Which IOP measuring

device to have in your

clinic?
Dr. Aows AlJammal
M.B.Ch.B, C.A.B.Opth, MRCS (Glasgow)
 • One of the screening tools for glaucoma.
• Diagnosis of OHT and all forms of glaucoma.
• Management and follow-up assessments of
IOP in patients with OHT and glaucoma.
• Diagnosis, management, and differential
Why diagnosis of numerous ophthalmologic
tonometer is conditions that cause elevated IOP (i.e.,
Posner-Schlossman syndrome, uveitis, a long-
used? term steroid medication, pigment dispersion
syndrome, etc.).
• IOP assessment before and after surgery.
• Diagnosis, management, and follow-up of
patients with infection, trauma without globe
rupture, inflammation, etc.
 Not effective alone

Is screening Measure the IOP

by IOP
measurement
alone Measuring the
Screening
effective? ONH & RNFL

Evaluation of VF
 Sensitivity Specificity
IOP >21 mmHg 47.1% 92.4%

Is screening by
IOP
50% of POAG IOP <22
measurement
alone
patients mmHg
effective?
1 in 10-15 Detectable
patients with optic disc
high IOP damage
Whom to offer  Low systolic and diastolic
 Elevated IOP
IOP  Older age
blood pressure
measurement?  Family history of glaucoma
 Disc hemorrhage Suspicious disc
 Large cup-to-disc ratio
(Patients at  Thin central
v cornea
 High pattern standard
risk of  Low ocular perfusion deviation on threshold visual
pressure
glaucoma)  Type 2 diabetes mellitus
field testing
 Hypothyroidism
 Myopia  Male sex
Principles of IOP measurement / Applanation
• most prolific method for measuring IOP.
• Its direct contact with the cornea and
determines IOP by utilizing the Imbert-Fick
principle to measure the force applied by the
device when a predetermined area of the
cornea is flattened.
Principles of IOP measurement / ORA
• measures corneal hysteresis (CH) and IOP
through a pneumatic mechanism with a
column of air.
• After sufficient pressure is applied to
applanate the cornea, the additional
pressure needed to indent the cornea is
used to calculate corneal elasticity and
therefore CH
• Algorithms are then used to adjust the
measured IOP to compensate for the
degree of measured CH.
 Principles of IOP measurement / indentation
• involves creating a corneal deformation with a
truncated cone.
Principles of IOP measurement / rebound

It involves bouncing a small plastic-tipped metal

probe against the cornea, which creates an
induction current to calculate IOP.
 Schioetz
tonometer
 Type Principle Advantages Disadvantages Performance Price
High variability
Simple Can be used in a
supine position only still used only in
Schioetz
indentation No need of slit- Affected by various developing feasible
tonometer
lam, electricity or sources of error countries
charging Topical anesthesia is
batteries needed
 Goldmann
applanation
tonometer
(GAT)
 Type Principle Advantages Disadvantages Performance Price
Affected by corneal
Quite simple to
thickness and other
use
corneal parameters

Accurate and The accuracy depends

reproducible on the clinician’s
measurements experience
Goldmann
applanation
applanation Needs to be used with good feasible
tonometer
a slit-lamp
(GAT)
It is currently
considered as the Can be used in the
gold standard in upright position only
IOP measurement

Topical anesthesia and

fluorescein are needed
 Perkins
tonometer
 Type Principle Advantages Disadvantages Performance Price

Affected by corneal
thickness and other
corneal parameters
Can be used in a
Perkins
applanation supine position good feasible
tonometer
too
Topical anesthesia and
fluorescein are needed
TonoPen
Type Principle Advantages Disadvantages Performance Price
Hight variability and
Lightweight and
quite poor
portable
repeatability

Quick and simple Can underestimate

to use IOP values

Can be used in Topical anesthesia is

indentation/ any position needed
TonoPen moderate feasible
applanation

No need of slit-
lamp or electricity

Influenced by corneal
parameters
Self-calibration,
provides quality
index
 Air-puff
tonometers
 Type Principle Advantages Disadvantages Performance Price
Easy and fast to Need of regular
use calibration

