REVIEW

CURRENT
OPINION Measuring intraocular pressure
Kingsley C. Okafor and James D. Brandt

Purpose of review
Tonometry is undergoing a long-overdue renaissance. Goldmann applanation tonometry (GAT) is 50-year-
old technology. Although GAT is considered a ‘reference standard’, it has many limitations and
confounders. This review compares GAT to some of the newer technologies that have recently been
commercialized or are in development.
Recent findings
Dynamic contour tonometry is fairly cornea-independent, but requires technical skill to carry out. Rebound
tonometry requires no anesthetic and is particularly useful in children. The ocular response analyzer
quantifies corneal biomechanical factors and provides other useful measures relevant to glaucoma risk. A
transpalpebral tonometer that claims to measure intraocular pressure (IOP) through the closed eyelid has
been introduced, but studies comparing it to conventional tonometers suggest it is too unreliable for routine
use. Various new technologies including IOP-sensing contact lenses and implantable sensors are in clinical
evaluation.
Summary
There is no perfect tonometer, and clinicians must choose which to use in their daily practice, balancing
accuracy, precision, convenience, and cost. Clinicians should recognize that a single IOP measurement is
but an often error-prone snapshot of a widely varying physiologic parameter. IOP data should only be used
in the context of the overall clinical picture.
Keywords
central corneal thickness, corneal hysteresis, glaucoma, intraocular pressure, tonometry

INTRODUCTION types of commercially available tonometry tech-

Ever since the 16th century, when Bannister
described a subset of blind patients with eyes that
were firm to the touch, intraocular pressure (IOP)
has been regarded as a core vital sign of the eye,
along with visual acuity, the pupillary exam, and the
visual field. The measurement of IOP (tonometry) in
a consistent and reliable manner is fundamental to
the diagnosis and management of glaucoma and
allied disorders.
All clinical measurements are an ‘estimate’ – we
can never approach the true underlying value of a
clinical measurement without first understanding
the pitfalls and limitations of a given measurement
technique, as well as obtaining numerous measure-
ments to average out noise in the data [1]. The terms
‘accuracy’ and ‘precision’ are not the same, though
they are often used interchangeably. In the context
of tonometry, ‘accuracy’ reflects how closely tono-
metric measurements reflect the ‘true’ IOP (e.g.
what you would measure if you were to cannulate
the eye with a manometer), whereas ‘precision’
refers to the consistency and repeatability of the
measurements. This review will discuss the several
niques, especially newer devices, highlighting their
accuracy and precision, strengths, and limitations.
APPLANATION TONOMETRY
Goldmann applanation tonometry (GAT) is the
most widely used method of tonometry and is
generally regarded as a reference standard despite
its limitations, which we will discuss. First intro-
duced in the mid-1950s [2], Goldmann applanation
is based on the Imbert–Fick principle, which states
that the pressure inside a sphere is directly related to
the force applied to flatten a given area.
Department of Ophthalmology & Vision Science, University of California
Davis Eye Center, Sacramento, California, USA
Correspondence to James D. Brandt, MD, Department of Ophthalmology
& Vision Science, University of California, Davis, 4860 Y Street, Suite
2400, Sacramento, CA 95817-2307, USA. Tel: +1 916 734 6969;
fax: +1 916 734 0411; e-mail: jdbrandt@ucdavis.edu
Curr Opin Ophthalmol 2015, 26:103–109
DOI:10.1097/ICU.0000000000000129

