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BioMed Research International
Volume 2013 (2013), Article ID 370592, 5 pages
http://dx.doi.org/10.1155/2013/370592
Research Article

Repeatability and Reproducibility of Measurements Using a NT-530P Noncontact Tono/Pachymeter and Correlation of Central Corneal Thickness with Intraocular Pressure

1Department of Rehabilitation, Orthoptics and Visual Science Course, School of Allied Health Sciences, Kitasato University, 1-15-1 Kitasato, Minamiku, Sagamihara, Kanagawa 252-0373, Japan
2Department of Ophthalmology, Kitasato University Hospital, 1-15-1 Kitasato, Minamiku, Sagamihara, Kanagawa 252-0373, Japan
3Department of Ophthalmology, School of Medicine, Kitasato University, 1-15-1 Kitasato, Minamiku, Sagamihara, Kanagawa 252-0373, Japan

Received 21 June 2013; Revised 30 August 2013; Accepted 3 September 2013

Academic Editor: Toshiaki Kubota

Copyright © 2013 Fusako Fujimura et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose. To investigate the repeatability and reproducibility of intraocular pressure (IOP) and central corneal thickness (CCT) measurements using a noncontact tono/pachymeter (NT-530P) and to assess the correlation of CCT with IOP. Methods. Forty-six eyes of healthy volunteers were measured by two examiners. Three consecutive measurements per eye were performed. Repeatability was assessed using the coefficient of variation, and reproducibility was assessed using Bland-Altman plots. Linear correlations were used to determine agreement between CCT and noncorrected IOP and CCT and corrected IOP, which was calculated using a formula built into the NT-530P. Results. The coefficient of variation for IOP was 6.4% and for CCT was 0.4%. The 95% limits of agreement between examiners were  mmHg (range: to 2.61 mmHg) for IOP, μm (range: to 7.64 μm) for CCT. The corrected IOP was significantly higher than the noncorrected IOP (). The noncorrected IOP significantly correlated with CCT (, ). The corrected IOP showed no significant correlation with CCT (, ). Conclusions. NT-530P offered repeatability and reproducibility in both IOP and CCT measurements. The corrected IOP calculated using the NT-530P was independent of the CCT, suggesting that this IOP may be less influenced by the central corneal thickness.

1. Introduction

Intraocular pressure (IOP) plays an indispensable role in the diagnosis and the management of glaucoma. At present, we often use applanation tonometry based on the Imbert-Fick law to measure the IOP error in which central corneal thickness (CCT) is considered to be a major confounding factor. Several studies have found that the IOP values measured using an applanation tonometer were overestimated in eyes with thicker corneas or underestimated in eyes with thinner corneas [13]. Accordingly, there is a need for correcting the IOP values using CCT in order to accurately determine IOP by means of the established formulas for correcting IOP values [4, 5]. Since the applanation tonometry is measured by a contact procedure and requires topical anesthesia, there is a possible risk of infection. Moreover, the applanation tonometry can be affected by the hydration state of the cornea.

A newly developed noncontact tono/pachymeter (NT-530P, NIDEK) has two simultaneous functions, one is as a noncontact applanation tonometer which utilizes an air jet for the measurement of IOP values, which can reduce the possible risk of transmission of infectious diseases, and the other is as a noncontact pachymeter using a rotating Scheimpflug camera for measuring CCT. Both IOP and CCT measurements are noninvasive and do not require topical anesthesia. It can also calculate the corrected IOP using the measurement data of CCT. It is thus expected to offer a simple and useful method for the simultaneous assessment of IOP and CCT in a clinical setting. Since it enables us to perform simultaneous IOP and CCT measurements, and to calculate the corrected IOP by CCT, this instrument is clinically useful for glaucomatous screening. However, to our knowledge, the effect of CCT on IOP measurements has not so far been elucidated using this device. The purpose of the study was two fold, to prospectively investigate the repeatability and reproducibility of IOP and CCT measurements obtained with the NT-530P, and to assess the correlations of CCT with non-corrected or corrected IOP.

