[Ophthalmic agents during pregnancy]. / Ophthalmika in der Schwangerschaft.

The use of ophthalmic agents during pregnancy and breastfeeding always represents an off-label use. Therefore, the use of drugs must be particularly carefully assessed with respect to the risk-benefit assessment. In this overview the literature databank of the PubMed library, pharmaceutical lists (Red List, Swiss pharmaceutical compendium), guidelines of the specialist societies the German Society of Ophthalmology (DOG), the Swiss Society of Ophthalmology (SOG), the European Glaucoma Society (EGS), the American Academy of Ophthalmology (AAO) and internet portals (embryotox, reprotox) were inspected and recommendations for the use of ophthalmic agents during pregnancy and breastfeeding were derived. More attention should be dedicated to this topic in the specialist societies.

Intraocular cataract lens replacement and light exposure potentially impact procedural learning in older adults.

Procedural learning declines with age and appropriately timed light exposure can improve cognitive performance in older individuals. Because cataract reduces light transmission and is associated with cognitive decline in older adults, we explored whether lens replacement (intraocular blue-blocking [BB] or UV-only blocking) in older patients with cataracts enhances the beneficial effects of light on procedural learning. Healthy older participants (n = 16) and older patients with post-cataract surgery (n = 13 with BB or UV lens replacement) underwent a randomized within-subject crossover laboratory design with three protocols. In each protocol, 3.5 hr dim-dark adaptation was followed by 2 hr evening blue-enriched (6,500K) or non-blue-enriched light exposure (3,000K or 2,500K), 30 min dim post-light, ~8 hr sleep and 2 hr morning dim light. Procedural learning was assessed by the alternating serial reaction time task (ASRT), as part of a larger test battery. Here, ASRT performance was indexed by type of trial (random or sequence) and sequence-specific (high or low probability) measures. During evening light exposure, we observed a significant effect of the interaction of "group" versus "light condition" on the type of trial (p = .04; p = .16; unadjusted and adjusted p-values, respectively) and sequence-specific learning (p = .04; p = .16; unadjusted and adjusted p-values, respectively), whereby patients with UV lens replacement performed better than patients with BB lens or non-cataract controls, during blue-enriched light exposure. Lens replacement in patients with cataracts may potentially be associated with beneficial effects of blue light on procedural learning. Thus, optimizing spectral lens transmission in patients with cataracts may help improve specific aspects of cognitive function, such as procedural learning.

Evaluation of Visual Comfort and Mental Effort Under Different Light Conditions for Ultraviolet-Absorbing and Additional Blue-Filtering Intraocular Lenses for Cataract Surgery.

PATIENTS AND METHODS: Patients with an ultraviolet blocking lens (UV) (n = 5) or blue filter lens (BB) (n = 8) after intraocular lens (IOL) replacement for cataract and age-adjusted controls (AACs) (n = 16) underwent a balanced crossover within-subject design. After 1.5 h of dark adaptation, they were exposed to polychromatic light at 6500 K (blue-enriched) and 2500 K and 3000 K (non-blue-enriched) for 2 hours in the evening. Visual comfort and mental effort were repeatedly assessed by the Visual Analogue Scale (0 - 100) and the Visual Comfort and Mental Effort Rating Scale (0 - 100) for each light condition. The results were compared using mixed model analysis. RESULTS: The mean (± SD) age for AAC and patients with UV or BB was 69.8 ± 6.2 y, 70.8 ± 4 y, and 63.6 ± 5.6 y, respectively. Irrespective of the light condition, patients with UV and BB felt mentally more tired during the experiments compared to AACs (F = 6.15, p = 0.003). However, patients with BB were mentally more motivated to perform the exercises compared to patients with UV and AACs (F = 8.1, p < 0.001). Patients with BB perceived ambient light as less glary (F = 4.71, p = 0.01) than patients with UV. Blue ambient light was felt less intensely in patients with BB (F = 2.51, p = 0.042) compared to those with UV and the AACs. CONCLUSION: Lens replacement in older cataract patients may increase visual comfort and minimize mental effort. While subtle, the magnitude of these effects may depend on the type of intraocular lens. BB intraocular lenses may have potential benefits, as ambient light is perceived as having less glare and less visual tension.

[The Impact of Multiple Intravitreal Anti-VEGF Injections on Intraocular Pressure]. / Der Einfluss multipler Anti-VEGF-Injektionen auf den intraokularen Druck.

