Learning objectives

To be able to assess intraocular pressure using appropriate techniques

(Group 2.1.1)
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There are many factors that aect the measurement of intraocular pressure. This article explores the short,
medium and long-term factors, which can have an impact on the results, allowing the practitioner to take these
into account when they perform tonometry on their patients.
Factors afecting intraocular
pressure measurement
Dr Kirsten Hamilton-Maxwell PhD, BOptom (Hons), FHEA

About the author
Dr Kirsten Hamilton-Maxwell is a lecturer and clinical optometric supervisor in the School of Optometry and Vision Sciences at Cardi
University, where she teaches a range of clinical techniques. Her research interests include tonometry, corneal properties and intraocular pressure.
Course code: C-35741 | Deadline: April 11, 2014
Learning objectives
To be able to obtain a full history relevant to intraocular pressure
measurement (Group 1.1.1)
To understand the importance of recording full detail with respect
to intraocular pressure measurement (Group 2.2.4)
To be able to interpret the results when undertaking tonometry
(Group 3.1.6)
To be able to recognise anomalies in intraocular pressure readings
(Group 6.1.5)
Learning objectives
To be able to explain to the patient about the implications of intraocular pressure
readings (Group 1.2.4)
To be able to understand the implications of intraocular pressure readings
(Group 3.1.6)
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Introduction
Intraocular pressure (IOP) is the primary risk
factor for the development and progression
of glaucoma, and is presently the only
modiable one. Since the introduction of NICE
CG85 for Glaucoma in 2009,
1
and subsequent
guidance from the College of Optometrists
and the Royal College of Ophthalmologists,
2
optometrists have been required to refer
patients to the Hospital Eye Service or to a
specialist optometrist when the IOP is higher
than 21mmHg, even in the absence of other
glaucomatous changes.
Recent research has shown that the
requirement for IOP-based referrals has resulted
in a large increase in the total number of
patients being referred by optometrists, as well
as an increase in the proportion of patients who
do not have an IOP above the threshold level
after referral.
3
Enhancing the accuracy of IOP
measurements is, therefore, vital. The purpose
of this article is to highlight factors that can
inuence IOP and provide recommendations
to make measurements more reliable.
Intraocular pressure (IOP)
The aqueous humour is secreted continuously
at a rate of approximately 2.750.63L/min
(range 1.8 to 4.3L/min) by the epithelia of the
ciliary body into the posterior chamber of the
eye, with a much smaller component
originating from the ltration of blood plasma
in the ciliary processes.
4
It circulates through
the pupil into the anterior chamber, then drains
through Schlemms canal via the trabecular
meshwork, with a lesser amount passing
through uveoscleral channels.
4
The aqueous
humour has several important functions within
the eye including the supply of nutrients and
the removal of waste products from anterior
ocular structures.
5
It also exerts a uid pressure
that keeps the globe of the eye inated.
IOP is often said to be normal if it is between
1021mmHg; a gure calculated as the range
over which 95% of IOPs are expected to lie.
6

However, IOP is a highly dynamic quantity
that changes over time. At any given moment,
the IOP depends on the combination of three
factors, which are all uctuating independently
over diering timescales:
The amount of fuid within the eye, which
is determined by the balance of aqueous
humour production and drainage
External forces acting upon the eye, including
the tension within the ocular walls themselves
The intraocular volume.
Common circumstances in which these
factors can inuence IOP measurement will
now be discussed and are summarised in
Table 1.
Figure 1 Position of the GAT semi-circular mires during the highest (right) and lowest (left) parts
of the ocular pulse cycle (green). The tonometer should be aligned so that the mires oscillate
around an imaginary central point of alignment (grey)
Short-term Medium-term Long-term/permanent
Ocular pulse
Breath-holding
Straining
Tight clothing around the neck
Posture
Accommodation
Eye position
Lid squeezing
Opening eyes wide
Eye rubbing
Contact lens removal
Diurnal variation
Eating and drinking
Smoking
Systemic medication
Exercise
Accommodation/reading
Optometric techniques
Age
Lifestyle (e.g. smoking)
General health
Gender
Season
Ocular factors
Table 1 Common factors that afect IOP. (Note that this list is not exhaustive)
Figure 2 IOP changes induced by walking
for a short distance. Adapted from Hamilton-
Maxwell and Feeney (2012)
45
Baseline IOP After walking After 20 min rest
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or a decrease if the patient breathes in.
9,10