2. Materials and Methods

2.1. Study Population

This prospective study examined forty-six eyes (only the right eye) of 46 healthy volunteers without ophthalmological disease except for refractive error, whose mean age was years (range: 20 to 57 years), whose mean spherical equivalent refractive error was  D (range: −6.50 to +1.36 D), and whose mean corneal astigmatism was  D (range: −3.00 to −0.25 D). The study was approved by the Institutional Review Board at Kitasato University School of Allied Health Sciences (number 2010-001) and followed the tenets of the Declaration of Helsinki. Written informed consent was obtained from all patients after explanation of the nature and possible consequences of the study.

In all cases, two experienced examiners (A and B) (examiners A and B have 10 and 5 years of experience, resp.,) measured the IOP and the CCT of each eye three times using a NT-530P, and the average value was used for statistical analysis. The volunteer was positioned on the chinrest of the device and asked to look at the target. All measurements by both examiners were performed on the same day at almost the same time. The two examiners took turns randomly in taking measurement.

2.2. Repeatability and Reproducibility

The repeatability of the three measurement values made by examiner (A) was assessed using coefficient of variation (CoV) as a normalized standard deviation (SD), as shown in A smaller CoV means better repeatability. Most authors regard devices with a CoV < 10% as having high repeatability, and a CoV < 5% indicates very high repeatability [6].

The reproducibility of the measurements made by the two examiners was assessed using the method of Bland and Altman, whereby 95% of the differences or limits of agreement lie between of the mean difference.

2.3. Correlation between CCT and IOP

The measurement values obtained by examiner (A) were used to compare the non-corrected IOP with the corrected IOP, the latter of which was calculated using a formula incorporated in the NT-530P. The relationship between CCT and corrected IOP and CCT and non-corrected IOP was evaluated by linear regression analysis.

2.4. Comparison of the IOP Values Measured by NT-530P and Goldmann Applanation Tonometry

In order to compare the IOP values measured by NT-530P and the Goldmann applanation tonometry (GAT), we additionally examined twenty eyes (only the right eye) of 20 healthy volunteers without ophthalmological disease except for refractive error, whose mean age was 32.8 ± 9.1 years (range: 22 to 58 years), whose mean spherical equivalent refractive error was  D (range: −5.13 to +1.25 D), and whose mean corneal astigmatism was  D (range: −2.50 to 0.00 D). In all cases, the IOP of each eye was measured three times using NT-530P and GAT. The between-instrument agreement was assessed by the Bland-Altman method.

2.5. Statistical Analysis

The Wilcoxon signed-rank test was used to make comparison between non-corrected IOP and corrected IOP and comparison the IOP values between measured by NT-530P and by GAT. Spearman’s rank correlation coefficient test was used to determine the correlations between CCT and non-corrected or corrected IOP. Linear correlations were used to determine agreement between CCT and corrected IOP and that between CCT and non-corrected IOP. The results are expressed as mean ± standard deviation (SD), and a value of was considered statistically significant.

3. Results

3.1. Repeatability and Reproducibility

The mean and SD of non-corrected IOP acquired by examiner (A) were 13.8 ± 2.6 mmHg, and non-corrected IOP acquired by examiner (B) was 13.9 ± 2.6 mmHg. The mean and SD of CCT acquired by examiner (A) were 543.3 ± 27.9 μm, and CCT acquired by examiner (B) was 544.3 ± 27.8 μm. The coefficient of variation values for non-corrected IOP and CCT was 6.4% and 0.4%, respectively (Table 1). The mean difference (95% limits of agreement) in non-corrected IOP between the two examiners was  mmHg (range: −2.95 to 2.61 mmHg) (Figure 1). The mean difference (95% limits of agreement) in CCT between the two examiners was μm (range: −9.50 to 7.64 μm) (Figure 2).

tab1
Table 1: Summary of results obtained from the NT-530P measured by two examiners ( eyes).
370592.fig.001
Figure 1: Mean difference (solid line) and 95% limits of agreement (dashed line) for IOP.
370592.fig.002
Figure 2: Mean difference (solid line) and 95% limits of agreement (dashed line) for CCT.
3.2. Correlation between CCT and IOP

The non-corrected IOP by CCT was 13.8 ± 2.6 mmHg, and the corrected IOP by CCT was 14.2 ± 2.3 mmHg. The corrected IOP was statistically significantly higher than the non-corrected IOP (, Wilcoxon signed-rank test). Moreover, there was a significant positive correlation between the non-corrected IOP and the CCT (, Spearman’s rank correlation coefficient test) (Figure 3). On the other hand, there was no significant correlation between the corrected IOP and the CCT (Figure 4).