No need to touch Readings are device-

the cornea dependent

No need of topical
anesthesia and Possible germs aerosol
Air-puff fluorescein ideal as a
applanation medium
tonometers screening tool

Influenced by corneal
parameters
Can be used by
paramedical staff
Less accurate when
IOP > 20 mmHg
 There is no generally accepted correction
formula.
The World Glaucoma Association Consensus
on IOP suggests that a correction factor
should not be used to adjust values
measured in individual patients
risk of developing POAG
OHTS was greater in eyes with
corneal thickness less than
European Glaucoma 555 µm compared with eyes
Prevention Study trials with corneal thickness 588
µm or greater.
 Ocular
Response
Analyzer
 Type Principle Advantages Advantages Disadvantages Performance Price
Simple to use, IOP correction for
self-calibration, corneal
provides quality biomechanical
index parameters

No need of topical Useful after

anesthesia and corneal refractive
fluorescein surgery
Ocular
Response applanation Possible germs aerosol good expensive
Can be used by Detection of
Analyzer
paramedical staff corneal diseases

Provides additional information

(corneal central thickness and
biomechanics)
Corvis ST
 Type Principle Advantages Advantages Disadvantages Performance Price
Simple to use, IOP correction for
self-calibration, corneal
provides quality biomechanical
index parameters

No need of Useful after

fluorescein and corneal refractive
topical anesthesia surgery
Tends to
indentation/ underestimate the GAT
Corvis ST Can be used by Detection of good expensive
applanation IOP
paramedical staff corneal diseases
values

Provides additional information

(corneal central thickness and
biomechanics)
 Type Principle Advantages Disadvantages Performance Price
Pneumotono OBF provides Affected by corneal
Pneumoton information on thickness
meters
ometers
applanation
the ocular blood Overestimates IOP
controversial expensive
pulse values
 iCare
tonometer
 Type Principle Advantages Advantages Disadvantages Performance Price
Can be used in
Ease of use with a
supine positions Needs a proper central
short learning
(iCare PRO and positioning of the tip
curve
iCare 200)
Minimal corneal
Portable and self- trauma (useful in
calibrated post-operative
patients)

iCare ballistic probe The home version

No slit-lamp or excellent feasible
tonometer (rebound) can be useful in
topical anesthesia
self-twenty-four- Influenced by corneal
or fluorescein dye
hour monitoring thickness
required
of IOP

Can be used by trained non-medical

staff
 Dynamic
contour
tonometer
 Type Principle Advantages Advantages Disadvantages Performance Price

No need of
fluorescein,
High precision
disposable
probes

Self-calibration,
provides quality
Dynamic index
contour
contour Need of slit lamp and
tonometer poor medium
matching topical anesthesia
(DCT, Additional
PASCAL) Independent
information
from corneal
(ocular pulse
properties
amplitude)

Useful after
corneal refractive
surgery
BioResonat
or ART
 Type Principle Advantages Disadvantages Performance Price

No need of Need of slitlamp and

fluorescein local anesthetic

Self-calibration,
Need of probe
provides quality
disinfection
index

BioResonato
applanation moderate medium
r ART

Required training to
High reliability use
(median of
repeated IOP
measurements)

Affected by corneal
properties
Sensimed
Triggerfish
 Type Principle Advantages Disadvantages Performance Price

Continuous
measurements It does not provide
over a 24-hour direct IOP values
period

corneal
Sensimed
curvature moderate feasible
Triggerfish
monitoring
Good tolerability

IOP estimation
accuracy not known
High
reproducibility
To sum up, what to
have in my clinic?
I think that 2 criteria are the most important, accuracy and
cost.
 Excellent
• iCare

Good
• GAT, Perkins, ORA, Corvis,
Accuracy
Moderate
• Tonopen, BioResonator ART, Airpuff

Poor
• Dynamic Contour, Schiotz
 Feasible
• iCare, GAT, Perkins, tonopen, airpuff

Moderate
Cost • BioResonator ART, Dynamic contour

Expensive
• Corvis, Ocular response analyzer