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O parte important a examinrii oculare o constituie cercetarea oricror stri anormale ale ochilor. Cele mai comune tipuri de probleme oculare sunt: glaucomul, degenerarea macular, cataracta i bolile diabetice. Optometristul verific presiunea cu care apas fluidul din ochi (umoarea apoas) asupra nervului optic. Aceast presiune se numete presiune intraocular /tensiune intraocular i ar trebui s msoare ntre 10 i 21mmHg. O tensiune mai mare dect cea normal poate fi semn de glaucom sau desprindere a retinei. mpreun cu tonometria, se pot folosi i alte teste, cum este gonioscopia, oftalmoscopia, teste de cmp vizual, etc. Cea mai util n cazul unei presiuni intraoculare mari este pahimetria. Aceasta folosete ultrasunetele pentru a msura grosimea corneei. O cornee groas poate avea o presiune intraocular mare. Metoda ajut mult la determinarea anselor de dezvoltare a glaucomului.

Disc optic sntos

Disc optic cu glaucom

Aparatul folosit pentru msurarea presiunii intraoculare se numete tonometru. Este utilizat pentru a msura umoarea apoas i gradul (proporia) n care aceasta dreneaz esutul din jurul corneei. Tonometrul nregistreaz rezistena corneei la presiune. Metode de evaluare a presiunii intraoculare Exist mai multe metode folosite pentru a msura tensiunea intraocular: tonometria prin palpare digital tonometria prin indentaie tonometria prin aplatizare tonometria prin contur dinamic tonometria transpalpebral tonometria non-contact cu jet de aer tonometria electronic pneumotonometria analizorul de rspuns ocular Tonometria prin palpare digital

Este o metod de evaluare estimativ a presiunii intraoculare. n vederea testrii, pacientul trebuie s priveasc n jos cu ambii ochi deschii. Examinatorul adduce degetele mijlociu i inelar ale ambelor mini n contact cu fruntea pacientului, deasupra sprncenelor pentru ai rezema minile i palpeaz pleoapele cu arttorul sub placa tarsal i sub nivelul limbului. Examinatorul apas alternativ cu arttoarele celor dou mini. Tonometria prin indentaie Acest tip de tonometrie, numit i tonometrie de impresie, folosete un mic plonjor, de o anumit greutate, pentru a presa uor cornea. Presiunea din ochi este determinat prin evaluarea greutii necesare pentru aplatizarea corneei. Testarea nu este foarte exact, fiind folosit mai mult de medicii de families au la urgen. Tonometrul Schiotz este cel folosit n acest tip de tonometrie. Acesta are o greutate prins de un picior, care oscileaz liber. Deoarece raza de aciune este mai mare dect cea a corneei, instrumental aplatizeaz uor cornea. n mijloc se afl o gaur prin care trece un plonjor. Acesta poate fi ncrcat cu greuti adiionale, astfel greutatea variind de la 5,5g (normal) pn la 7,5g sau 15g (ncrcat). Micarea plonjorului prin apsarea corneei amplific un ac indicator mecanic, care citete valoarea pe o scal aflat la vrful instrumentului. Scala este convertit n valori de mmHG.

Tonometrul Schiotz

Tonometria prin aplatizare Aceast metod msoar presiunea intraocular, fie cu ajutorul unei fore necesar pentru a aplatiza o zon constant a corneei, fie prin intermediul ariei aplatizate de o for constant. n tonometria prin aplatizare, se folosete o prob calibrat special, bine dezinfectat i ataat la un biomicroscop cu lamp cu fant, pentru a aplatiza zona central a corneei. Deoarece proba intr n contact cu ochii, se utilizeaz picturi speciale de ochi. Sunt mai multe tipuri de aparate ce folosesc tonometria prin aplatizare: - tonometrul Perkins este un tip special portabil de tonometru, care permite msurarea tensiunii intraoculare la copii i ali pacieni ce nu pot fi examinai cu biomicroscopul cu lamp cu fant.

Tonometru portabil Perkins tonometrul MacKay Marg

tonometrul Goldmann este considerat standardul de aur n tonometrie, fiind cea mai bine acceptat metod de determinare a presiunii intraoculare.

