Lately I've been upddating the lanes in some of our offices. Some of the younger Ods have been inquiring about tonopens instead of Goldman tonometers.
The more I look into, it seems like the results of the tonopen are more in line with that of an NCT, and are more appropriate for screenings, rather than diagnosing.
I also ran across this article:
http://www.ncbi.nlm.nih.gov/entrez/q...&dopt=Abstract
What are your thoughts ?
Last edited by Johns; 06-19-2006 at 06:55 AM. Reason: Still kant spell...
Interesting subject. I would probably go with whatever the docs feel most comfortable with. Even the highly touted goldmann has what many consider very serious flaws, none of them are perfect. Are they diagnosing and treating glaucoma in office? There are so many more important things in glaucoma detection nowadays anyway, IOP measurements are usually more useful with treatment anyway.
I know of several offices that only have Tonopens.. those little rubber caps do get expensive over time, you are supposed to change them with each patient. But, less drops than with goldman.
No, we haven't been diagnosing and treating glaucoma in the office for the last 5 years. There are were so many changes in instrumentation that we thought we'd let the MDs pay those leases, and we refer everything suspect. We do however, want to get as accurate reading as possible, so that not every pt. is a suspect and we're not needlessly refering out.
The ODs used to prefer the NCTs, but I wasn't comfortable with them. I switched over to all aplination about 10 years ago, and now none of them would want to go back.
If I thought the tonopen was as accurate, I would switch them all tommorrow. I just hate to jump the gun.
Personally, I'd feel way more comfortable with the tonopen than I do with the NCT. NCT is only nice cause its easy and fast. I get wildly various readings with the NCT. lots of patients of mine that are 22 on NCT are about 17 or 18 with goldmann, so I'm usually left doing a lot of goldmann anyway just to be precise. But then I have a lot of 22s, that turn out to be 21 or 23 on goldmann also, so there is no set pattern that i can figure out.
You could always ask those that you refer to what they would prefer, or at least what they don't like. probably the best answer.
there is also the perkins tonometer and kowa makes a handheld. Both pretty reasonable in price. The most expensive is this new thing called the pascal, like goldmann as far as patient experience, but you only need anesthetic. some like the perkins for portability.
Originally Posted by Johns
What is the rationale given by the young OD's who are requesting the Tonopen over the Goldmann?
That makes me sick. For the sake of the optometric profession, practice to the fullest extent.
This is why some of us should have a special certification called "Board Certified Optometric Physician" and then the rest of you not interested in patient care can be called Optometric Lens Flippers.
Don't ask what you can do. DO what you can do. -My Paternal Grandpa
What is the rationale................
They should be advised of the new FDA rule that the Goldman is considered the standard in Tonometers.
Glaucoma diagnosis has a lot less to do with pressure than you think. Sure, certain people have very high pressure and it is important to know this. Just about any tonometer will pick that up. A large percentage of people who actually have glaucoma can have low tension or normal tension glaucoma. So no matter how accurate your tonometer is, even if you use Goldman on everybody, you will "miss" at least half of all glaucomas if you do not look at other factors.
By no means be fooled if a patient has pressures of say, 17 with Goldman, that they DON"T have glaucoma. And tons of people with Goldman readings of 26 don't have glaucoma.
It is much more important to view the optic nerve head for signs of cupping, disk hemmorhages, NFL dropout, corneal thickness, visual field loss, ONH topography, and the like. It is probably more important to do a DFE than it is tonometry. Family history plays an important role also. I am much more worried about a 65 year old man, with systemic hypertension, who's sister has glaucoma, with pressures of 20 and cups of .5 than I am of a 65 year old man in good health with pressures of 25, with cups of .3 and no family history.
Goldman is better when treating glaucoma and you need to determine how many points your treatment regimen has lowered the pressure. I will even go so far as to say Goldman is better for measuring pressure in all cases, but only the doctor can really determine if the patient has glaucoma by considering all factors.
So, if you want your office to be good at detecting glaucoma, it doesn't much matter which tonometer you have. Make sure your doctor is doing what he/she should be doing.
While fjpod has relevant comments about the importance of IOP in glaucoma management, IOP is still a vital sign and it's measurement should be consistent and accurate. In my opinion, taking the IOP is much like taking your temperature when you go to the primary care doctor.
Goldman is more fun than tonopen. Tonopen sucks!
good points.
I don't think its a crime to refer patients out. Not all practices can afford a pachymeter, laser scanning machine, adequate visual field machine, gonio, fundus photos, etc. I think its more a crime to treat glaucoma without using these, refusing to refer to someone that does, and think you are doing what's best for the patient. Be nice if we all had them though. It really sucks to have to make the decision to refer out or not because someone has suspicious looking C/Ds, slightly above average IOP (at least at one instant), and no family history. Would be a lot more convienent to have all the stuff there.
That was why I said to perhaps as the ODs to talk to who they refer to. Nothing a referring doc likes less than to get information that he/she doesn't think is useful/valid.
From a legal standpoint, I think most docs are smart enough to not rely on one IOP reading (and nothing else) for virtually any type of glaucoma detection.
And goldman may be standardized, but its far from perfect, or even pretty good. The other devices have errors, but so does goldmann.
1.) NPDR knows his stuff. I know that personally.
2.) Optoblog needs to have a beer.
3.) Tonpen is only better than Goldmann for one reason: you can buy one, keep it in your pocket, and jump to multiple exam rooms, making it very cost effective, ergo, popular.
4.) Goldmann is the serious (real) way to do it.
5.) NCT is way better as a screener than Tonopen, but the cost issue...
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