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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Glaucoma
KEY POINTS
 All methods of tonometry have strengths and
weaknesses, and provide only a snapshot of IOP.
 Corneal and material properties of the eye strongly
influence the accuracy and precision of all
tonometry techniques.
 Each method of tonometry has different demands on
operator training and different cost profiles.
 248 tonometry is in development and promises to
revolutionize how we manage glaucoma.
In its current design (little has changed since the
1950s), GAT arrives at an estimate of IOP based on
the force needed to flatten the corneal apex to a
given area. A clear plastic tonometer tip is pressed
against the anesthetized cornea. Two internal
prisms split the image of the fluorescein meniscus
by 1.53 mm, so that when the internal edges of the
meniscus circles (’mires’) are aligned by the
operator, a circle 3.06 mm in diameter has been
flattened at the corneal apex.
Goldmann and Schmidt empirically chose a
diameter in this range to offset the surface tension
of the tear film (which tends to draw the tonometer
tip towards the eye) and ocular rigidity (which
resists applanation, independent of IOP). The
specific diameter of 3.06 mm was chosen by the
inventors because at this diameter, 0.1 g of force
(Dynes) corresponds to 1 mmHg of IOP – thus the
‘1’ on the dial of a Goldmann applanation tonom-
eter corresponds to 1 g of force and 10 mmHg of IOP.
In their original study, the inventors explicitly
pointed out several limitations in their design. They
based their design on what they believed was a
relatively constant central corneal thickness (CCT)
of 0.5 mm among otherwise normal individuals.
They acknowledged that the accuracy of their device
would be affected if CCT deviated from this value.
We now know CCT varies greatly among the general
population, to a degree that impacts the accuracy of
most tonometry techniques in daily practice. Other
sources of error affecting GAT include Valsalva’s
maneuver, astigmatism, corneal curvature, inappro-
priate amount of fluorescein, eyelid squeezing, and
indirect pressure on the globe [3]. Both slit lamp
mounted and hand-held versions of the Goldmann
applanation tonometer are commercially available.
The hand-held Perkins tonometer has an internal
counterbalance mechanism to permit use on a
supine or upright patient.
The theoretical effects of CCT on GAT was con-
firmed in 1975 when Ehlers et al. [4] cannulated the
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otherwise normal eyes undergoing cataract surgery
and correlated corneal thickness with errors in GAT.
He found that GAT most accurately reflected true
intracameral IOP when the CCT was 520 mm. Inves-
tigators using modern pressure transducers have
since confirmed Ehlers et al.’s basic findings [5,6].
Ehlers et al.’s data set was limited to only 29 eyes
from a racially homogeneous population in Scandi-
navia in whom a limited range of CCTs was
observed – we now know that CCT varies far more
among otherwise normal individuals than imagined
by Goldmann and Schmidt. Differences in CCT are
found among different racial and ethnic groups
[7–9] and may lead to misclassification of patients
with normal tension glaucoma and ocular hyper-
tension [10–12]. This was all brought to the fore-
front when the Ocular Hypertension Treatment
Study demonstrated that CCT was an important
component of a multivariate model predicting
which study participants would go on to develop
glaucoma [13].
Goldmann applanation tonometry is particu-
larly susceptible to errors induced by corneal refrac-
tive surgery and other alterations in the normal
biomechanical behavior of the cornea. Studies have
shown that the mean change in IOP after refractive
surgery is negative, but the range of measured
change is enormous. Chang and Stulting [14]
suggested that the lamellar corneal flap makes no
contribution to the load-bearing characteristics of
the post-LASIK cornea. IOP measurements acquired
by GAT in patients who have undergone corneal
refractive surgery should be used with great caution.
Finally, the Goldmann applanation tonometer
is a 50-year-old mechanical device whose calibration
must be physically verified by the user on a regular
schedule to maintain factory-specified accuracy.
Choudhari et al. [15] evaluated 132 tonometers at
their institution and found that only 4% of the
devices were within the manufacturer’s recom-
mended calibration error tolerance of
0.5 mmHg
at 20 mmHg. They also found that devices out of
calibration had an unacceptable degree of measure-
ment variability [16].
Despite these many limitations, GAT remains a
popular and widely used method of tonometry due
to its low cost, lack of consumables, simplicity, and
integration into the workflow of the slit lamp exam-
ination in a busy clinic.
NONCONTACT TONOMETRY
Noncontact (colloquially known as ‘air puff’) ton-
ometry (NCT) is a form of applanation tonometry
that employs a calibrated column of compressed air
to briefly flatten the corneal apex. Because this
Volume 26  Number 2  March 2015

