and a fluorescein strip may be used.
• Positioning and cooperation of the patient are vital. Ensure the patient is
comfortable with the chin on the chin rest and forehead firmly against the bar.
Ask the patient to look straight ahead with eyes wide open (say ‘stare’ rather
than ‘don’t blink’).
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CHAPTER 133
Tonometry 34
Fig. 34.1 Goldmann tonometry: the
approach. Note that the prism and patient
are at the same height and that the slitlamp
joystick is pointing backwards, ready to
carefully place the prism on to the cornea
using a fine movement.

A B
Fig. 34.2 Holding open the lids in Goldmann tonometry. Carefully holding the lids
against the orbital rims allows correct measurement of pressure in patients who are
otherwise unable to keep eyes open.

• Patients are often unable to keep the eyes open without blinking, in which
case you must gently hold open the lids with one hand (Fig. 34.2). It is
important not to apply any pressure to the globe, as this would increase the
measured IOP. To avoid this, hold the lids against the orbital rim.
• Advance the whole slitlamp towards the eye with the joystick held towards
you (Fig. 34.1). When the tip is within a centimetre or so of the cornea, use the
joystick to gently bring the tip into contact under direct vision. The limbus
will light up when you have made contact. Ensure the upper lid lashes are
avoided, as touching these often stimulates a blink.
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Examination of patients

A B C
Fig. 34.3 Views down the eyepiece using Goldmann tonometry. A. The rings of
fluorescein are too wide apart and the pressure will be measured low. B. Rings just
touching. Correct reading. C. Rings overlap. Pressure will be measured high.

• Look down the slitlamp eyepiece (only one eyepiece will be lined up with the
prism). You should see two semicircles of fluorescein shifted away from each
other along the horizontal axis (Fig. 34.3).
• Use the slitlamp joystick to position the semicircles at the centre of the prism.
Now adjust the dial to alter the force on the prism and thus alter the size and
overlap of the semicircles. The end point is when the inner edges are just
touching. The overlap will usually vary with ocular pulsation; the correct
value is the mid-point of this variation. The intraocular pressure in mmHg is
the value on the dial multiplied by ten.

Pitfalls
• If the slitlamp is moved too far forward, the feeler arm will reach its limit. The
result is large overlapping semicircles, which do not pulsate and do not
change size when the measuring dial is turned.
1
• The width of the fluorescein semicircles should be about ⁄10th the diameter of
the ring. A thin ring indicates insufficient fluorescein and tear film drying.
This will underestimate the pressure. Ask the patient to blink or instil more
fluorescein and try again. If there is too much fluorescein in the tear film,
or the prism touches the upper lid, a thick ring will be seen, resulting in
overestimation of the pressure. Dry the prism and repeat.
• Pressing on the globe whilst holding open the patient’s lids, or excessive
squeezing of the lids by the patient, will result in artificially raised pressure.
Wearing a neck tie may also lead to a falsely raised IOP measurement.
• Corneal anatomy is assumed to be normal; inaccurate values will result from
the presence of abnormal corneal thickness or pathology such as distortion. It
is possible to measure corneal thickness with a pachymeter and make an
approximate correction to the value obtained.
• Repeating the measurement allows you to take an average to improve the
accuracy.
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CHAPTER 135
Tonometry 34
Further
F
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Patients with marked astigmatism
In patients with astigmatism of greater than 3 D, the applanated area will be
elliptical, not circular. This error can be avoided by applanation at 43° to the
meridian of the greatest radius or axis of minus cylinder (see ‘Basic clinical
optics’ section). This is done by lining up the angle of minus cylinder on the
prism graduation with the red mark on the prism holder.

Further
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Calibration of the Goldmann tonometer
It is possible to check the calibration of the tonometer. This is done at dial
position 0, 2 and 6 (0, 20 and 60 mmHg equivalents).

• Insert the prism in the holder and place the tonometer on the slitlamp.
• At setting 0, the feeler arm should be in free movement; if the dial position
is moved to −0.05 the arm should fall towards the examiner, if the drum is
moved to position +0.05 the arm should fall towards the patient.
• To check settings 2 and 6, the check weight is used (this is normally found
in the case with the tonometer prisms or in the drawer of the slitlamp).
There are five markings engraved on the bar. These represent 0 centrally,
then 2 on either side and 6 towards the edges. Line up the adjustable
holder with index mark 2 on the weight. With the longer end of the bar
facing you, put it into the insert on the side of the tonometer and push all
the way in. Repeat the above manoeuvre (for setting 0), this time moving
the dial from 2 to 1.95 and 2.05. To check position 6, move the weight bar
to the end position and repeat at 6 rotating to 6.1 and 5.9. If these
measurements show that the tonometer is inaccurate, it should be returned
to the manufacturer for recalibration.

Other types of tonometer

Perkins
The Perkins tonometer works on the same principle as the Goldmann but is
portable and does not require a slitlamp, allowing measurement of the supine
patient. It is often more difficult to get accurate readings.
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Examination of patients

Tonopen
The tonopen uses a force transducer and microprocessor to calculate the IOP. It
is a self-contained battery powered device useful for children, supine patients
and gross corneal pathology. The tonopen is less accurate than a Goldmann,
especially at extremes of pressure.

Further
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How to use the Tonopen
Ensure that there is a new rubber cover over the tip. Instil an anaesthetic drop
into the eye. Turn on the tonopen by holding down the button. It will require
calibrating on start-up (for a given day); this is done by holding it tip down,
then when it displays ‘UP’ on the readout hold it tip pointing upwards.
Repeatedly tap the tonopen gently on the central cornea; it beeps with each
reading then gives a longer beep when it has enough results. An average
value will be supplied on the readout along with a 5% (best) to >20%
confidence value. Do not leave the tonopen without a new rubber cover on
the tip (even in its box) as this protects the mechanism from dust.

Non-contact tonometers
These are devices used primarily by optometrists in the community, which use
a puff of air to applanate an area of cornea, which is optically sensed by the
machine. They are less accurate than Goldmann tonometers and tend to
overestimate pressures.