TONOMETRIA

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 "# i
$"mm%g. O tensiune mai mare dec&t 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 c&mp vi(ual, etc. Cea mai util !n ca(ul unei presiuni
intraoculare mari este pahimetria. Aceasta folosete ultrasunetele pentru a msura
grosimea corneei. O cornee groas poate avea o presiune intraocular mare. )etoda a*ut
mult la determinarea anselor de de(voltare a glaucomului.

+isc optic sntos +isc optic cu glaucom
Aparatul folosit pentru msurarea presiunii intraoculare se numete tonometru.
,ste utili(at pentru a msura umoarea apoas i gradul (propor-ia) !n care aceasta
drenea( -esutul din *urul corneei. .onometrul !nregistrea( re(isten-a corneei la
presiune.
Metode de evaluare a presiunii intraoculare
,xist mai multe metode folosite pentru a msura tensiunea intraocular:
tonometria prin palpare digital
tonometria prin indenta-ie
tonometria prin aplati(are
tonometria prin contur dinamic
tonometria transpalpebral
tonometria non/contact cu *et de aer
tonometria electronic
pneumotonometria
anali(orul de rspuns ocular
Tonometria prin palpare digital
,ste o metod de evaluare estimativ a presiunii intraoculare. 'n vederea testrii,
pacientul trebuie s priveasc !n *os cu ambii ochi deschii. ,xaminatorul adduce
degetele mi*lociu i inelar ale ambelor m&ini !n contact cu fruntea pacientului, deasupra
spr&ncenelor pentru ai re(ema m&inile i palpea( pleoapele cu arttorul sub placa
tarsal i sub nivelul limbului. ,xaminatorul apas alternativ cu arttoarele celor dou
m&ini.
Tonometria prin indentaie
Acest tip de tonometrie, numit i tonometrie de impresie, folosete un mic
plon*or, de o anumit greutate, pentru a presa uor cornea. 0resiunea din ochi este
determinat prin evaluarea greut-ii necesare pentru aplati(area corneei. .estarea nu este
foarte exact, fiind folosit mai mult de medicii de families au la urgen-.
.onometrul 1chiot( este cel folosit !n acest tip de tonometrie. Acesta are o
greutate prins de un picior, care oscilea( liber. +eoarece ra(a de ac-iune este mai mare
dec&t cea a corneei, instrumental aplati(ea( uor cornea. 'n mi*loc se afl o gaur prin
care trece un plon*or. Acesta poate fi !ncrcat cu greut-i adi-ionale, astfel greutatea
variind de la 2,2g (normal) p&n la 3,2g sau "2g (!ncrcat). )icarea plon*orului prin
apsarea corneei amplific un ac indicator mecanic, care citete valoarea pe o scal aflat
la v&rful instrumentului. 1cala este convertit !n valori de mm%4.
.onometrul 1chiot(
Tonometria prin aplatizare
Aceast metod msoar presiunea intraocular, fie cu a*utorul unei for-e necesar
pentru a aplati(a o (on constant a corneei, fie prin intermediul ariei aplati(ate de o for-
constant.
'n tonometria prin aplati(are, se folosete o prob calibrat special, bine
de(infectat i ataat la un biomicroscop cu lamp cu fant, pentru a aplati(a (ona
central a corneei. +eoarece proba intr !n contact cu ochii, se utili(ea( picturi speciale
de ochi. 1unt mai multe tipuri de aparate ce folosesc tonometria prin aplati(are:
/ tonometrul 0er5ins este un tip special portabil de tonometru, care permite
msurarea tensiunii intraoculare la copii i al-i pacien-i ce nu pot fi examina-i cu
biomicroscopul cu lamp cu fant.
.onometru portabil 0er5ins
/ tonometrul )ac6a7 )arg
/ tonometrul 4oldmann este considerat 8 standardul de aur9 !n tonometrie, fiind cea
mai bine acceptat metod de determinare a presiunii intraoculare.
Dynamic Contour Tonometry
+7namic contour tonometr7 (+C.) is a novel measuring techni:ue using the principle of
contour matching instead of applanation to eliminate the s7stematic errors inherent in
previous tonometers. .hese factors include the influence of corneal thic5ness, rigidit7,
curvature, and elastic properties. ;t is not influenced b7 mechanical changes, such as
those seen in refractive surger7 that <ould other<ise cause error in applanation
tonometers. .he 0A1CA=> +7namic Contour .onometer (?iemer Ophthalmics) is a
relativel7 ne< device that uses +C. to measure ;O0. Although this device is similar in
appearance to a 4oldmann, the 0A1CA=> it is unli5e 4oldmann applanation in that it is
not a variable force tonometer.
0A1CA=> uses a miniature pressure sensor embedded <ithin a tonometer tip contour/
matched to the shape of the cornea. .he tonometer tip rests on the cornea <ith a constant
appositional force of one gram. .his is an important difference from all forms of
applanation tonometr7 in <hich the probe force is variable. @hen the sensor is sub*ected
to a change in pressure, the electrical resistance is altered and the 0A1CA=As computer
calculates a change in pressure in concordance <ith the change in resistance.
.he contour matched tip has a concave surface of radius "#.2 mm, <hich approximates
the corneaBs shape <hen the pressures on both sides of it are e:ual. .his is the 5e7 to the
0A1CA=Bs abilit7 to neutrali(e the effect of intra/individual variation in corneal
properties. Once a portion of the central cornea has ta5en up the shape of the tip, the
integrated pie(oresistive pressure sensor begins to ac:uire data, measuring ;O0 "## times
per second. A complete measurement c7cle re:uires about C seconds of contact time.
+uring the measurement c7cle, audio feedbac5 is generated, <hich helps the clinician
insure proper contact <ith the cornea. =iterature references:
DEFD2FDGF
Transpalpebral (Diaton) Tonometry
+iaton tonometer measures intraocular pressure through the ,7elid. ;t is regarded as a
simple and safe method of ophthalmotonometr7. .ranspalpebral tonometr7 re:uires no
contact <ith the cornea, therefore sterili(ation of the device and topical anesthetic drops
are not re:uired and there is ver7 little ris5 of infection. Compared <ith the current
standard of 4oldmann applanation tonometr7 and .ono/0en, recent data suggests that
transpalpebral tonometr7 via the +iaton tonometer is clinicall7 useful device for
measuring ;O0 in routine e7e exams.
D3F