However, a more recent study suggests that
the impact of breath-holding, of the type that
is likely to occur during tonometry, is likely to
be minimal.
10
Until there is more supporting
evidence, it is still advisable to remind patients
to breathe normally during tonometry.
Straining
Straining to reach equipment is also likely
to cause an articial rise in IOP of around
5mmHg.
9,11
If it is not possible to position the
patient at the slit lamp without diculty, then
an alternative tonometer should be used,
if available.
11
Tight clothing
Pressure around the neck from a necktie can
cause an increase in venous pressure and
subsequently raise the IOP by 13mmHg.
12

It has been proposed that the IOP returns
to normal levels if the necktie is left in
place.
13
It is, however, still possible that tight
clothing around the neck may become an
issue when the patient leans forward into
position at the slit lamp;
9
that being the case,
it is recommended that any tight clothing
around the neck be loosened prior to IOP
measurement.
Posture
IOP increases when a person changes their
position from sitting to reclined; most
studies have reported a range of around
16mmHg in healthy eyes and up to 9mmHg
in glaucomatous eyes.
14
An increase in IOP of
approximately 2mmHg has also been found
even when the patient is only slightly reclined
by 15 degrees.
15
In most optometric practices,
IOP is measured in a seated patient, however
should a measurement need to be taken
when the patient is reclined, such as during a
domiciliary visit, the patients posture should
be recorded. It would be unwise to try to make
an adjustment based on posture because
the size of the eect varies widely between
individuals.
Accommodation
Accommodation has an interesting eect on
the eye, being able to increase or decrease
the IOP depending on the circumstances. It
is likely that the accommodative eect on
Short-term fuctuations in IOP
Short-term uctuations of IOP occur over a
timescale of seconds or minutes; this is of
signicance to practitioners as they can occur
during the time of measurement. Although
this means that they can have a clinical impact,
they are also among the easiest type of IOP
uctuations to monitor or control.
Ocular pulse
The ocular pulse results from changes to
intraocular volume that occurs when the
choroid expands and contracts during the
cardiac cycle. It causes the IOP to change
by an average of 3mmHg (range 1-7mmHg)
every time the heart beats.
7
Even though the
ocular pulse cannot be eliminated, it can be
controlled in several ways. When performing
Goldmann applanation tonometry (GAT),
the ocular pulse is visible as an oscillation of
the semi-circular mires around an imaginary
central point of alignment. Aligning the
upper and lower semi-circular mires, so that
they oscillate by an equal amount around
that central point, will allow for a reasonable
approximation of the IOP to be made (see
Figure 1). For tonometers that take their
measurements over a period that is shorter
than the ocular pulse cycle, such as non-
contact tonometers (NCT), it is recommended
that four readings are taken and the average
value calculated capturing snapshots of IOP at
various points across the ocular pulse cycle.
8
Increased venous pressure
Venous pressure can elevate the IOP via
an increase in choroidal volume, reducing
the space available for the intraocular uid;
common examples of this are forceful
breathing, breath holding, straining and
changes in posture.
Breath holding
It is common for patients to hold their breath
during tonometry for a variety of reasons
including anxiety, trying to be a good patient,
some may simply be unconscious they are
doing it. Many practitioners may remember
being taught that IOP increases during breath-
holding due to evidence from studies showing
that activities involving forced breathing such
as the Valsalva manoeuvre causes an IOP rise
of at least 5mmHg if the patient breathes out,
IOP is related to eort rather than the amount
of accommodation used, so will occur in
presbyopes and in cyclopleged pre-presbyopes,
as well as in patients with a full accommodative
amplitude.
16,17
During accommodation, an IOP increase
of 24 mmHg takes place.
16
Should
accommodation occur during tonometry, such
as a patient who xates on the tonometer, slit
lamp or practitioner, the IOP will be higher
than normal. Patients should, therefore, be
encouraged to xate on a distant object during
tonometry. However, following a period of
sustained accommodation for as little as one
minute, the IOP will decrease by 15mmHg, and
this eect will last for at least 15 minutes.
9
It is
theoretically possible that optometric tests such
as amplitude of accommodation or near vision
testing (without an addition) will subsequently
inuence the IOP; the practitioner may,
therefore, wish to consider the order of testing.
Similarly, consideration should also be given
to whether a patient may have been viewing a
near target such as a smartphone, or reading a
magazine, while waiting for their appointment.
Eye position
The force exerted by the extraocular muscles on
the globe can cause the IOP to increase when
the direction of gaze changes from the primary
position, particularly in upgaze. Though this
eect is modest (<2mmHg) in most patients,
9
those with disorders of the extraocular
muscles, for example, in thyroid eye disease,
will exhibit a much higher increase in IOP.
18