method of tonometry does not involve direct con-
tact with the eye, no topical anesthetic agents are
required and the technique can be used in children
and poorly cooperative adults. These devices
employ electro-optical sensors to detect the exact
moment of apical flattening. They then extrapolate
the IOP by determining what force of air had been
required to deform the cornea at the exact time-
point of flattening.
As applanation devices, however, NCTs are also
influenced by biomechanical factors such as CCT
and ocular rigidity. Tonnu et al. [17] compared NCT
to GAT and several other tonometers, and found
that NCT is affected by CCT significantly more than
is GAT; Ito et al. [18] found that both GAT and NCT
were significantly correlated with CCT. Because the
IOP estimate is acquired by NCT devices over just a
few milliseconds, the NCT is influenced by ocular
pulse amplitude, and multiple measurements are
needed. Yaoeda et al. [19] demonstrated that linking
the NCT to the ocular pulse improved the precision
of the device.
Modern NCT devices are far more reliable than
the early models introduced in the 1970s, and cor-
relate well with GAT in numerous clinical studies
[20,21]. Both desktop and hand-held devices are
available. NCT holds the attraction of not needing
anesthetic, of being operable by a lesser-trained
office personnel, and general acceptance by
patients. Used in a high-throughput clinical setting,
however, a single NCT device can become a rate-
limiting step in patient flow.
OCULAR RESPONSE ANALYZER
The ocular response analyzer (ORA) is a modern
NCT designed to not only measure IOP but also to
measure and account for variability in corneal bio-
mechanical properties among patients. Like other
NCT devices, a pulse of compressed air flattens the
corneal apex and electro-optical sensors measure the
physical behavior of the cornea. Unlike convention-
al NCT, the device measures both the inward and
outward movement of the cornea. The cornea is not
a perfectly elastic structure; in other words, it does
not behave like a spring, but rather as a viscous
damping system (e.g. a hydraulic shock absorber).
As such, the cornea deforms and then returns to its
original shape at different velocities – a physical
property called hysteresis. Hysteresis is a widely
studied physical property of biological structures
such as joints and blood vessels. The ORA is the
first clinical device to measure hysteresis in the eye.
By measuring the velocity of the inward and
outward movement of the cornea, the ORA derives
a measure of the cornea’s viscoelastic properties
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Measuring intraocular pressure Okafor and Brandt
(corneal hysteresis) and the corneal response factor
(CRF). Corneal hysteresis is thought to predomi-
nantly reflect the viscous dampening properties of
the cornea, whereas CRF is correlated to CCT and is
most associated with the cornea’s elastic response
[22]. The ORA provides IOP estimates that are corre-
lated to but not identical to GAT [23–25]. Similar to
standard NCT, the ORA acquires its measurements in
just a few milliseconds, and can therefore be affected
by the cardiac cycle and ocular pulse. Xu et al. [26]
found that ocular pulse amplitude was positively
correlated with large within-patient variance in
IOP measurements with the ORA, and they recom-
mended that multiple repeated measurements are
important for reliable IOP estimates by the ORA.
Corneal hysteresis, discussed elsewhere in this
issue of Current Opinion in Ophthalmology, appears to
be an independent factor related to glaucoma risk
and severity [27,28], and may be a heritable
parameter related to glaucoma risk [29].
Corneal ectasias such as keratoconus can lead to
altered corneal biomechanical behavior; ORA may
be helpful in monitoring progression in these dis-
eases [30,31].
DYNAMIC CONTOUR TONOMETRY
Dynamic contour tonometry (DCT) employs a 7-
mm diameter tip that matches the contour of the
average cornea with a base curve of 10.5 mm. A
piezoelectric sensor is incorporated into the curved
surface and measures IOP directly via hydrostatic
coupling [32]. IOP estimates acquired by the DCT
compare favorably to directly measured IOP in can-
nulated eyes, and appears to be mostly unaffected by
prior corneal surgery [33–35]. DCT is more repeat-
able and reproducible than GAT and ORA [36], but
IOP estimates from the three devices are not inter-
changeable [23].
Dynamic contour tonometry holds the attrac-
tion of being among the most accurate and precise
of currently available tonometry techniques and
mostly independent of corneal factors. However,
it is not particularly convenient to use – Anderson
et al. [37] found that DCT was significantly more
time-consuming and difficult than GAT in routine
practice, taking over 2.5 min to perform in a healthy
patient population; most eyes required repeated
measurements and for some an acceptable result
could not be obtained.
HAND-HELD TONOMETRY DEVICES
Several commercially available tonometers are port-
able, and can be carried by the clinician from room
