E.M.B. Sept.

2000
Goldmann Applanation
Tonometry
Ted Barnett
E.M.B. Sept. 2000
Introduction
Applanation tonometry: measures IOP by
providing force which flattens the cornea.
Variable force applanation tonometers
(Goldmann, Perkins, Draeger, MacKay-
Marg, and Tono-Pen and
Pneumatonometer): area of the cornea being
applanated held constant, variable for
applied.
E.M.B. Sept. 2000
Principles
based on Imbert-Fick law:
pressure within a sphere (P) is roughly equal to the
external force (f) needed to flatten a portion of the
sphere divided by the area (A) of trhe sphere
which is flattened: P = f / A
applies to surfaces which are perfectly spherical,
dry, flexible, elastic and infinitely thin
E.M.B. Sept. 2000
Principles (cont.)
include force of cornea which pushes applanating
surface away from eye (N), subtract surface
tension of tear film toward the eye (M)
since cornea has thickness, consider only
flattening of inner corneal area (A
1
)
P = f / A1 + M - N
when A1 = 7.35, M and N cancel out so:
P = f / 7.35 mm2
E.M.B. Sept. 2000
Principles (cont.)
this internal area achieved when diameter of
external area of corneal applanation is 3.06mm
at this external diameter, grams of force applied
multiplied by 10 is directly converted to mmHg
measured pressure is 3% greater than IOP before
applanation (not corrected)
minimal displacement (0.5ul) of fluid or increase
in IOP with applanation, thus unaffected by ocular
rigidity
E.M.B. Sept. 2000
E.M.B. Sept. 2000
Technique of measurement
plastic biprism which contacts cornea creates two
semicircles
edge of corneal contact is visible after placing
fluorescein into tear film & viewing with cobalt
blue light
manually rotate the dial calibrated in grams, force
is adjusted by changing the length of a spring
within the device.
inner margins of semicircles touch when 3.06 mm
of cornea is applanated.
E.M.B. Sept. 2000
E.M.B. Sept. 2000
Instructions to patient
press head firmly against chin and forehead
rest.
look straight ahead and fixate on a target
(e.g. examiners opposite ear)
breathe normally, do not hold your breath
blink immediately prior to measurement to
moisten cornea.
E.M.B. Sept. 2000
Measurement (cont.)
position patients head with forehead rest well
above eyebrows, allowing raising of eyebrows.
anesthetic & fluorescein (0.25%) ,separately, or as
mixture (preserved) placed in inferior cul-de-sac.
with maximal illumination of biprism the lamp is
moved toward the eye until the tip of biprism
contacts the apex of the cornea
stop moving forward when limbus shines with
light, best observed with naked eye
E.M.B. Sept. 2000
Measurement (cont.)
After contact, semicircles visible through left (or
right) ocular. Center in field of view.
Adjust vertically until semicircles equal in size.
Tension dial adjusted so that inner edge of upper
and lower semicircles are aligned.
Multiply dial reading (grams of force) by 10 to
obtain IOP (mmHg)
Read at median over which arcs glide to control
for excursions due to ocular pulsations.
E.M.B. Sept. 2000
E.M.B. Sept. 2000
Measurement (cont.)
If slit-lamp moved too far toward patient the
pressure arm will push against a spring
which will press against the eye with a low
inoffensive force.
Mires (flattened area) too large, moving dial
doent alter appearance.
Solution: Draw back until regular pulsation
noted and appearance of mires normalizes.
E.M.B. Sept. 2000
Measurement (cont.)
Blue central area represents applanated cornea,
green semicircles are fluorescein-stained tears,
inner border of ring is demarcation between
flattened and non-flattened cornea.
Without staining of tears, bright reflection from
air-cornea interface is seen; leads to
underestimation of IOP.
Mires should be approximately 10% of circle
width.
E.M.B. Sept. 2000
Errors in Measurement
The fluorescein ring is too wide or too narrow:
Too wide: occurs if prism not dried after cleaning
or lids touch prism. Overestimates IOP.
Solution: dry prism
Too narrow: inadequte fluorescein concentration
may cause hypofluorescence. Underestimates
IOP. Solution: patient blinks or additional
fluorescein added.
E.M.B. Sept. 2000
Errors (cont.)
thin corneas produces underestimate
thick cornea d/t increased collagen gives
overestimate, if d/t edema gives underestimate.
inadequate vertical alignment of semicircles leads
to overstimate of IOP.
distortion d/t irregular cornea influences accuracy,
less useful with corneal scarring.
E.M.B. Sept. 2000
Errors (cont.)
squeezing of eyelids, breath holding or
other Valsalva maneuvers, pressure on
globe, excessive EOM force applied to
restricted globe, vertical gaze, tight collars,
retreating patient, inaccurately calibrated
tonometer.
repeated tonometry may induce decline in
estimated IOP.
E.M.B. Sept. 2000
Error d/t corneal curvature
increase of 1 mmHg for every 3D increase in
corneal power.
more fluid displaced under steep cornea, increases
contribution of ocular rigidity in overestimating
IOP.
the steeper the cornea, the more cornea must be
indented to produce standard area of contact.
>3D astigmatism produces elliptical rather than
circular area
E.M.B. Sept. 2000
Correction for astigmatism
With semicircles displaced horizontally, IOP
underestimated by 1 mmHg for every 4D of
WTR astigmatism, vice versa for ATR
astigmatism.
To minimize, prisms should be rotated so that axis
of least corneal curvature is opposite red line on
prism holder (i.e. align negative cylinder axis).
Can average reading with vertical and horizontal
alignment of prism.
E.M.B. Sept. 2000
Sterilization
CDC recommendation (HIV, HSV, and
adenovirus): wipe tip clean and disinfect tip
only with bleach (1:10 dilution x 5,
changed once daily).
Alternative is 3% H2O2, changed at least
twice daily (affects tip less than bleach or
ETOH).
Alternative #2: wiping tip with 70% ETOH
E.M.B. Sept. 2000
Reliability
Goldmann applanation is standard against
which others measured.
Good accuracy in gas-filled eyes.
Inter- and intraobserver variability (>30%
varied by 2-3 mmHg), due to subjective
nature of optical endpoint.
Assume error of 2 mmHg.
E.M.B. Sept. 2000
Calibration: Wessels & Oh (1990)
Tested tonometers in ophthalmologists offices.
19% outside range of manufacturers specifications
(1mmHg of calibration), 4.5% > 2mmHg error.
Annual recalibration in 86% of instruments.
Practitioners who themselves performed
calibration had the most accurate instruments.
Less than 15% knew how to perform calibration
check.
Calibration here done 4 times/year