BACKGROUND: To evaluate the possible effects of multiple intravitreal anti-vascular endothelial growth factor (VEGF) injections on intraocular pressure (IOP). METHODS: This study included 50 eyes of 50 patients who underwent multiple (≥ 10 injections) intravitreal anti-VEGF injections in one eye with age-related macular degeneration, diabetic macular edema or retinal vein occlusion. IOP was recorded after every injection on the first postoperative day. IOP > 21 mmHg was regarded as abnormal. For statistical analysis, the IOP was correlated with the number of injections. RESULTS: A total of 669 IOP-measurements (mean 13.4 treatment/eye) were analyzed. No IOP-elevation was recorded in 43 eyes (86%). Transient elevated IOP > 21 mmHg was measured after 19 intravitreal injections (2.8%, one patients with 8 IOP elevations). In general, there was no increasing risk of IOP elevation with time, no case of sustained IOP elevation and no additional long term glaucoma treatment necessary. Eyes with pre-existing glaucoma were significantly more affected from transient IOP-elevation than non-glaucoma eyes (5.5 vs. 2.2%). CONCLUSIONS: Multiple anti-VEGF injections are not associated with an increased risk of sustained IOP-elevation. On the other hand, individual risk factors exist and predispose to IOP-elevation (e.g., pre-existing glaucoma).

[Status of Selective Laser Trabeculoplasty (SLT)]. / Stellenwert der selektiven Lasertrabekuloplastik (SLT).

Purpose Worldwide, in recent years, selective laser trabeculoplasty (SLT) has developed into a very successful therapy for glaucoma. Material and Methods The article provides a review of the literature from PubMed and clinical experience. Results SLT is equally efficacious to argon laser trabeculoplasty (ALT) and to a first-line glaucoma medication. SLT can be used in most common forms of open-angle glaucoma and ocular hypertension. In contrast to ALT, SLT is repeatable and requires much less energy. SLT has been reported to be also successful in some rare forms of ocular hypertension/glaucoma. There is no negative influence of SLT to other forms of glaucoma treatment. Complications are rare and include intraocular pressure spikes, corneal scarring or corneal decompensation due to endothelial cell damage and cystoid macular edema. The potential of SLT as a first-line treatment of glaucoma is now under investigation. Conclusion SLT is a low-risk procedure to treat glaucoma in a broad range of indications. Advantages of SLT include the potential to use SLT more and more as a primary treatment procedure. Therefore, SLT is now under intensive investigation worldwide.

Multifocal corneal ablation (Supracor) in hyperopic presbyopia: 1-year results in a cross-sectional study.

PURPOSE: To evaluate the efficacy and safety of the multifocal excimer laser corneal ablation profile (the Supracor procedure) in hyperopic presbyopia 1 year after laser treatment. METHODS: This prospective, consecutive, one-center, cross-sectional study included 20 patients with hyperopic presbyopia 1 year after treatment with the Supracor procedure. The main outcome measures were monocular uncorrected distance visual acuity (UDVA) and uncorrected near visual acuity (UNVA), photopic contrast sensitivity (Pelli-Robson charts), patient satisfaction, and functioning at 12 months. RESULTS: Thirty-nine eyes of 20 patients (mean age 59 ± 7.2 years) were treated. Mean UDVA improved from 0.56 ± 0.31 (mean 0.34 logMAR) preoperatively to 0.9 ± 0.15 (mean 0.06 logMAR) 12 months after surgery. Mean UNVA increased from 0.15 ± 0.07 (mean 0.84 logMAR) before surgery to 0.62 ± 0.24 (mean 0.23 logMAR) 12 months after treatment. Four eyes lost 2 lines of corrected distance visual acuity (10.3%). Monocular photopic contrast sensitivity was within age-correlated normal range (Pelli-Robson chart, mean contrast sensitivity 1.83 ± 0.18). A total of 75% of the patients would undergo Supracor again (1 not, 4 perhaps). The most frequently reported side effects were increased glare, reduced distance vision, and fluctuations in vision. Most patients used artificial tears. CONCLUSIONS: One year after Supracor, UDVA and UNVA improved markedly, photopic contrast sensitivity was in normal age-correlated range, and the majority of patients (75%) was satisfied with the results. Side effects like loss of distance vision, fluctuations of vision, and increased glare have a greater influence on patient satisfaction than the improvement of spectacle-free near vision.

Selective laser trabeculoplasty (SLT): 1-year results in early and advanced open angle glaucoma.