Provided that the slit lamp chin rest is adjusted
so that the outer canthus is aligned with
the canthus marks, there will be no vertical
discrepancy in the position of gaze. However,
care must be taken when choosing a xation
target that avoids the practitioners head (which
would induce accommodation) but is also not
positioned too far laterally. Of course, variations
to both vertical and horizontal position of
gaze can easily occur when using hand-held
tonometers, so caution should be exercised
under these conditions.
Lid squeezing
Lid squeezing where a patient struggles to
keep their eyes open during measurements
has been shown to cause an increase in IOP of
around 5mmHg.
16
In its most extreme form,
Table 1 Characteristics of anterior lid margin disease
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IOPs of over 80mmHg have been recorded
during blepharospasm. This can be overcome
in most patients by encouraging the patient
to relax, trying again later (a few minutes
is often long enough), or using a dierent
tonometer with which the patient is more
comfortable.
Open your eyes wide
Contact with the eyelids can cause errors in
IOP measurements. In an attempt to avoid
this, practitioners often ask the patient to
open their eyes more widely. Research shows
that this instruction can cause the IOP to
increase by 2mmHg.
9
Gentle encouragement
to refrain from blinking can often solve this,
but where the problem persists, it may be
advisable to manually position the eyelids
against the orbital bone.
49
Eye rubbing and contact lens removal
Applying manual pressure to the globe will
cause the IOP to increase initially, but this
will be followed by a period of reduced IOP
once the external force has been removed.
In particular, the IOP is likely to be very high
while eye rubbing is taking place, but will
subsequently be lower by an average of
1mmHg.
10
It would, therefore, be advisable
to ask a patient to avoid rubbing their eyes
immediately prior to tonometry, but it might
also be useful to ask a patient about recent eye
rubbing if there is a history ocular allergies for
patients whose IOPs are near the borderline for
referral.
Similarly, soft contact lens removal can place
transient pressure on the eye. Although the
average uctuation in IOP is small (-0.8mmHg
if the lens is plucked or +0.5mmHg when
using a sliding technique), it can be as much
as 4mmHg in some patients.
19
This error can
be avoided completely if there is ve minutes
or more between soft contact lens removal
and IOP measurement.
19
There is currently no
evidence regarding the eect of rigid contact
lens removal on IOP.
Medium term fuctuations
in IOP
In the context of this article, medium term
uctuations in IOP are those that occur over a
timescale of a few hours to a few days. These
uctuations can be more dicult to deal with
because the practitioner cannot, in most cases,
control them.
Diurnal variation
One of the most signicant uctuations in
Figure 3 Factors to consider when measuring IOP
Use a standard tonometry protocol, paying careful attention to patient set-up and
instructions
Consider the order of your clinical routine
Avoid IOP measurements in the frst two hours after waking, as this is when the IOP is
likely to uctuate the most
If you intend to repeat IOP measurements on a diferent day, provide advice that will
minimise IOP uctuations
Identify potential problems by taking a thorough clinical history
Note any likely sources of fuctuation to aid interpretation
For example, an asymmetric IOP can indicate pathology such as a retinal
detachment or uveitis
Eliminate or minimise IOP fuctuations whenever possible
For IOP fuctuations that cannot be eliminated
Consider other conditions that may cause changes in IOP,
as well as glaucoma
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IOP is the diurnal variation, where the IOP
uctuates over a cycle lasting approximately
24 hours. The diurnal variation may be due to:
Posture
14
Ambient illumination
20,21
Stage of sleep
22
Circulating cortisol levels
23
Suspension and resumption of eye
movements and accommodation
24
Errors in IOP measurement
25
Many others have been proposed
(Prostaglandin, aldosterone, oestrogen,
thyroxine, catecholamine, ADH, plasma pH,
serum osmolarity, hypothalamus activity,
and adrenaline).
26

