Ординатура / Офтальмология / Английские материалы / Shields Textbook of Glaucoma, 6th edition_Allingham, Damji, Freedman_2010

Figure 2.12 Measurement of IOP using the handheld Icare rebound tonometer. Comparison of Tonometers

The most precise method for evaluating the accuracy of a tonometer is to compare it with manometric measurements of the cannulated anterior chamber. Although this technique is frequently used with animal and autopsy eyes, its use in largescale human studies has been limited. The alternative is to compare the tonometer in question against the instrument that previous studies have shown to be the most accurate. In eyes with regular corneas, the Goldmann applanation tonometer is generally accepted as the standard against which other tonometers must be compared. Even with this instrument, however, inherent variability must be taken into account. When two readings were taken on the same eye with Goldmann tonometers in a short time frame, at least 30% of the paired readings differed by 2 and 3 mm Hg or more (213). In another study, intraobserver variation was 1.5 ± 1.96 mm Hg and interobserver variation was 1.79 ± 2.41 mm Hg, which could be reduced by 9% and 11%, respectively, by using the

median value of three consecutive measurements (214).

Clinically, the most widely used methods for measuring IOP are by Goldmann applanation tonometry and with use of the Tono-Pen; the noncontact tonometer, Perkins tonometer, pneumotonometry, and the Schiötz tonometer are not used as much. In general, the Schiötz tonometer reads lower than the Goldmann, even when the postural influence on IOP is eliminated by performing both measurements in the supine position (215). The Perkins applanation tonometer compared favorably against the Goldmann tonometer (216). In a comparison of readings obtained by the Perkins tonometer, the Tono-Pen, and the Schiötz tonometer, the greatest agreement was betwe en the Perkins and Tono-Pen tonometers in children under anesthesia (217).

The Tono-Pen has been compared favorably with manometric readings in human autopsy eyes (218, 219). In clinical comparisons with Goldmann applanation readings, some studies found a good correlation, especially within the normal IOP range, although most studies agree that the Tono-Pen underestimates Goldmann IOP in the higher range and overestimates in the lower range (195, 220).

In multiple comparative studies, readings taken with the pneumotonometer correlated closely with those obtained by using Goldmann tonometers, although the pneumotonometer readings tended to be higher (221, 222). In comparing IOPs in eyes before and after LASIK for myopia, pneumotonometry showed less IOP lowering compared with Goldmann applanation tonometry after LASIK-induced cornea thinning, which was interpreted to mean that post-LASIK IOP measurements obtained by pneumotonometry were more reliable than those taken by Goldmann applanation (223). In cat eyes, pneumotonometry was more accurate than the Tono-Pen, compared to the set IOPs established by manometry (224).

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Tonometry for Special Clinical Circumstances Tonometry on Irregular Corneas

The accuracy of Goldmann and Tono-Pen tonometers and the noncontact tonometers is limited in eyes with irregular corneas. The pneumatic tonometer has been shown to be useful in eyes with diseased or irregular corneas (225). In eyes after penetrating keratoplasty, the Tono-Pen significantly overestimated Goldmann readings (226).

Tonometry over Soft Contact Lenses

It has been claimed that pneumotonometry and the Tono-Pen can measure with reasonable accuracy the IOP through bandage contact lenses (227, 228). In cadaver eyes with four different brands of therapeutic contact lenses, readings from the pneumotonometer correlated well with manometrically determined IOP, whereas the Tono-Pen consistently underestimated the pressure (229).

Tonometry with Gas-Filled Eyes

Intraocular gas significantly affects scleral rigidity, rendering indentation tonometry particularly unsatisfactory. A pneumatic tonometer underestimated Goldmann IOP measurements in eyes with intravitreal gas, whereas measurement with the Tono-Pen compared favorably with Goldmann readings in eyes after pars plana vitrectomy and gas-fluid exchange (230). In a study of 50 eyes with irregular corneas after vitrectomy and air-gas-fluid exchange, readings with the Tono-Pen and pneumotonometer were highly correlated, although there was a mean difference of 1.4 mm Hg, with the Tono-Pen usually reading lower (220). A manometric study with human autopsy eyes indicated that both instruments significantly underestimated the IOP at pressures greater than 30 mm Hg (231).

Tonometry with Flat Anterior Chamber

In human autopsy eyes with flat anterior chambers, IOP readings from the Goldmann applanation tonometer, pneumotonometer, and Tono-Pen did not correlate well with manometrically determined pressures (232).

Tonometry in Eyes with Keratoprostheses

In patients at high risk for corneal transplant rejection, implantation of a keratoprosthesis is now a viable option for vision rehabilitation (233). However, given that most keratoprostheses have a rigid, clear surface, it is impossible to measure IOP by using applanation or indentation instruments. In such eyes,

tactile assessment appears to be the most widely used method to estimate IOP (234). KEY POINTS

The mean IOP value in the general population is approximately 15 mm Hg, and two SDs to either side of the mean gives a “normal” range of roughly 10 to 20 mm Hg.

IOP is a quantitative trait with a Gaussian distribution. IOP is an important consideration for diagnosis of glaucoma, for setting a target pressure (discussed further in Chapter 27), and for evaluating treatment outcomes.

IOP is influenced by genetics, environment, and physiology.

IOP is measured by essentially two different types of instruments that use either applanation methods, such as Goldmann tonometer, or indentation, like the Schiötz tonometer.

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