Dynamic Contour Tonometry

Dynamic contour tonometry (DCT) is a novel measuring technique using the principle of contour matching instead of applanation to eliminate the systematic errors inherent in previous tonometers. These factors include the influence of corneal thickness, rigidity, curvature, and elastic properties. It is not influenced by mechanical changes, such as those seen in refractive surgery that would otherwise cause error in applanation tonometers. The PASCAL Dynamic Contour Tonometer (Ziemer Ophthalmics) is a relatively new device that uses DCT to measure IOP. Although this device is similar in appearance to a Goldmann, the PASCAL it is unlike Goldmann applanation in that it is not a variable force tonometer. PASCAL uses a miniature pressure sensor embedded within a tonometer tip contourmatched to the shape of the cornea. The tonometer tip rests on the cornea with a constant appositional force of one gram. This is an important difference from all forms of applanation tonometry in which the probe force is variable. When the sensor is subjected to a change in pressure, the electrical resistance is altered and the PASCAL's computer calculates a change in pressure in concordance with the change in resistance. The contour matched tip has a concave surface of radius 10.5 mm, which approximates the corneas shape when the pressures on both sides of it are equal. This is the key to the PASCALs ability to neutralize the effect of intra-individual variation in corneal properties. Once a portion of the central cornea has taken up the shape of the tip, the integrated piezoresistive pressure sensor begins to acquire data, measuring IOP 100 times per second. A complete measurement cycle requires about 8 seconds of contact time. During the measurement cycle, audio feedback is generated, which helps the clinician insure proper contact with the cornea. Literature references: [4][5][6]

Transpalpebral (Diaton) Tonometry

Diaton tonometer measures intraocular pressure through the Eyelid. It is regarded as a simple and safe method of ophthalmotonometry. Transpalpebral tonometry requires no contact with the cornea, therefore sterilization of the device and topical anesthetic drops are not required and there is very little risk of infection. Compared with the current standard of Goldmann applanation tonometry and Tono-Pen, recent data suggests that transpalpebral tonometry via the Diaton tonometer is clinically useful device for measuring IOP in routine eye exams. [7] [8] [9] Although requiring practice of the technique [10] , transpalpebral tonometery has been described as sufficient for clinical use and it may have applications in the home-monitoring of intraocular pressures.[11] Use of transpalpebral tonometry may be indicated in those for whom Goldmann tonometry is not indicated[12], such as in children, those with corneal pathology, or those who have had corneal surgery.[2][13]

non-contact tonometry or air-puff tonometry (NOT the same thing as pneumatonometry) invented by Bernard Grolman of American Optical, uses a rapid air pulse to applanate the cornea. Corneal applanation is detected via an electro-optical system. Intraocular pressure is estimated by detecting the force of the air jet at the instance of applanation.[3] Historically, Non-contact tonometers were not considered to be the most accurate way to measure IOP. They have generally been considered a fast and simple way to screen for high IOP. However, modern-day non-contact tonometers have been shown to correlate very well with goldmann tonomtery measurements. It is an easy way to test children. Because non-contact tonometry is accomplished without the instrument contacting the cornea the potential for disease transmission is reduced. Another interesting application of non-contact tonometers is demonstrated by this large case history where tens of thousands of intraocular pressure measurements have been recorded on a single individual under a wide variety of conditions. As part of this case history, as many as 200 intraocular pressure measurements are recorded in a single day -- something not possible with tonometry instruments that contact the cornea. This case history web site includes further discussion of non-contact tonometry vs. other forms. Electronic indentation tonometry. The Tono-Pen is a portable electronic, digital pen-like instrument that determines IOP by making contact with the cornea, afer use of topical anesthetic eye drops. This is especially useful for very young children, patients unable to reach a slit lamp due to disability, patients who are uncooperative during applanation tonometry, or patients with cornea disease in whom contact tonometer cannot be accurately performed. Pneumatonometry A pneumatonometer utilizes a pneumatic sensor (consisting of a piston floating on an air bearing). It is touched to the anesthetized cornea. A precisely regulated flow of filtered air (from an internal air pump) enters the piston. A small (5-mm dia.) fenestrated membrane at the end of the piston reacts to both the force of the air blowing through it and to the force represented by the pressure behind the cornea, against which it is being pressed. The precise balance between these two forces represents the precise intra-ocular pressure (I.O.P.) Ocular Response Analyzer The Ocular Response Analyzer (ORA, Reichert, Inc) utilizes non-contact tonometer (air puff) technology. However, in the ORA, the air pulse causes the cornea to go beyond applanation, into an indented state, before returning to normal curvature. As such, the cornea passes through applanation twice during the process, once on the way inward, and again on the way back out. Viscous damping (energy absorption) in the corneal tissue results in two different pressure values from the inward and outward applanation events. The difference between these two pressure values is termed "corneal hysteresis" and is a measurement of the cornea's biomechanical tissue properties. The ability of the ORA to measure these properties enables the calculation of an IOP measurement called IOPcc (Corneal Compensated IOP). This is an IOP measurement that is less influenced by corneal properties such as resistance or

thickness. As such, it has been shown to be more accurate than other methods of tonometry.