TONOMETRY AND GONIOSCOPY

Presented by Dr. Ranjani K J 1st year PG student Department of Ophthalmology St.Johns Medical College

TONOMETRY
INSTRUMENT USED TO MEASURE INTRA OCULAR PRESSURE CONTACT INDENTATION APPLANATION NON-CONTACT

HISTORY
VON GRAFFE- 1865 Maklakov instrument- late 19th century

Schiotz- indentation tonometer , first two- thirds 20th century Goldmann applanation tonometer, 1950

PRINCIPLE OF OPERATION
CONTACT
Deforming the globe and correlating the force responsible for the deformation to the pressure within the eye

NON CONTACT
Time required to deform the corneal surface in force produced by jet of air

INDENTATION TONOMETRY
Scale

SCHIOTZ TONOMETER
Needle

Weight Holder

Plunger Footplate

OPERATING TECHNIQUE

ADVANTAGES Handy and easy to use Economical

DISADVANTAGES False high iop

High scleral rigidity Hypermetropes Long standing glaucoma ARMD

Low iop- low ocular rigidty

Myopes Drugs : miotics, vasodilators Surgeries: Vitrectomy, RD using Croyopexy, scleral buckling, intra vitreal injection of compressive gas

DISINFECTION
Disassembled, barrel cleaned with two pipe cleaners, first soaked in alcohol and second dry. Footplate: alcohol swab Disposable covers

APPLANATION TONOMETRY
IMBERT FICKS LAW:
PRESSURE INSIDE = A SPHERE [P] VARIABLE FORCE TONOMETRY Goldmann tonometer Perkin tonometer Draeger tonometer Macky Marg tonometer Tonopen Cat ioo tonometer Keta tonometer Pneumatic tonometer FORCE REQUIRED TO FLATTEN SURFACE [W] AREA OF FLATTENING [A]

CONSTANT FORCE TONOMETRY

Maklakov tonometer

GOLDMANNS TONOMETRY

Thick lines

Thin lines

Settings magnification- 10x max light beam Cobalt blue filter used Illumination arm and microscope-60 measuring drum-10

POTENTIAL ERRORS

Inappropriate fluorescent pattern

Excess fluorescein- semicircles too thick , radius too small Insufficient fluorescien- semicircles too thin , radius too large Quenching of fluorescience- despite adequate concentration, Fluorescien loses its fluorescence in acidic solutions- saline, proparcaine [ph 4.5] , benoxinate [ph 4] and cause under estimation of iop as 9 mm of hg

Thickness of cornea
Thin- low iop Thick increased collagen fibrils- high iop stromal or epithelial edema- low iop

 Curvature of cornea 1mm hg- every 3D increase in corneal power With the rule astigmatism- iop is under estimated 1mm hg for every 4D Against the rule of astigmatism- over estimated

Incorrect calibration of tonometer- incorrect reading

Other factors- tight collarincrease venous return- high iop - anxiety

STERLIZATION
Swabbing the tonometer tip with an alcohol pre pad and allowing it for drying for 10 min wiping and soaking the tip in 3%hydrogen peroxide for 5 min disposable sleeves

PERKINS TONOMETER
Uses Goldmann prisms adapted small light source ADVANTAGE Portable Performed in any position of patient

DRAEGER TONOMETER
Uses different set of prisms and operates with a motor adjusting the force on these prisms

MACKY-MARG TONOMETER
Consists of plunger, movement of which is electronically monitored by transducer and recorded on paper strip
CREST : IOP and force required to deform cornea TROUGH : IOP MAXIMUM : Artificially elevated iop

TONO PEN
Hand held, self contained battery powered, portable. Probe tip has transducermeasures the applied force and micro processor analyses force/time curve generated by transducer on corneal indentation to calculate iop ADVANTAGE Portable Measure iop in distorted and edematous cornea Through bandage contact lens

PNEUMATO TONOMETER
Four major components
1. Sensing unit: nozzle covered with sialistic diaphragm 2. Transducer: converts pneumatic signal to electrical signal 3. Amplifier and recording unit: processes signal and provides visual read out 4. Air supply unit: provides compressed air

ADVANTAGES Eyes with scarred, edematous, irregular corneas Continuous intra ocular pressure monitoring Soft contact lens

MAKLAKOV TONOMETER
(Constant force applanation tonometer)
Principle: iop estimated by measuring the diameter of corneal area flattened by fixed weight Dumbell shaped metal cylinder with end plates of polished glass, on which thin layer of dye is spread. Instrument is allowed to make contact with anaesthetised cornea. Tono end is pressed on to special paper circle of dye produced, diameter of which is measured and using conversion tables iop is measured

NON CONTACT TONOMETRY

Inventor- Bernard Grolman It uses a rapid air pulse to applanate the cornea. Corneal applanation is detected via an electrooptical system. Intraocular pressure is estimated by detecting the force of the air jet at the instance of applanation.