370592.fig.003
Figure 3: A graph showing a significant linear correlation between the noncorrected IOP and the CCT, (Spearman’s rank correlation coefficient).
370592.fig.004
Figure 4: A graph showing no significant correlation between the corrected IOP and the CCT, (Spearman’s rank correlation coefficient).
3.3. Comparison of the IOP Values Measured by NT-530P and Goldmann Applanation Tonometry

The IOP values acquired by NT-530P and GAT were 12.8 ± 3.4 mmHg and 12.7 ± 2.5 mmHg, respectively. There was no significant difference between the IOP values measured by NT-530P and GAT (, Wilcoxon signed-rank test). The mean difference (95% limits of agreement) in IOP between the NT-530P and GAT was 0.10 ± 1.97 mmHg (range: −3.76 to 3.95 mmHg) (Figure 5).

370592.fig.005
Figure 5: Mean difference (solid line) and 95% limits of agreement (dashed line) for IOP.

4. Discussion

In the present study, the two examiners (A and B) measured the values of the non-corrected IOP and CCT as 13.8 ± 2.6 mmHg (A) and 13.9 ± 2.6 mmHg (B) and 543.3 ± 27.9 μm (A) and 544.3 ± 27.8 μm (B), respectively. The CoV of the IOP measurements was 6.4% and that of the CCT measurements was 0.4%. With regard to the repeatability of IOP measured with the noncontact tonometer, the CoVs of the IOP measurements using NT-2000 and NT-4000 (Nidek) were reported to be 5.6% and 5.2%, respectively [7, 8]. Additionally, Nam et al. investigated the repeatability of CCT measurement with RTVue OCT, Pentacam, and ultrasound pachymetry and reported that the CoVs were 0.31%, 0.64%, and 0.34%, respectively [9]. In this study, the CoVs of IOP and CCT were less than 10%, and the repeatability of IOP and CCT measurements of NT-530P was same or better than that in previous studies. These results indicate that this device has good repeatability to measure IOP and CCT in a clinical setting.

Ogbuehi reported that the 95% limits of agreement for IOP measured in two sessions with the Topcon CT80 noncontact tonometer ranged from −2.45 to 2.65 mmHg, with a mean difference of 0.1 ± 1.3 mmHg [10]. Almubrad reported that the 95% limits of agreement for IOP between two sessions with the GAT and the PT100 noncontact tonometer (Reichert) were −2.0 to 2.1 mmHg and −2.2 to 1.8 mmHg, respectively [11]. The mean difference (95% limits of agreement) in IOP between two examiners in this study was −0.17 ± 1.42 mmHg (range: −2.95 to 2.61 mmHg), which were comparable with that in previous studies. Bourges et al. reported that the 95% limits of agreement in CCT between two examiners with Orbscan 2 and Pentacam were −10.7 to 10.0 μm and −10.0 to 8.6 μm [12]. In this study, the 95% limits of agreement in CCT between two examiners were −9.50 to 7.64 μm, which were the same as those in Bourges’ report. Considering the above circumstances, the repeatability and reproducibility of IOP and CCT measurements using this device were excellent.

Additionally, Ogbuehi et al. reported that there was statically significant difference in IOP readings between RKT7000 (Nidek) and GAT (2.6 ± 2.0 mmHg) and those between CT-80 (Topcon) and GAT (2.8 ± 2.0 mmHg). The 95% limits of agreement between GAT and RKT-7700, and those between GAT and CT-80 ranged from −6.5 to 1.3 mmHg and −6.7 to 1.1 mmHg, respectively [13]. In this study, there was no significant difference between the IOP values measured by NT-530P and GAT. The mean difference (95% limits of agreement) in IOP between the NT-530P and GAT was 0.10 ± 1.97 mmHg (range: −3.76 to 3.95 mmHg). Therefore, we assume that the NT-530P is clinically useful for the simultaneous assessment of CCT and IOP.