DCF

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Although re:uiring practice of the techni:ue
D"#F
, transpalpebral tonometer7 has been described as sufficient for clinical use and it ma7
have applications in the home/monitoring of intraocular pressures.
D""F
Ise of
transpalpebral tonometr7 ma7 be indicated in those for <hom 4oldmann tonometr7 is not
indicated
D"$F
, such as in children, those <ith corneal patholog7, or those <ho have had
corneal surger7.
D$FD"JF
non-contact tonometry or air-pu tonometry (KO. the same thing as
pneumatonometr7) invented b7 Lernard 4rolman of American Optical, uses a
rapid air pulse to applanate the cornea. Corneal applanation is detected via an
electro/optical s7stem. ;ntraocular pressure is estimated b7 detecting the force of
the air *et at the instance of applanation.DJF %istoricall7, Kon/contact tonometers
<ere not considered to be the most accurate <a7 to measure ;O0. .he7 have
generall7 been considered a fast and simple <a7 to screen for high ;O0. %o<ever,
modern/da7 non/contact tonometers have been sho<n to correlate ver7 <ell <ith
goldmann tonomter7 measurements. ;t is an eas7 <a7 to test children. Lecause
non-contact tonometry is accomplished <ithout the instrument contacting the
cornea the potential for disease transmission is reduced. Another interesting
application of non-contact tonometers is demonstrated b7 this large case histor7
<here tens of thousands of intraocular pressure measurements have been recorded
on a single individual under a <ide variet7 of conditions. As part of this case
histor7, as man7 as $## intraocular pressure measurements are recorded in a
single da7 // something not possible <ith tonometr7 instruments that contact the
cornea. .his case histor7 <eb site includes further discussion of non-contact
tonometry vs. other forms.
Electronic in!entation tonometry. .he Tono-"en is a portable electronic,
digital pen/li5e instrument that determines ;O0 b7 ma5ing contact <ith the
cornea, afer use of topical anesthetic e7e drops. .his is especiall7 useful for ver7
7oung children, patients unable to reach a slit lamp due to disabilit7, patients <ho
are uncooperative during applanation tonometr7, or patients <ith cornea disease
in <hom contact tonometer cannot be accuratel7 performed.
"neumatonometry A pneumatonometer utili(es a pneumatic sensor (consisting
of a piston floating on an air bearing). ;t is touched to the anestheti(ed cornea. A
precisel7 regulated flo< of filtered air (from an internal air pump) enters the
piston. A small (2/mm dia.) fenestrated membrane at the end of the piston reacts
to both the force of the air blo<ing through it and to the force represented b7 the
pressure behind the cornea, against <hich it is being pressed. .he precise balance
bet<een these t<o forces represents the precise intra/ocular pressure (;.O.0.)
Ocular Response Analy#er .he Ocular Mesponse Anal7(er (OMA, Meichert, ;nc)
utili(es non/contact tonometer (air puff) technolog7. %o<ever, in the OMA, the
air pulse causes the cornea to go be7ond applanation, into an indented state,
before returning to normal curvature. As such, the cornea passes through
applanation t<ice during the process, once on the <a7 in<ard, and again on the
<a7 bac5 out. Niscous damping (energ7 absorption) in the corneal tissue results
in t<o different pressure values from the in<ard and out<ard applanation events.
.he difference bet<een these t<o pressure values is termed Ocorneal h7steresisO
and is a measurement of the corneaAs biomechanical tissue properties. .he abilit7
of the OMA to measure these properties enables the calculation of an ;O0
measurement called ;O0cc (Corneal Compensated ;O0). .his is an ;O0
measurement that is less influenced b7 corneal properties such as resistance or
thic5ness. As such, it has been sho<n to be more accurate than other methods of
tonometr7.