Diurnal uctuation is between 26mmHg
in healthy eyes, but may be 10mmHg or
more in glaucomatous eyes.
27,28
It may also
be higher in hypermetropes.
29
Most readers
will know that it is important to record the
time of day that IOP is measured. Although
it is advisable to continue to do so, there is
a growing body of evidence that question
whether time of day is as informative as once
believed.
The statements that are up for debate are
outlined in Table 2.

Eating and drinking
Consumption of food and drink appears to
have an eect on the IOP, although there is
limited research to date. It is known that IOP
increases upon the resumption of eating
and drinking in the evenings in patients who
observe Ramadan,
34
and that drinking large
volumes of uid also raises the IOP.
35
The
contents of the food and drink, e.g. caeine,
can also play a role.
36
Further research is
needed, however, before generalisations can
be made about the relationship between
food and drink consumption and IOP.
Tobacco
There is both a transient and long-term IOP
rise in patients who smoke. Eleven per
cent of non-glaucoma patients and 37% of
patients with glaucoma have an IOP spike
of at least 5mmHg following a cigarette,
although it is unknown how long the eect
may last.
37
The average IOP is also higher in
smokers, although when considered across
a population, the eect is just a fraction of a
mmHg.
38
The transient increase in IOP may
interfere with measurements in some patients
who have taken the opportunity to smoke a
cigarette while waiting for their appointment.
Alcohol
The relationship between alcohol
consumption and IOP is unclear. In the
short term, it can be hypothesised that IOP
would decrease following signicant alcohol
consumption due to dehydration; over a
longer term, the evidence is equivocal.
39
It
seems probable that other lifestyle factors
that are associated with alcohol consumption,
such as general health, body mass index
(BMI) and diet, may have confounding eects
on the IOP.
Recreational drugs
Recreational drugs can have varying eects
on IOP depending on their pharmacological
actions and it is beyond the scope of this
article to discuss them in any detail. It is
worth mentioning that cannabis decreases
the IOP to such an extent that it is being
investigated as a treatment for glaucoma,
provided that the psychoactive properties
can be removed.
40
Systemic and ocular corticosteroids
Oral and topical corticosteroid medications
are known to raise IOP. Approximately 46%
of the population will have an extreme
reaction where the IOP increases by
15mmHg or more; another third will have
a more moderate increase of 615mmHg,
while the remainder will see no increase
in IOP.
41
However, recent research has
shown that topical steroids, including those
commonly available over the counter for
hay fever, can also cause an increase in IOP.
41

Importantly, the IOP increase associated with
this type of steroid is not dose dependent
but instead based on whether the patient
has ever used them. A careful history is
essential to identify current and previous
steroid use.
41
Statement Debate
The IOP is always highest
in the morning
Though it is true that the IOP is probably at its highest level immediately after waking,
25
this has typically
subsided long before most practitioners open for business. Although there is still a slight tendency for an
IOP to be higher in the morning hours, there is a such a large variation in the timing of the maximum IOP
that it may be more appropriate to assume that it can occur at any time
27,28

The diurnal variation is
the same every day
Research has shown that the diurnal pattern is not the same every day, whether the eye is healthy or
glaucomatous.
30
This means that the reproducibility of IOP measurements obtained on diferent days, even
at the same time, is limited
31
The diurnal fuctuation is
the same in both eyes
Although it is long established that the IOP fuctuation will be diferent in the two eyes of patients with
glaucoma,
32
more recent evidence suggests that this asymmetric
fuctuation can also be seen in healthy eyes
33
Table 2 Uncertainties surrounding the diurnal variation of IOP