In the present study, we found that the corrected IOP by CCT was significantly higher than the non-corrected IOP and that there was a significant correlation between the non-corrected IOP and the CCT, but none between the corrected IOP and the CCT. The formula for correcting IOP in NT-530P was obtained from the results of Burvenich and De Clercq [5] study (2): The IOP measurements are influenced by the biomechanical properties of the cornea, such as CCT, corneal radius [14, 15], corneal astigmatism [16, 17], and corneal rigidity [18]. The other affective factors (gender, age, and race [3, 1921], measurement time [2224], and head location [25, 26]) affect the IOP measurement. Therefore, we cannot acquire an accurate IOP corrected independently by the CCT. In these circumstances, it is necessary to be attentive when interpreting the corrected IOP obtained with NT-530P.

5. Conclusion

Our results indicate that the NT-530P provides excellent repeatability and reproducibility of both IOP and CCT measurements, and that there was a significant correlation between non-corrected IOP and CCT, but none between corrected IOP and CCT. However, we should be aware that there is a possibility of slight IOP overestimation, when the corrected IOP by CCT is used with this device.

Conflict of Interests

The authors report no conflict of interests. The authors alone are responsible for the content and writing of the paper.

Acknowledgments

This study was approved by the Institutional Review Board at Kitasato University School of Allied Health Sciences (number 2010-001) and followed the tenets of the Declaration of Helsinki.