The purpose of this study was to examine the efficacy of selective laser trabeculoplasty (SLT) in eyes with early and more advanced stages of open angle glaucoma within 1 year of follow-up. Retrospective chart review in a consecutive series of patients treated by SLT to reduce intraocular pressure (IOP) or decrease number of topical medications in cases of discomfort and allergy. The cup-to-disc ratio of the optic nerve and the GSS 2 (glaucoma staging system 2) was used to differentiate between early (group 1) and more advanced (group 2) stages of glaucoma. At the time of SLT treatment, no new signs of glaucoma progression were seen. Only the first treated eye of every patient was included in the analysis. In group 1 (early glaucoma), 27 eyes were included. IOP reduction <21 mmHg/>20 % of the preoperative IOP-value and reduction of medication were achieved in 17 eyes (62.96 %). Successful re-treatment was necessary in 2 eyes (7.4 %). In group 2 (advanced glaucoma), 44 eyes underwent SLT. In eight eyes (18.18 %), filtrating surgery was necessary after initial SLT. In the remaining 36 eyes, IOP reduction <21 mmHg/>20 % of the baseline IOP was achieved in 26 eyes (59.09 % of 44 eyes) and IOP reduction <18 mmHg/> 30 % of the baseline IOP in 22 eyes (50 % of 44 eyes). SLT was safe and effective in nearly 2/3 of early glaucoma patients and also in 50 % of advanced glaucoma patients using stronger criteria of success. Failure of SLT in advanced glaucoma should lead to immediate filtrating surgery, which seems not to be associated with higher risk of fibrosis.

Serotonin (5-HT7) receptor-stimulated activation of cAMP-PKA pathway in bovine corneal epithelial and endothelial cells.

BACKGROUND: 5-Hydroxytryptamine (5-HT; serotonin) is a major neurotransmitter, and its receptors are found throughout the whole body. The 5-HT7 receptor subtype was detected in human corneal epithelial and endothelial cells and found to be functionally active in a corneal epithelial cell line. The aim of the present study was to demonstrate that native bovine corneal epithelial and endothelial cells express a functional 5-HT7 receptor positively coupled to adenylyl cyclase and protein kinase A (PKA) formation. METHODS: 5-HT7 receptors were studied using polyclonal antibodies. cAMP concentration after 5-HT7 receptor stimulation with 5-carboxamidotryptamine (5-CT, a 5-HT7 agonist) was tested by enzyme immunoassay, PKA activity was estimated by kinase consumption of ATP. RESULTS: Immunocytochemistry and immunofluorescence revealed the presence of 5-HT7 receptors in corneal epithelial and endothelial cells. Stimulation of corneal 5-HT7 receptors with 5-CT revealed a dose-dependent increase in intracellular cAMP concentration in corneal epithelium (0.01-0.34 pmol/ml) and endothelium (0.01-0.19 pmol/ml) between 10(-10) and 10(-7) mg/ml 5-CT (p = 0.001) with maximal stimulation from 10(-7) to 10(-3) mg/ml 5-CT (0.30 ± 0.03 and 0.18 ± 0.01 pmol/ml, respectively). Incubation with 10(-6) mg/ml SB269970 (a selective 5-HT7 antagonist) blocked 5-CT-induced cAMP increase in corneal epithelial (0.03 pmol/ml) and endothelial cells (0.02 pmol/ml; p = 0.001). Stimulation of corneal 5-HT7 receptors with 5-CT revealed a dose-dependent increase in PKA activity between 10(-10) and 10(-8) mg/ml 5-CT in corneal epithelium and endothelium (<1 to >99%; p = 0.013 and p = 0.017, respectively) with maximal stimulation from 10(-8) to 10(-4) mg/ml (>99%) 5-CT. CONCLUSIONS: Our data demonstrate that native corneal epithelial and endothelial cells express a functional 5-HT7 receptor positively coupled to adenylyl cyclase and PKA formation. However, at the present time, the physiological role of 5-HT receptors and the cAMP-PKA pathway in the cornea remains a matter of speculation.

Long-term results after transscleral diode laser cyclophotocoagulation in refractory posttraumatic glaucoma and glaucoma in aphakia.

