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Original Article
Comparison of Goldmann applanation tonometer, Tono-Pen
and noncontact tonometer in children
Usha Kaul Raina, Neha Rathie, Anika Gupta, Shantanu Kumar Gupta, Meenakshi Thakar
Department of Ophthalmology, Guru Nanak Eye Centre, Maulana Azad Medical College, NewDelhi, India
Background: To evaluate the agreement of Goldmann
applanation tonometer(GAT) with Tono-Pen and
noncontact tonometer(NCT) for measurement of
intraocular pressure(IOP) in pediatric age group
and to evaluate the correlation between central
corneal thickness(CCT) and IOP measured with the
tonometers used.
Materials and Methods: IOP was measured in 200
eyes in a group of Indian children, aged between 8 and
18years using three different tonometers: NCT, the
Tono-Pen and GAT. All IOP readings were made in the
office settings by the same examiner. Readings obtained
were compared between the instruments and with the
CCT for each tonometer. Tonometer intermethod
agreement was assessed by the BlandAltmann method.
The relations of CCT with absolute IOPvalues and
intertonometer differences were analyzed by linear
regression.
Introduction
Comprehensive eye care for children and adolescents requires
measurement of intraocular pressure(IOP). The World Glaucoma
Congress wrote that the question whether one tonometer is
superior to the others in pediatric patients is unresolved.[1] The
widely accepted international gold standard for IOP measurement
in adults is the Goldmann applanation tonometer(GAT).[2]
However, measuring IOP with conventional contact tonometers
can be difficult in young patients owing to their lack of
Correspondence:
Dr.Anika Gupta, E187, New Rajendar Nagar, NewDelhi110060, India.
Email:anika574@gmail.com
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DOI:
10.4103/0974-620X.176096
22
Results: The mean age was 13.373.51years. The
mean IOPvalues recorded with NCT; Tono-Pen and
GAT were 14.38, 15.63, and 12.44mmHg, respectively.
Both Tono-Pen and NCT recorded statistically higher
IOPvalues than the GAT(P=0.00) regardless of the
CCT. The percentage increase of IOP measured over
GAT was 15.66% for NCT and 25.70% for Tono-Pen
which was also statistically significant. Acorrelation
was found between CCT and IOPvalues obtained with
all the three tonometers.
Conclusion: IOP measurements on children vary
significantly between instruments and correlations are
affected by the corneal thickness. Further studies on
children are needed to determine which instrument is
most appropriate and to derive a normative IOP scale
for the growing eye.
Keywords: Central corneal thickness, intraocular
pressure in children, tonometers
cooperation.[3] In addition, there are various factors such as the
central corneal thickness(CCT), subjects seated or recumbent
position, eye movements or facial mask expressions, which
influence IOP measurement in children.[49]
The Tono-Pen tonometer was developed for use in patients
who present with the sort of measurement problems that
are often associated with children. The instrument is easy to
handle, portable, light weight, and does not require the use of
fluorescein.[10] Tonopen is useful for supine patients and in
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Cite this article as: Raina UK, Rathie N, Gupta A, Gupta SK, Thakar M.
Comparison of Goldmann applanation tonometer, Tono-Pen and noncontact
tonometer in children. Oman J Ophthalmol 2016;9:22-6.
2016 Oman Ophthalmic Society|Published by Wolters KluwerMedknow
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Raina, etal.: Tonometry methods in children
the presence of corneal pathology.[11] A significant advantage
of noncontact tonometry(NCT) is the elimination of potential
hazards associated with all contact tonometers viz., corneal
abrasion, reaction to topical anesthetic or flourescein and spread
of infection.[12] However, with NCT, the subject should be able
to fixate on the target and hence its use is limited in children
with poor fixation, nystagmus, and inability to see the target. Eyes
with corneal surface irregularities are also not suitable for use of
NCT because the instrument is designed for clear and smooth
corneas.[13]
Although accurate and consistent IOP measurements are difficult
to obtain, they are of extreme clinical importance when trying to
diagnose and manage pediatric glaucoma.[14] Moreover, there have
been few studies comparing the accuracy of various tonometers
conducted in children.[1,3,15,16] The present study compared IOP
readings by GAT, Tono-Pen, and NCT to determine which type is
best tolerated in clinical practices with children and which is most
reliable. In addition, the influence of CCT on the IOPs measured