to room in a busy clinic.
www.co-ophthalmology.com 105
Glaucoma
Mackay–Marg applanation tonometry
(Tono-Pen)
First introduced in the 1950s by Mackay et al. [38],
electronic applanation tonometry invokes the
Imbert–Fick principle by using a free floating
plunger surrounded by an annular ring; a strain
gauge linked to the plunger measures the force
necessary to flatten a small region of the cornea.
The modern version of Mackay–Marg tonometry is
the Tono-Pen, first introduced in the 1980s as a
hand-held, battery-powered device. This device is
portable and extremely easy to use. As with all
applanation tonometers, the Tono-Pen is affected
by CCT and other corneal parameters, and tends to
overestimate IOP compared to GAT, especially at
higher IOP levels [39,40]. Because the device appla-
nates only a tiny portion of the cornea, the device
offers clinicians the ability to estimate IOP using the
most ‘normal’ area of cornea unaffected by corneal
disease, for example, calcific band keratopathy,
ectatic disease, host cornea following grafting or
keratoprosthesis, and so on. However, the device
is designed to be used on the central cornea, and if
an operator is not careful to apply the device at the
center of the cornea in an otherwise normal patient,
IOP estimates will trend higher due to the increased
thickness of the peripheral cornea [41]. Finally, in
typical use, the operator gently holds the patient’s
eyelids open. If any pressure is applied to the under-
lying globe, the measured IOP will be higher. Proper
training in technique is critical in the successful
clinical use of this device by clinicians and
ophthalmic technicians.
Transpalpebral tonometry (Diaton)
Intraocular pressure has been estimated through the
eyelids for centuries; the Diaton transpalpebral ton-
ometer attempts to do so in an automated fashion.
When using this device, a sitting or supine patient is
instructed to look up 458 superiorly and the device is
placed over the upper lid; a probe inside the device
falls via a gravity-dependent mechanism and the
acceleration of the rebounding probe is measured
and converted into an estimate of IOP. The current
commercial device is different from its predecessor –
the TGDc-01 – as it takes six measurements and
averages the measurements; the devices are believed
to estimate scleral rigidity thought the lid [42] and
appears to be significantly affected by CCT [43]. For
the device to accurately determine the IOP, it must
be held perpendicular to the globe, but the device
employs no stabilization or orientation features and
the device begins to take measurements immedi-
ately upon being placed on the eye. Although the
device is well tolerated and in fact preferred by
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patients compared to GAT [44], all the studies
comparing the Diaton device to GAT demonstrate
high variability and poor agreement with GAT, and
several investigators recommend against its clinical
use [42,44,45].
Rebound tonometry (iCare)
First described by its inventor Kontiola in 1996,
rebound tonometry employs a magnetized probe
that is accelerated onto the cornea at a fixed velocity
using a solenoid; the same solenoid is used to detect
the impact and rebounding velocity of the probe
[46,47]. The rebounding velocity is closely corre-
lated with IOP in animal and cadaver eyes, and
clinical trials of the commercialized device (the
iCare Pro Rebound Tonometer) suggest sufficient
correlation with GAT for clinical use. The device
is portable and does not require topical anesthesia,
and accordingly is well tolerated by young children
and uncooperative patients [48]. The device gener-
ally overestimates the IOP when compared to Gold-
man tonometry, especially at higher IOPs [49], and
this effect is amplified at higher CCTs [50].
The iCare tonometer appears to be most useful in
young children [51–53]. A recent Ophthalmic Tech-
nology Assessment by the American Academy of
Ophthalmology suggested that rebound tonometry
was a reasonably accurate instrument that in many
children avoided the need for general anesthesia; the
authors concluded that more comparative studies
were needed to fully assess the differences among
tonometry techniques in children [54].
Rebound tonometry lends itself nicely to home
tonometry, and a device to do so (the iCare ONE) has
been commercialized outside the USA. The device
appears to have reasonable comparability to both
GAT and rebound measurements by a physician
[55–57].
TWENTY-FOUR HOUR CONTINUOUS
TONOMETERY
Glaucoma is unique among chronic diseases in that
the primary (and likely causative) risk factor and
treatment target for the disease, IOP, is measured
rarely – just a few times a year for most patients.
Ultimately, what is needed is a simple way to acquire
continuous IOP measurements over the course of
days, weeks, and months. Such devices are now
appearing on the horizon.
Sensimed Triggerfish
The Triggerfish contact lens sensor is capable of
providing 24-h continuous IOP estimates. The
Volume 26  Number 2  March 2015
 Table 1. Comparison matrix of currently available tonometers

