SAMJ

VOLUME 69

, MARCH 1986

309

Tonometry in general practIce - Its use in early detection of primary open-angle glaucoma
H. L. E. KONIG
insidious with few or no acute intervening episodes until failing vision and ultimate blindness result. The diagnosis is difficult to make and a screening test such as routine intraocular pressure measuring is invaluable. Not all patients who have raised intra-ocular pressure will develop glaucoma. The number of people in the population over 45 years with abnormal intra-ocular pressures is approximately 10%,1 many more than the number who have frank glaucoma (approximately 2%).1 There are thus two distinct clinical entities: ocular hypertension (persons with raised intra-ocular pressure only) and primary open-angle glaucoma (raised intra-ocular pressure, cupping of the optic nervehead and visual field loss). Most patients with ocular hypertension will not develop glaucoma, even if not treated, 7 and in some the eyes may even become normotensive. S The incidence of patients with ocular hypertension who develop glaucoma is 5 - 7%.7 It is also probable that patients with glaucoma have graduated from the ocular hypertensive group over a period of time. 1 An isolated finding of raised intra-ocular pressure is not an indication for initiating treatment and such patients should undergo a thorough ophthalmological evaluation.

Summary
The intra-ocular pressure of 1 078 general practice patients aged over 45 years was measured with the Schiotz tonometer. Primary open-angle glaucoma was found in 29 patients (2,7%) and ocular hypertension in 40 (3,7%). The technique of using the tonometer is described and a plea is made for general practitioners to make more use of it in screening their patients for glaucoma.
SAfrMed J 1986; &9: 309-311.

Primary open-angle glaucoma is the second major cause of blindness in developed countries, 1 and is by far the most common cause of preventable blindness. 2 The disease occurs in 2% of all people over the age of 45 years 1 and is more common in females and blacks. 2 Patients over the age of 60 years are most liable to develop the disease} and nearly 80% of registrations of blindness due to open-angle glaucoma occur in people over the age of 70 years. 4 In the RSA over 100 000 people suffer from the disease. s It is thus not rare, but is a disease progressive with age leading ultimately to blindness. The disease is asymptomatic, which makes the diagnosis difficult. From personal experience and communications with other general practitioners it is evident that primary openangle glaucoma is rarely diagnosed in general practice. To be able to diagnose glaucoma, the general practitioner should be aware of its prevalence and know which patients are especially at risk of developing the condition. The ability to use the Schiotz tonometer as well as an understanding of the pathology . of glaucoma are essential for its early detection.

Measurement of intra-ocular pressure

The process of measuring the intra-ocular pressure is known as tonometry. The Schiotz indentation tonometer is a convenient, inexpensive and easy-to-care-for instrument. In the USA it is used widely to perform routine clinical measurements.} It is the ideal instrument for the general practitioner. The tonometer is placed over the eye, and the plunger is allowed to indent the cornea until the pressure in the eye is sufficient to overcome the gravitational force exerted against the cornea by the weight of the plunger. 6 The extent to which the plunger indents the cornea is shown on a scale by a simple lever-arm indicator needle. The lever arm magnifies the motion of the plunger 20-fold. The scale readings merely indicate the depth to which the plunger indents the eye. A conversion table is required to convert them into corresponding mmHg intraocular pressure (Figs I and 2). 9 The Schiotz tonometer has one liability. By indenting the cornea, the plunger causes an alteration in the steady state of the eye. Aqueous humour in the anterior chamber is displaced, causing alteration in the shape of the eye. If the eyeball has an elastic or distensible scleral coat, a larger amount of fluid can be displaced than if it has a rigid or less distensible coat. In the former case, the plunger would travel much further and indicate a lower intra-ocular pressure than might be true, while with extremely rigid walls it might give a falsely high reading. The accuracy of the instrument is thus limited by the elastic properties of the eye, as well as by variations in the curvature of the cornea. 6,9 Contraindications for tonometry.1O These are: (I) corneal or conjunctival infection; (il) corneal injury; and (iil) marked corneal distortion, i.e. conical or badly scarred corneas.