References

  1. N. Ehlers, T. Bramsen, and S. Sperling, “Applanation tonometry and central corneal thickness,” Acta Ophthalmologica, vol. 53, no. 1, pp. 34–43, 1975. View at Scopus
  2. P. J. Foster, J. Baasanhu, P. H. Alsbirk, D. Munkhbayar, D. Uranchimeg, and G. J. Johnson, “Central corneal thickness and intraocular pressure in a Mongolian population,” Ophthalmology, vol. 105, no. 6, pp. 969–973, 1998. View at Publisher · View at Google Scholar · View at Scopus
  3. R. C. W. Wolfs, C. C. W. Klaver, J. R. Vingerling, D. E. Grobbee, A. Hofman, and P. T. V. M. De Jong, “Distribution of central corneal thickness and its association with intraocular pressure: the Rotterdam study,” American Journal of Ophthalmology, vol. 123, no. 6, pp. 767–772, 1997. View at Scopus
  4. S. Suzuki, Y. Suzuki, A. Iwase, and M. Araie, “Corneal thickness in an ophthalmologically normal Japanese population,” Ophthalmology, vol. 112, no. 8, pp. 1327–1336, 2005. View at Publisher · View at Google Scholar · View at Scopus
  5. H. Burvenich and J. De Clercq, “The combined IOP and CCT measurement in glaucoma screening,” Bulletin de la Société Belge d'Ophtalmologie, vol. 276, pp. 15–18, 2000. View at Scopus
  6. V. Pueyo, V. Polo, J. M. Larrosa, F. Mayoral, A. Ferreras, and F. M. Honrubia, “Reproducibility of optic nerve head and retinal nerve fiber layer thickness measurements using optical coherence tomography,” Archivos de la Sociedad Espanola de Oftalmologia, vol. 81, no. 4, pp. 205–212, 2006. View at Scopus
  7. A. K. C. Lam, R. Chan, R. Chiu, and C.-H. Lam, “The validity of a new noncontact tonometer and its comparison with the Goldmann tonometer,” Optometry and Vision Science, vol. 81, no. 8, pp. 601–605, 2004. View at Publisher · View at Google Scholar · View at Scopus
  8. K. Yaoeda, M. Shirakashi, A. Fukushima et al., “Measurement of intraocular pressure using the NT-4000: a new non-contact tonometer equipped with pulse synchronous measurement function,” Journal of Glaucoma, vol. 14, no. 3, pp. 201–205, 2005. View at Publisher · View at Google Scholar · View at Scopus
  9. S. M. Nam, C. Y. Im, H. K. Lee, E. K. Kim, T.-I. Kim, and K. Y. Seo, “Accuracy of RTVue optical coherence tomography, pentacam, and ultrasonic pachymetry for the measurement of central corneal thickness,” Ophthalmology, vol. 117, no. 11, pp. 2096–2103, 2010. View at Publisher · View at Google Scholar · View at Scopus
  10. K. C. Ogbuehi, “Assessment of the accuracy and reliability of the Topcon CT80 non-contact tonometer,” Clinical and Experimental Optometry, vol. 89, no. 5, pp. 310–314, 2006. View at Publisher · View at Google Scholar · View at Scopus
  11. T. M. Almubrad, “Performance of the PT100 noncontact tonometer in healthy eyes,” Clinical Ophthalmology, vol. 5, no. 1, pp. 661–666, 2011. View at Publisher · View at Google Scholar · View at Scopus
  12. J.-L. Bourges, N. Alfonsi, J.-F. Laliberté et al., “Average 3-dimensional models for the comparison of orbscan II and pentacam pachymetry maps in normal corneas,” Ophthalmology, vol. 116, no. 11, pp. 2064–2071, 2009. View at Publisher · View at Google Scholar · View at Scopus
  13. K. C. Ogbuehi, S. Mucke, and U. L. Osuagwu, “Influence of central corneal thickness on measured intraocular pressure differentials: nidek RKT-7700, Topcon CT-80 NCTs and Goldmann Tonometer,” Ophthalmic and Physiological Optics, vol. 32, no. 6, pp. 547–555, 2012. View at Publisher · View at Google Scholar
  14. H. H. Mark, “Corneal curvature in applanation tonometry,” American Journal of Ophthalmology, vol. 76, no. 2, pp. 223–224, 1973. View at Scopus
  15. P. Gunvant, M. Baskaran, L. Vijaya et al., “Effecf of corned parameters on measurements using the pulsatile ocular blood flow tonograph and Goldmann applanation tonometer,” British Journal of Ophthalmology, vol. 88, no. 4, pp. 518–522, 2004. View at Publisher · View at Google Scholar · View at Scopus
  16. J. T. Holladay, M. E. Allison, and T. C. Prager, “Goldmann applanation tonometry in patients with regular corneal astigmatism,” American Journal of Ophthalmology, vol. 96, no. 1, pp. 90–93, 1983. View at Scopus
  17. H. H. Mark and T. L. Mark, “Corneal astigmatism in applanation tonometry,” Eye, vol. 17, no. 5, pp. 617–618, 2003. View at Publisher · View at Google Scholar · View at Scopus
  18. J. Liu and C. J. Roberts, “Influence of corneal biomechanical properties on intraocular pressure measurement: quantitative analysis,” Journal of Cataract and Refractive Surgery, vol. 31, no. 1, pp. 146–155, 2005. View at Publisher · View at Google Scholar · View at Scopus
  19. M. F. Armaly, “Age and sex correction of applanation pressure,” Archives of Ophthalmology, vol. 78, no. 4, pp. 480–484, 1967. View at Scopus
  20. B. E. K. Klein, R. Klein, and K. L. P. Linton, “Intraocular pressure in an American community: the beaver dam eye study,” Investigative Ophthalmology and Visual Science, vol. 33, no. 7, pp. 2224–2228, 1992. View at Scopus
  21. Y. Shiose, Y. Kitazawa, S. Tsukahara et al., “Epidemiology of glaucoma in Japan. A nationwide glaucoma survey,” Japanese Journal of Ophthalmology, vol. 35, no. 2, pp. 133–155, 1991. View at Scopus
  22. S. Asrani, R. Zeimer, J. Wilensky, D. Gieser, S. Vitale, and K. Lindenmuth, “Large diurnal fluctuations in intraocular pressure are an independent risk factor in patients with glaucoma,” Journal of Glaucoma, vol. 9, no. 2, pp. 134–142, 2000. View at Scopus
  23. J. H. K. Liu, A. J. Sit, and R. N. Weinreb, “Variation of 24-hour intraocular pressure in healthy individuals: right eye versus left eye,” Ophthalmology, vol. 112, no. 10, pp. 1670–1675, 2005. View at Publisher · View at Google Scholar · View at Scopus
  24. J. H. K. Liu, D. F. Kripke, R. E. Hoffman et al., “Nocturnal elevation of intraocular pressure in young adults,” Investigative Ophthalmology and Visual Science, vol. 39, no. 13, pp. 2707–2712, 1998. View at Scopus
  25. D. R. Anderson and W. M. Grant, “The influence of position on intraocular pressure,” Investigative ophthalmology, vol. 12, no. 3, pp. 204–212, 1973. View at Scopus
  26. A. K. Weber and J. Price, “Pressure differential of intraocular pressure measured between supine and sitting position,” Annals of Ophthalmology, vol. 13, no. 3, pp. 323–326, 1981. View at Scopus