Clinical Scorecard: Glaucoma: Beyond Goldmann
At a Glance
| Category | Detail |
|---|---|
| Condition | Glaucoma |
| Key Mechanisms | Intraocular pressure (IOP) measurement influenced by corneal biomechanics and thickness |
| Target Population | Patients undergoing glaucoma screening and management, including post-refractive surgery and normal tension glaucoma patients |
| Care Setting | Optometry and ophthalmology clinics, including at-home monitoring |
Key Highlights
- Goldmann applanation tonometry (GAT) remains the standard but newer devices adjust for corneal biomechanics and thickness to improve accuracy.
- Devices like CATS prism, air-puff tonometers, dynamic contour tonometers, and handheld tonometers offer complementary IOP measurements.
- At-home IOP monitoring devices capture diurnal fluctuations, aiding personalized glaucoma management.
Guideline-Based Recommendations
Diagnosis
- Use Goldmann applanation tonometry as the reference standard for IOP measurement.
- Incorporate devices that compensate for corneal properties (e.g., CATS prism, corneal-compensated IOP) especially in post-refractive surgery eyes.
- Consider corneal hysteresis measurements as a predictor of glaucoma conversion and progression.
Management
- Integrate complementary tonometry devices to refine diagnosis and personalize treatment plans.
- Utilize at-home IOP monitoring devices to detect diurnal IOP fluctuations not captured during office visits.
- Adjust treatment intensity based on dynamic IOP data, particularly in normal tension glaucoma patients showing progression.
Monitoring & Follow-up
- Employ handheld and dynamic contour tonometers for repeated IOP measurements with minimal patient discomfort.
- Use continuous or self-monitoring IOP devices to track fluctuations over 24 hours.
- Monitor corneal hysteresis as part of risk assessment for glaucoma progression.
Risks
- Be aware that some handheld and rebound tonometers may overestimate true IOP, especially at lower pressures.
- Operator technique and corneal thickness can influence readings from certain devices.
- No device perfectly captures true IOP in all patients; interpret results considering device limitations.
Patient & Prescribing Data
Glaucoma patients including those with normal tension glaucoma and post-refractive surgery eyes
Use of advanced IOP measurement devices and at-home monitoring can reveal IOP fluctuations leading to more tailored and aggressive treatment when necessary.
Clinical Best Practices
- Combine Goldmann tonometry with newer devices that adjust for corneal biomechanics to improve IOP measurement accuracy.
- Incorporate corneal hysteresis measurement into glaucoma risk assessment protocols.
- Encourage use of at-home IOP monitoring devices for patients with progressing glaucoma despite normal office IOP readings.
- Train operators thoroughly to minimize technique-related measurement variability.
- Interpret IOP readings in context of corneal properties and device-specific biases.
References
- McCafferty et al. Goldmann and error correcting tonometry prisms compared to intracameral pressure. BMC Ophthalmol. 2018
- Zhang et al. Comparison of IOP measured by ocular response analyzer and Goldmann after refractive surgery. BMC Ophthalmol. 2020
- Zimprich et al. Corneal Hysteresis as a Biomarker of Glaucoma. Clin Ophthalmol. 2020
- Frenkel et al. Comparison of the Tono-Pen to Goldmann applanation tonometer. Arch Ophthalmol. 1988
- Ertel et al. Comparison of IOP readings with various tonometers to manometry in cadaveric eyes. Int J Ophthalmol. 2022
- Quérat & Chen. iCare Home vs Goldmann applanation tonometry. Eur J Ophthalmol. 2023
- Kniestedt et al. Assessment of Pascal dynamic contour tonometer after LASIK. J Cataract Refract Surg. 2005
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