ADVANTAGES No corneal abrasions, reaction to topical anesthetic, transmission of infectious agents Mass screening DISADVANTAGES In abnormal corneas- sub epithelial bubbles

TRANS PALPREBAL TONOMETER

Measuring intraocular pressure through the eyelid

DIATON TONOMETER
The patient is positioned so that the tip of the device and lid are overlying sclera.

Principle: The Diaton tonometer calculates pressure by measuring the response of a free falling rod from constant height interaction with eye through eyelid. Device has a position sensor and rod movement is remembered by built in processor.
F [eye elasticity force influencing the rod]

P =
S [area of eye and rod interaction] According to Newtons second law, F= m a, m= mass of rod, a= acceleration of the rod P= directly proportional to acceleration of the rod

ADVANTAGES Does not involve contact with the cornea No sterilization of the device No topical anaesthetic.

DISADVANTAGES Only moderate correlation with those provided by applanation tonometry More affected by the corneal thickness than Goldmann tonometry.

TONOMETRY IN CHILDREN
1. Under general anesthesia, use tono pen or perkins hand held tonometer Effect of anesthetising agents on iop: except ketamine and trichloroethylene, other general anaesthestics reduce iop Depolarizing muscle relaxants- sudden elevation of iop Non depolarizing muscle relaxants prevent rise in iop EXCEPT d- tubocurarine, gallamine Increased Pco2- rise in iop, Increased Po2- decrease in iop 2. Non contact tonometer

Tonography
Grant- 1950

Dynamic test used to measure facility of aqueous humor outflow

Procedure: electronic schiotz tonometr has electrical analog of pointer position is used. Electrical output signal from this instrument, to drive a chart recorder, creating a continous graphic record of pressure changes. as tonometer rests on eye, increased amounts of aqueous humor leave eye and eye softens. as this occurs, corneal indentation increases , scleral distension decreases. combined volume change with driving force and duration of test- to derive co-efficient of aqueous humour outflow-C

 Grants equation C= V
T( Ptav- Po)

v - change in vol(microlitres) T- duration of test Ptav- average pressure elevation Po- baseline pressure

Potential errors sudden eye movements or eyelid contractions frequent coughing, sneezing, breath holding Abnormal scleral rigidity

GONIOSCOPY
Gonioscopy is a clinical technique used to examine structures in the anterior chamber angle.
In 1907, Trantas, using indentation in an eye with keratoglobus, first visualized the anterior chamber angle in a living eye and coined the term gonioscopy.

Principle: The normal angle of the eye is not

visible to us due to total internal reflection of light emanating from the angle.

DIRECT GONIOSCOPES
Curve of contact lens is such that critical angle is not reached and light rays are refracted at contact lens- air interface Eg:Koeppe goniolens, Huskins Barkans lens, Swan jacobs lens,Richardson-Shaffers lens

INDIRECT GONIOSCOPES
Light rays are reflected by a mirror in contact lens[gonio prism] and leave lens nearly at right angle to the contact lens- air interface. Eg: Goldmann single, and three mirror lenses, Ziess four mirror lenses, posner and susmann four mirror lenses, Thorpe four mirror, Ritch trabeculoplasty lens

DIRECT GONIOSCOPY

50D concave lens is placed on anaesthetized cornea

space b/w inner surface of lens and cornea is filled with saline or viscous solution. Angle is viewed through binocular magnifier held with one hand, while eye is illuminated by hand held light.