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Refective learning Having completed this CET exam, consider whether you feel more condent in your clinical skills how will you change the way you
practice? How will you use this information to improve your work for patient benet?
are separated by ve minutes or more.
50
The
origin of this behaviour is uncertain, and
it has been proposed that there may be a
true reduction in IOP resulting from ocular
massage, or it may be a measurement error
resulting from corneal ow.
9
A third option is
that it may be due to a reduction in patient
apprehension about the procedure.
51
It is
suggested that GAT should be performed
as quickly as possible to reduce the number
and duration of contacts with the eye, and
that the rst measurement in each session be
discarded.
52
Repeated measurements using
NCT does not cause an IOP reduction.
53
Visual felds
IOP and visual eld assessment (VFA)
are integral clinical procedures required
for the diagnosis and management of
glaucoma. Several factors that may inuence
IOP are modied during VFA, including
accommodation, pupil size, posture and
anxiety levels.
9
Reports have shown that IOP
increases in patients with primary open angle
glaucoma (POAG) following VFA but not in
controls.
54
Others have noted, however, that
there is no mean change in IOP in either
treated POAG, suspect POAG or ocular
hypertensive (OHT) patients.
55
Equivocal
ndings between studies may relate to
the length of the visual eld test, with
longer tests causing an increase in IOP and
short tests having no eect. It is, therefore,
recommended that IOP is measured prior to
VFA, if it is likely that the test duration will be
longer than four or ve minutes.
Longer-term
Age, lifestyle and general health
The eect of age on IOP depends on two key
factors: racial origin and general health. In
a western white population, the IOP might
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Systemic anti-hypertensive medication
Anti-hypertensive medications also act upon
the eye, so it would be typical of patients
taking these medications to have a reduced
IOP; this can be useful, reducing the need for
topical IOP lowering medications in glaucoma
patients.
42
Exercise
Patients who have recently participated in
strenuous aerobic exercises such as running
and cycling will have an IOP that is lower than
normal. Decreases of up to 6mmHg have been
reported in healthy eyes,
43
with up to 13mmHg
reduction in glaucomatous eyes.
44
It is thought
that IOP returns to pre-exercise levels after
approximately 2060 minutes, although
recovery time can vary a great deal.
43
A more subtle eect is the IOP decrease that
can occur after a short walk of just two thirds
of a mile, reducing measures by 1.4mmHg with
levels not recovering even after 20 minutes
(see Figure 2).
45
The fall in IOP appears to be
related to the level of exertion, rather than the
total time walked.
45
Where IOP measurements
are critical, practitioners are advised to seek
information regarding a patients mode
of transport and their perceived level of
exertion.
45
If there were any doubt, it would be
advisable to repeat the measurements after
the patient has been resting for approximately
one hour.
Optometric techniques
Tonometry
An important factor to consider with IOP
uctuations is the eect of the tonometer
itself. Repeatedly subjecting a cornea to GAT
can cause the IOP to decrease by 34mmHg, if
the measurements are repeated at one-minute
intervals over a period of several minutes.
49
This eect disappears if IOP measurements
increase by a very small amount,
56
if at
all.
57
An increase of approximately 1mmHg
per decade can be expected in patients
of African descent,
58
whereas a decrease
with age is found in patients of east-Asian
origin.
59
Changes in IOP with age are probably
associated with systemic factors such as
hypertension, diabetes, BMI, smoking and
cholesterol.
56,57
All of the aforementioned
factors can also contribute to elevated IOP
in younger individuals who have these
conditions.
60
Gender
Gender has also been indicated as an
important factor for IOP levels in a number
of studies, with a higher IOP reported in
women,
61
though this observation is not a
universal nding.
56,57
Hormone replacement
therapy in menopausal women appears to
cause IOP to decrease by an average of
1.4mmHg.
62
Other factors
There is a seasonal inuence on IOP, and it
is has been reported that it may be up to
2mmHg higher in winter than in summer.
63
IOP tends to be higher in myopes,
64
and it is
also higher in brown eyes than blue eyes in
Caucasians, although the eect is small in
both cases.
65
Conclusion
In conclusion, there are many factors that can
aect IOP; these can be natural or induced,
avoidable or unavoidable, and can be over
a short or long term. It is important to
eliminate sources of IOP uctuation wherever
possible (see Figure 3, page 49). Where it is
not possible, a good understanding of the
sources of IOP uctuations is essential to
interpret IOP measurements with condence.