Noncontact Dual Dynamic

Goldmann Electronic tonometry applanation Scheimpflug NCT Pneumatic contour Rebound
applanation applanation (NCT) NCT tonometer tonometer tonometer Transpalpebral

Tonometry Fixed-area, Makay–Marg Single inward Bi-directional Single inward Fixed-area, Contour-matched Ballistic probe Ballistic probe
principle variable-force applanation applanation; applanation; applanation; air variable-force piezoresistive (through eyelid)
applanation air puff air puff puff; Scheimpflug applanation sensor
image capture for
corneal analysis
Product or Goldmann Tono-Pen, Many Reichert Ocular Oculus Corvis ST Reichert Pascal DCT iCare Rebound Diaton
brand name tonometer; Accupen manufacturers Response Model 30 Tonometer
Perkins Analyzer
tonometer
Contact/ Contact Contact Noncontact Noncontact Noncontact Contact Contact Contact Contact (through
noncontact eyelid)
Sterilization Yes No (requires use No No No Yes No (requires use No (requires use Yes
required of disposable of disposable of disposable
covers) covers) probes)
Anesthesia Yes, þ Yes No No No Yes Yes No No
required fluorescein
Hand-held, table Slit lamp or Hand-held Table Table Table Table with Slit lamp Hand-held Hand-held
or slit-lamp hand-held hand-held
mounted (Perkins) probe

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Operator skill High Medium Low–medium Low–medium Low–medium Medium–high High Low–medium Low–medium
and training
requirements
Approximate unit $750–$1200, $2750–$3750 $7500 $8500– $25 000 $7000 $6500 $3750 $2750
cost (US$) in late often bundled $15 000
2014 with slit lamp
purchase
Consumables None Tonometer None None None Tip and Sensor caps Probes $0.80– Consumer-grade
covers membrane $1.00–$1.50 $1.00 each. CR2032
$0.10–$0.45 replaced a few each; batteries Consumer-grade batteries
each; batteries times a year @ $25 each AAA batteries
$45 each $50 80

DCT, dynamic contour tonometry; NCT, noncontact tonometry.

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Measuring intraocular pressure Okafor and Brandt

107
Glaucoma
device does not directly measure IOP, but rather
records changes in corneal curvature presumed to
be related to fluctuations in IOP [58]. The device
takes a 60-s recording every 10 min, giving 144 read-
ings over a 24-h period [59]. The device appears to
provide reproducible results and is generally well
tolerated, even with overnight use while sleeping
[60]. However, in a small clinical trial comparing the
ability of GAT and the Triggerfish to detect a pros-
taglandin analog-induced drop in IOP, Hollo et al.
& Conflicts of interest
[61 ] could not detect a drop in IOP using the
Triggerfish device even when GAT could. It there-
fore remains to be seen if the device will prove
clinically useful.
Wireless intraocular pressure transducer
Ultimately, it would be ideal to surgically implant an
IOP sensor at the time of routine cataract or glau-
coma surgery, when the risk of incisional surgery is
already being taken and a miniaturized device can
be placed with acceptable additional risk. Melki et al.
&&
[62 ] recently reported on the first implantation of
such a device in a human. The wireless IOP trans-
ducer (WIT) measures IOP using an array of capaci-
tive pressure sensors linked to an application-
specific integrated circuit and a micro-coil antenna;
the device is powered and interrogated via inductive
coupling. They report acceptable comparison to
GAT measurements and reasonable stability of the
measurements over 18 months of follow-up.
CONCLUSION
There are many ways to measure and monitor IOP.
Each tonometry technique has its advantages and
disadvantages. Most clinicians will be comfortable
with two or three ways of performing tonometry,
but depending upon the nature of their practice, will
depend on only one or two techniques.
There is no perfect tonometer or tonometry
technique. Clinicians decide which to use based
on their own clinical needs, and cost is not a small
consideration. A tonometer ideal for glaucoma
screening will not have the same profile as one
employed in a high-volume specialty clinic. A
pediatric ophthalmologist has different tonometry
needs than a refractive surgeon. Table 1 provides a
profile (including costs) of many commercially
available tonometers including those discussed
here. The list is not exhaustive.
Finally, it is incumbent upon clinicians to
understand the limitations of whatever techniques
they choose to use, and to further recognize that any
single measurement is but an estimate of a dynamic,
ever-changing physiologic parameter. Every IOP
measurement in an individual patient should be
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taken with a healthy dose of skepticism and used
in clinical decision-making only in the context of
the overall clinical picture.
Acknowledgements
None.
Financial support and sponsorship
None.
Dr Okafor has no proprietary or financial interests to
disclose related to the subject of this study.
Dr Brandt serves on the Scientific Advisory Board of the
Reichert Instruments Division (Depew, New York, USA)
of Ametek, Incorporated. Reichert Instruments is the
manufacturer of both the Ocular Response Analyzer
and the Tono-Pen, discussed in this article.
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