Primary open-angle glaucoma

Glaucoma is a condition producing visual field loss of a characteristic type in that peripheral precedes central field loss, there is excavation or atrophy of the optic nerve head called cupping and usually, but not invariably, elevated intraocular pressure. 6 Glaucoma is not a distinct disease entity but exists in many forms with different causes, clinical courses and treatments. In open-angle glaucoma the aqueous humour has free access to the trabecular meshwork, the drainage apparatus in the anterior chamber angle. The course of the disease is slow and

16 Burger Street, Standerton, Tvl H. L. E. KONIG, M.B. CH.B., M.F.G.P. (S.A.),

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Hospital, Johannesburg, and then made sure that the measurements I was obtaining were accurate by measuring the intra-ocular pressure for every patient I referred to an ophthalmologist for whatever reason the morning before he was seen. It took about 3 months or 15 referrals before I was convinced that the readings with the Schiiiu tonometer were comparable to the ophthalmologist's tonometer (usually the Goldman applanation tonometer) readings. Then I undertook a survey in my practice by measuring the intra-ocular pressure in all patients over 45 years of age who attended for treatment of general complaints. Patients were asked to agree to a test of eye pressure; the nature and purpose of the examination being explained to them. No one refused. Although it has been stated that glaucoma screening should only be done in patients older than 60 years if any real cost benefit is to be derived/I I I felt that I needed the tonometry practice so the costbenefit aspect did nor play such a large part in my decision. Today I test routinely only those patients over the age of 60 years and those under 60 years if there is any special reason to suspect disease. The Schiiitz tonometer was checked before use for accuracy at zero on the metal test block supplied with the instrument! The footplate was sterilized by passing it briefly through a flame and allowing to cool,' or immersing it in a solution of chlorhexidine gluconate. Day-to-day cleanliness should be maintained by frequent washing with warm sterile water and drying with cotton, since it is important that the plunger should move freely and that the curvature of the footplate is not altered by foreign material. The patient is asked to lie on the examination couch and the cornea is inspected for any contraindications to tonometry. Ophthalmoscopy is performed on each eye and the condition of the optic disc and cup noted. Both eyes are anaesthetized with a drop of oxybuprocaine 0,4% (Novesin Wander; Restan Laboratories) and the patient asked to look at a Spot marked on the ceiling above his head. Both eyes should be kept wide open. While holding the eyelids open, the examiner should make sure he is only applying pressure to the orbital rim and never to the globe, and never pulling the lids so that they distort the globe. 9 The tonometer is held just above the cornea without touching it for several seconds, until the patient is under the impression that the test is actually being performed, and until he has relaxed his initial and normal apprehension. The tonometer is then lowered gently until it rests on the centre of the cornea. The weight of the tonometer can be varied until the lever-arm indicator needle gives a reading of between 5 and 8 units on the scale. This is in the middle range at which the tonometer functions most accurately. The weight used for most eyes with normal pressure is the 7,5 g one (5 g and 10 g weights are also supplied with the instrument). The indicator needle should show the ocular pulse, and the footplate should at no time touch the lid margins.- The reading is then taken and the intra-ocular pressure read off the conversion table. Finally, as a prophylactic measure against any possible infection, I% chloramphenicol eye drops are instilled into each eye.' The procedure is safe - in a series of 40 000 patients examined by Schiiitz tonometry in the USAI2 no case of trauma or infection was reported.

Results
From 1978 to 1983 the intra-ocular pressure of I 078 patients over the age of 45 years was measured; there were 642 women and 436 men in the study group. Intra-ocular pressure above 22 mmHg was found in 73 people (6,8%), their age groups are given in Table I. These 73 patients were then referred to a private ophthalmologist or to an ophthalmological unit at a provincial hospital; 4 were found nor to have raised intra-ocular pressure (5,5% error). Of these false-positive results I patient was in the 51 - 55-year-old age group, 2 in the 56 - 60-year group and only I was over 65 years. This was surprising since more false-positive results were expected in the older age groups as scleral rigidity becomes an increasing problem in Schiiiu tonometry with advancing age. Of the 69 patients with increased intra-ocular pressure 29 were found to have primary open-angle glaucoma (2,7% of all patients examined, 42% of patients with raised intra-ocular pressure), their

Fig. 2. Working mechanism of the Schiotz tonometer.