with each tonometer was evaluated.
Materials and Methods
An observational study was performed at Guru Nanak Eye Centre,
Maulana Azad Medical College, NewDelhi from 2012 to 2013.
Two hundred eyes of 100 pediatric were included in the study
who presented to either the Outpatient Department or Pediatric
Ophthalmology Clinic. Children included in the study were
between 8 and 18years of age with the ability to have CCT and
IOP measurements taken in the office. Children with any anterior
segment dysgenesis, cataract, active inflammation, glaucoma, and
those with any gross ocular pathology such as microphthalmos,
aniridia, and coloboma were excluded from the study. The study
was reviewed and approved by the Institutes Ethics Committee.
A written informed consent was obtained from parents or
guardians of all the children. All children underwent a detailed
ophthalmologic examination including visual acuity using
Snellens chart, cycloplegic refraction with 2% homatropine, slit
lamp examination, fundus examination, keratometry, and axial
length measurement. CCT was measured using Pac scan plus
digital biometric ruler(Pacscan 300 AP, Sonomed, Lac Success,
NewYork). The pachymeter probe was placed on the center of the
cornea, and three consecutive central corneal pachymetry values
were recorded. The mean of the readings also was calculated and
recorded.
IOP measurements were done using noncontact tonometer(NCT
10, Shin Nippon, Japan), Tono-Pen(Medtronic Ophthalmic
Incorporation, Jacksonville, Florida, USA) and GAT(HaagStreit
AG, Bern, Switzerland) in that sequence, at an interval of 15min,
right eye followed by left. For NCT and Tono-Pen readings, an
average of three successive measurements was taken. Before
the measurement of GAT, the drum was reset to approximately
10mmHg after each reading, and the biprism was cleaned with
3% hydrogen peroxide. IOP was recorded after instilling topical
Oman Journal of Ophthalmology, Vol. 9, No. 1, 2016
anesthetic(proparacaine hydrochloride) and fluorescein dye in
the eye. All measurements were done in the afternoon between 2
and 3 pm in sitting position and by the same examiner to avoid any
interobserver variation. To avoid any intrainstrument variability,
the same tonometers were always used. GAT was calibrated each
week, and Tono-Pen calibration was carried out each day prior to
IOP recording.
The mean value of three consecutive measurements by each
tonometer was used for final analysis. For CCT also, an average
of three successful readings was used. Intermethod agreement
was assessed, and the influence of CCT on the IOPs measured
was evaluated.
Statistical analysis
The data thus obtained was analyzed using SPSS 17 (SPSS Statistics
for Windows, Version 17.0. Chicago: SPSS Inc.). The difference
between the two means was observed by the paired ttest, and a
P<0.05 was considered statistically significant. Agreement between
the methods was observed by estimating the limits of agreement and
assessed using Bland and Altmann plots.[17] Correlation between
the CCT and the IOP measured by various instruments was studied
using Pearsons/Spearmans rank correlation coefficient.
Results
Results of 200 eyes of 100 healthy subjects(47 boys and 53
girls) were included in the study. Mean age of the subjects was
13.373.51(range: 818years).
Mean IOP recorded was 14.382.35mmHg by NCT,
15.632.78mmHg by Tono-Pen and 12.461.44mmHg by
GAT. There was statistically significant difference between the
IOP measured by the three instruments regardless of the corneal
thickness(P=0.00). The percentage increase over GAT was
15.66% for NCT and 25.70% for Tono-Pen. On an average NCT
overestimated IOP readings by GAT by 1.964.16mmHg while
Tono-Pen overestimated GAT by 3.25.18mmHg within the
IOP range studied. The difference in IOP measurement was more
in the higher IOP range when the average IOP was more than
14mmHg.
There was good intermethod agreement, i.e.,between
GAT and Tono-Pen and GAT and NCT with 95% limits of
agreement falling between 1.98 to 8.38 and 2.2 to 6.12,
respectively[Figures1 and 2].
Mean CCT was 539.6530.48m(range: 464604m).
Thicker corneas were associated with higher IOP with all the
three tonometers used. CCT was found to have a significant
correlation with IOP measured with Goldmann and NCT while
Tono-Pen readings varied less with a change in corneal thickness.
For 100m change in CCT, IOP changed by 1.03mmHg with
GAT, 2.41mmHg with NCT and only 0.81mmHg with Tono-
Pen[Figures35]. Of the other factors studied such as axial length,
average keratometry values, and spherical equivalent, none was
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Raina, etal.: Tonometry methods in children

