Potential effects of systematic errors in intraocular pressure measurements on screening for ocular hypertension

Raised intraocular pressure (IOP) increases the risk of glaucoma. Eye-care professionals measure IOP to screen for ocular hypertension (OHT) (IOP>21 mm Hg) and to monitor glaucoma treatment. Tonometers commonly develop significant systematic measurement errors within months of calibration, and may not be verified often enough. There is no published evidence indicating how accurate tonometers should be. We analysed IOP measurements from a population study to estimate the sensitivity of detection of OHT to systematic errors in IOP measurements.

We analysed IOP data from 3654 participants in the Blue Mountains Eye Study, Australia. An inverse cumulative distribution indicating the proportion of individuals with highest IOP>21 mm Hg was calculated. A second-order polynomial was fitted to the distribution and used to calculate over- and under-detection of OHT that would be caused by systematic measurement errors between -4 and +4 mm Hg. We calculated changes in the apparent prevalence of OHT caused by systematic errors in IOP.

A tonometer that consistently under- or over-reads by 1 mm Hg will miss 34% of individuals with OHT, or yield 58% more positive screening tests, respectively. Tonometers with systematic errors of -4 and +4 mm Hg would miss 76% of individuals with OHT and would over-detect OHT by a factor of seven. Over- and under-detection of OHT are not strongly affected by cutoff IOP.

We conclude that tonometers should be maintained and verified at intervals short enough to control systematic errors in IOP measurements to substantially less than 1 mm Hg.