Survey of patients in a Standerton general practice

Patients and methods
I was shown how to use the Schiiitz tonometer at St John's Eye

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TABLE I. AGE DISTRIBUTION OF PATIENTS WITH INTRAOCULAR PRESSURE> 22 mmHg Age (yrs)

45-50
No. % of total

51-55 8 0,74

56-60
17

61-65
21 1,94

65
22

5 0,46

1,57

2,04

TABLE 11. AGE DISTRIBUTION OF PATIENTS WITH OPENANGLE GLAUCOMA Age (yrs)

45-50
No. % of total

51-55
1

56-60

61-65 11 1,02

65+ 15 1,39

0,09

2 0,18

TABLE Ill. AGE DISTRIBUTION OF PATIENTS WITH OCULAR HYPERTENSION Age (yrs)

have been diagnosed. A further 40 were found to be ocular hypertensives and needed further follow-up. It is therefore important for doctors in the frontline of medical care such as general practitioners to be able to recognize both ocular hypertension and glaucoma. Recognition depends on the ability to measure intra-ocular pressure and to diagnose the abnormality of the optic nervehead by ophthalmoscopy.t These are relatively easy procedures, take a minimum of time and can be carried out singlehandedly during normal consultation hours. The general practitioner or primary care doctor alone has the opportunity to examine a high proportion of the older patients in society and enjoys a personal relationship with his patients which will readily induce them to submit to an examination of their eyes even if they have noticed no eye symptoms. 3 The general practitioner can thus make a worthwhile contribution to the problem of diagnosis and detection of glaucoma at a stage at which treatment may be effective in preventing further deterioration of vision. The use of the Schiotz tonometer in his practice will also provide him with increased job satisfaction and patient gratitude. 'If one can diagnose primary open-angle glaucoma in the first affected eye it is probably true to say, if the appropriate treatment is commenced, that in the majority of cases, the patient will have adequate vision in his working life.'13

45-50
No. % of total

51-55
6

56-60 13 1,20

61-65 10 0,92

65+

5 0,46

0,55

6 0,55

REFERE 'CES
1. Luntz MH. The glaucomas. S Afr J Hasp Med January 1978, p. 2. 2. Soli DB, Phillips AJ. Update on glaucoma managemenl. Drug Ther 1979; 5: 88-100. 3. Phillips MA. Early detection of chronic simple glaucoma in general practice. J R Call Gm Pract 1977; 27: 601-604. 4. Perkins ES. Blindness from glaucoma and the economics of prevention. Tram Ophthalmol Sac UK 1978; 98: 293-295. 5. Cenrral Stati tical Services. Census 80. Pretoria: Governmenr Printer, 1982. 6. Wilensky JT. Glaucoma. In: Peyman GA, Sanders OR, Goldberg MF, eds. Principles and Practice of Oplllhalmology. Philadelphia: WB Saunders, 1980: 671-674; 683-685. 7. Kolker AE, Becker B. Ocular hypertension or early glaucoma. Arch Ophthalmol 1977; 95: 585-587. 8. Leading Article. Ocular Hypertension. Br MedJ 1978; I: 1230. 9. Chandler PA, Grant WM. Glaucoma. Philadclphia: Lea & Febiger, 1979: 14-15,79. 10. Miller D. Ophthalmology - The Essentials. Boston: Houghton Mifflin, 1979: 46, 121, 123. 11. Ross AK. Organization of a glaucoma screening in general practice. J R Call Gm Pract 1968; 15: 358-362. 12. Perkins ES. Glaucoma in its sociological aspecl. Tram Ophthalmol Sac UK 1968; 88: 375-395. 13. Morgan OG. The early clinical diagnosis of glaucoma. Trans Ophthalmol Sac UK 1958; 78: 471-492.

age groups are given in Table 11. The remaining 40 patients (3,7% of all patients examined) were regarded as ocular hypertensives and will be regularly monitored, their age groups are given in Table Ill. The findings in this study correlate well with those of Phillips3 who examined 300 patients over 60 years of age and found an incidence of primary open-angle glaucoma of 2,3% and of ocular hypertension of 2,6%. The percentage of patients in my study population with abnormally high intra-ocular pressures was 6,4%, lower than the approximately 10% quoted by Luntz. t

Discussion
During the 4 years of this survey 29 patients were found to have primary open-angle glaucoma. These would not otherwise