14 8

12

IOP difference (NCT-GAT) in mmHg

IOP difference (Tonopen-GAT) in mmHg

10 6 6.12

8 8.38
4
6

4
2
2

0
8 10 12 14 16 18 20 0
-2 8 10 12 14 16 18 20

-4 -1.98
-2
-2.2
-6

-8 -4
Mean IOP (mmHg) Mean IOP (mmHg)

Figure 1: BlandAltman plot for Goldmann applanation tonometer and Tono-Pen Figure 2: BlandAltman plot for Goldmann applanation tonometer and noncontact
tonometry

19 25

23
17

21
15
19
GAT (mm Hg)

13
17
NCT (mm Hg)

11 15

13
9

11
7
9

5
450 470 490 510 530 550 570 590 610 630 7
CCT (m)
5
Figure 3: Correlation of Goldmann applanation tonometer and central corneal thickness
450 470 490 510 530 550 570 590 610 630
CCT (m)
found to have a significant correlation with IOP measured with
Figure 4: Correlation of noncontact tonometry and central corneal thickness
the three instruments.

Studies in the past have determined the agreement between different

Discussion
For many years, applanation tonometry was considered to set
a standard against which other instruments were measured.
Measuring IOP in children is more challenging because it requires
certain capabilities from the instrument and some degree of
experience from the user. The instrument must provide quick,
accurate readings. For these reasons, the standard Goldmann
tonometer, which is mounted on a slit lamp, is not suitable for
children. However, recent reviews that have compared a number
of instruments suggest that depending on the population and the
application, different instruments may be preferred.[1,3,15,16]
tonometers. Minckler etal.[18] compared GAT with the first generation
Tono-Pen(Tonopen1) in adults and found similar readings in the
IOP measured by the two methods. They reported that Tonopen1
underestimated the IOP in eyes with higher IOP and overestimated
the IOP in eyes with lower IOP. Frenkel etal. also compared Tono-Pen
and GAT in adults and concluded that the Tonopen measures IOP in a
manner that corresponds well to the GAT in the 1120mmHg interval,
and fairly well in the 410mmHg and 2130mmHg interval.[11]
Bradfield etal.[1] in their study in children and adolescents found
that in an office setting, Tono-Pen measurements tended to be