Koeppe lens

ADVANTAGES Straight on view more panoramic angle recession- comparison DISADVANTAGES Difficulty of learning the technique. Instrumentation expensive and difficult to obtain. Less magnification. USES: Goniotomy for infantile glaucoma

INDIRECT GONIOSCOPY
Operating technique

 Goldmann single mirror- mirror inclined at 62

Goldmann 2 mirror- mirrors inclined at 62

Goldmann single mirror

GOLDMANN LENS

ZEISS LENS

 Goldmann 3- mirror gonio prism semicircular mirror- 59, used for gonioscopy 2 rectangular mirrors , inclined 67examine pars plana area of ciliary body another inclined 73 - examine ora serrata area of peripheral fundus Zeiss gonio lens 4 identical mirrors angled at 64

General guidelines: Use magnification- 10 to 25x Short and narrow beam [2-3mm] Use a dark room since pupillary constriction makes narrower angle appear more open

GOLDMANN TYPE LENSES

ADVANTAGES Ease in learning technique and less expensive. Greater visibility of detail than with the Koeppe technique because of higher magnification. Therefore, it is better for detection of details such as subtle neovascularization in the angle. Stability of lens over cornea better.

DISADVANTAGES Cannot perform dynamic, or indentation Gonioscopy.

FOUR MIRROR LENSES- ZIESS TYPE

ADVANTAGES Allows quick evaluation of angle structures. No coupling solution necessary. Enables differentiation between appositional (reversible) and synechial angle closure DISADVANTAGES Mastery of proper technique requires skill and practice. Tendency to underestimate the narrowness of the angle; it is difficult to avoid inadvertently applying pressure to the central cornea, thus artificially widening the angle.

NORMAL ANGLE STRUCTURES

Corneal wedge identification of Schwalbes line

 Schwalbes line- best identified by locating corneal wedge . Trabecular meshworkant- non pigmented trabecular meshwork post-pigmented Scleral spur-thin white or grey band Ciliary body- dark brown band

GRADING SYSTEMS FOR ANGLE OF ANTERIOR CHAMBER

SHAFFER SYSTEM: Grade 0 partial or complete closure Grade I 10 angle of approach Grade II 20 angle of approach Grade III 2035 angle of approach Grade IV 3545 angle of approach

SCHEIE SYSTEM:
Grade 0 - Entire angle visible as far posterior as a wide ciliary body band Grade I - Last roll of iris obscures part of the ciliary body Grade II - Nothing posterior to trabecular meshwork visible Grade III - Posterior portion of trabecular meshwork hidden Grade IV - No structures posterior to Schwalbes line visible Based upon the most posterior structure visible in the angle

INDENTATION GONIOSCOPY
1. Helps to distinguish narrow from closed angle 2. Determine whether closed portions of circumference of angle- reversible apposition of iris to mesh work or by peripheral anterior synechiae 3. Identifies plateau iris configuration 4. Identifies lens induced angle closure

Synechial closure

Appositional closure

Angle closure

Peripheral anterior synechiae in chronic angle closure

Abnormal structures:
1. Peripheral anterior synechiae 2. Neovascularisation 3. Abnormal pigmentation

Angle blood vessels

Normal vessels Neovascularisation Radial orientation Fine Thick Arborising Non-branching Crosses scleral spur Does not cross the scleral spur

NEO VASCULARISATION

NORMAL BLOOD VESSEL

 Abnormal pigmentation Exfoliation syndrome- segmental Pigmentary glaucoma- diffuse, darker brown / black

SCHEMATIC REPRESENTATION OF GONIOSCOPIC FINDINGS

Color code for gonioscopic findings

Findings 1. Iris 2. Iris pathology eg: iridectomy 3. Blood vessels 4. Synechiae 5. Membranes 6. Pigment 7. Depigmentation 8. Angle recession Color Drawn in color of eye eg: blue brown Black, cross hatched Red Orange Yellow Black Purple Brown, cross hatched

Clinical uses

Diagnostic uses:
Diagnose and provide prognosis for congenital glaucoma
Diagnose secondary glaucoma ,especially subtle angle recession, uvietic glaucoma, neovasculirisation,irido corneal endothelial syndromes. Differentiate between POAG and PACG

Black pigment balls- characterstic of resolved hyphema, s/o past trauma Diagnose- tumours of anterior segment, intra ocular foreign body, early detection of KF ring Unusual causes of glaucoma, eg. haptic of pciol protruding through peripheral iridectomy and resting in angle of anterior chamber.

Therapeutic uses:
Perform laser trabeculoplasty, iridoplasty,cryo photocoagulation, Congenital glaucoma- goniotomy Indentation gonioscopy- to break an attack of angle closure glaucoma

Limitations of gonioscopy
Cannot be formed in painful inflamed eyes Patients who are on mydriatics- as they obscure angle by bunching up of iris

Disinfection
Concave contact area- wiped with alcohol sponge Lenses - cleaned with 2% glutraldehyde Glass lenses - autoclaved

THANK YOU