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Raina, etal.: Tonometry methods in children
25
23
21
19
Tonopen (mm Hg)
17
15
13
11
9 In this study also, thicker corneas were associated with higher
7 to have a significant correlation with IOP measured with GAT
5
450 470 490 510 530 550 570 590
CCT (m)
Figure 5: Correlation of Tono-Pen and central corneal thickness
slightly lower than GAT when IOP was<11mmHg and slightly
higher than GAT when IOP was>11mmHg. In normal children,
average differences between IOP measured by Tono-Pen and GAT
were small, although there was substantial testretest variability.
Bordon et al.[3] compared the accuracy of IOP measurement
in pediatric patients afflicted with retinopathy of prematurity
using three tonometers: Perkins, Schiotz, and Tono-Pen. Agood
correlation was found between Tono-Pen and Perkins tonometers,
whereas the Schiotz measurements were significantly higher.
Hence, they suggested that Tono-Pen with a higher correlation
coefficient can be used reliably to assess IOP in pediatric patients.
Kageyama etal.[15] compared the ICare rebound tonometer with
NCT in healthy children and concluded that IOP measurements
performed using ICare are better tolerated in the pediatric
population, as compared with measurements using NCT,
especially in children below the age of 6years. Arecent study by
Feng etal. compared rebound tonometry, NCT, and GAT and their
relationships to CCT in children. They suggested that all three
tonometers would be clinically acceptable for pediatric patients
with IOP within the normal range of values, but children with
IOPs within a suspicious range should be reevaluated carefully.[16]
In our prospective study, we compared GAT, Tono-Pen
and NCT in pediatric eyes. Findings from this study show
that both Tono-Pen and NCT provided statistically higher
IOPvalues(15.632.78mmHg and 14.382.35mmHg,
respectively) than GAT(12.461.44mmHg) regardless of the
corneal thickness. The difference in the IOP recordings with
different tonometers was more for higher IOP range. This is
probably because a lesser amount of force is required to applanate
a softer eye and vice versa. This difference is probably exaggerated
in the case of Tono-Pen as its principle combines both indentation
and applanation.
Oman Journal of Ophthalmology, Vol. 9, No. 1, 2016
IOP measurement is influenced by the CCT.[19] IOP measurements
obtained with GAT tended to be overestimated in eyes with
thick corneas and underestimated in eyes with thin corneas in
children.[20] Bradfield etal. found that the GAT measured IOP was
1.9mmHg higher for every 100 um increase in CCT in children.[21]
This accords with the results of a prior small pediatric study by
Muir etal.[22] They suggested that this small difference in the
effect of CCT may be secondary to the large corneal surface area
contacted by the GAT device. Whereas, Tono-Pen measurements
have been found to be less dependent than GAT on the biochemical
properties of cornea.[19] Recently, Feng et al.[16] also found the
rebound and noncontact tonometry to overestimate IOP relative
to GAT for thicker CCT.
IOP recordings with all three tonometers used. CCT was found
and NCT while Tono-Pen readings varied less with a change in
610 630 corneal thickness. These findings are probably because Tono-Pen
applanates a smaller area of cornea compared to GAT and hence,
its recordings are less influenced by the CCT.
To the best of our knowledge, this is the first study of IOP
measurements on healthy Indian children. It contributes to the
literature on IOP in the young eye and provides a comparative study
to compare the commonly used tonometers in children along with
the correlation between CCT and IOP measurements. However, our
study has a few limitations. First, we enrolled only normal subjects
and hence it might not be appropriate to extrapolate this data in
children with or suspected of glaucoma. Second, in this study,
IOP was measured sequentially with NCT, Tono-Pen, and GAT.
As noted by Feng etal., this might contribute to the higher mean
IOPs recorded with NCT and Tono-Pen because after repeated
IOP measurements the child may feel more comfortable with the
procedure. The application of topial anesthetic for GAT may also
contribute to less anxiety and increased cooperation by the child.
Conclusion
Each of the three tonometers evaluated in this study can be
routinely used in the clinical setting for IOP measurement in
children. However, eyes with high IOP measurements must be
carefully evaluated for the effect of CCT and other factors which
might influence IOP readings in children. Tonopen may be used
for children in the presence of corneal pathology, as it is least
affected by variations in corneal thickness and NCT may be used
in the presence of corneal or other ocular infection when a contact
procedure is contraindicated. However, further studies for IOP
measurements on large populations of children, with and without
eye disease or conditions that may affect IOP, from a variety of
countries and ethnic groups is required, to find an ideal and
accurate tonometer applicable for every age group.
Financial support and sponsorship
Nil.
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Raina, etal.: Tonometry methods in children
Conflicts of interest
There are no conflicts of interest.
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