PURPOSE: To evaluate the long-term effect and safety of transscleral diode laser cyclophotocoagulation (TDLC) in eyes with advanced glaucoma in aphakia and posttraumatic glaucoma. PATIENTS AND METHODS: Twenty-one eyes of 21 patients with glaucoma in aphakia and 25 eyes of 25 patients with posttraumatic glaucoma were treated with TDLC between 1996 and 2004. If the intraocular pressure (IOP) remained above 21 mmHg despite medication for more than 4 weeks after TDLC, the procedure was repeated. The IOP, number of medications, visual acuity, complications and need of further surgical intervention were all recorded during the follow-up period. RESULTS: Follow-up ranged from 12 to 93 months (mean 42.0 +/- 29.2) in glaucoma in aphakia and from 12 to 73 months (mean 33.3 +/- 17.4) in posttraumatic glaucoma. TDLC was successful in 48% of aphakic eyes with glaucoma and 40% of eyes with posttraumatic glaucoma. More than one TDLC was performed in 85% of cases of glaucoma in aphakia and 76% of cases of posttraumatic glaucoma). In both groups, TDLC was more effective in older patients than younger patients. Further glaucoma surgeries other than TDLC were performed in 43% of glaucoma in aphakic cases, and 44% of posttraumatic glaucoma cases, within the follow-up period. Loss of any light perception was recorded in two aphakic eyes with glaucoma (9.5%) and three eyes with posttraumatic glaucoma (12%). No hypotonia and no phthisis occurred. CONCLUSIONS: TDLC is moderately effective in advanced posttraumatic glaucoma and glaucoma in aphakia, more effective in older than younger patients, not influenced by prior other glaucoma surgery, and despite a high re-treatment rate very safe in both groups of glaucoma. For younger patients with severe secondary glaucoma in particular, new treatment strategies are needed.

Transscleral diode laser cyclophotocoagulation as primary and secondary surgical treatment in primary open-angle and pseudoexfoliatve glaucoma. Long-term clinical outcomes.

BACKGROUND: Transscleral diode laser cyclophotocoagulation (TDLC) has been used successfully in the treatment of refractive glaucoma. However, little is known about TDLC as a primary or secondary surgical procedure in primary open-angle and pseudoexfoliative glaucoma. METHODS: In a retrospective chart review we analyzed 90 eyes (48 OD/42 OS) in 90 patients (mean age 75 years, range 60-92 years; 51 men/39 woman) with primary open-angle glaucoma (n=66) and pseudoexfoliative glaucoma (n=24) who consecutively underwent TDLC with a minimum follow-up of 24 months. In 24 eyes (26.7%) TDLC was the primary surgical treatment. Mean energy was 80 J (60-92 J). Success was defined as a final intraocular pressure (IOP) between 4 and 18 mmHg, a minimum IOP reduction of 20% and the absence of major complications. RESULTS: The overall success rate was 36.7% after 24 months. A mean of 1.3 procedures was performed per patient. No correlation between age and success rate (p=0.887) or gender and success rate (p=0.895) was seen. There was no significant reduction in antiglaucomatous medication (p=0.208), no significant loss of visual acuity (p=0.324) nor a significant relationship between loss of visual acuity and failure of treatment (p=0.201). In patients with primary open-angle glaucoma the success rate was 40.9% after 24 months; in patients with pseudoexfoliative glaucoma it was 25.0% after 24 months. There was no significant difference between primary open-angle glaucoma and pseudoexfoliative glaucoma (p=0.684). Previous ocular surgery decreased the success probability from 45.8 to 33.3% (p=0.001). Prolonged hypotonia occurred in 1 patient. No phthisis bulbi developed. CONCLUSIONS: Transscleral diode laser cyclophotocoagulation is an effective and safe method not only in the treatment of refractive glaucoma, but also as a primary surgical procedure in primary open-angle and pseudoexfoliative glaucoma. TDLC may be used more widely in glaucoma therapy, although further long-term studies have to confirm these findings.

Pars plana-modified Ahmed Glaucoma Valve for treatment of refractory glaucoma: a pilot study.

PURPOSE: This study was conducted to report the safety and efficacy of pars plana-modified Ahmed Glaucoma Valve PS2 in advanced secondary glaucoma. METHODS: We performed a prospective, interventional case series that included patients with advanced secondary glaucoma and uncontrolled intraocular pressure (IOP). Eleven eyes of nine patients with aphakic, neovascular, traumatic, inflammatory and pseudoexfoliation glaucoma were included. All patients had pars plana vitrectomy before tube insertion. RESULTS: One year after surgery, IOP was controlled (21 mmHg or less) in ten of 11 eyes (91%), seven (64%) did not need medical antiglaucoma therapy. Average IOP decreased from 32.2 +/- 8.3 mmHg before surgery to 15.7 +/- 7.7 mmHg postoperatively (P < 0.0001). The average number of topically used medications used decreased from 2.9 +/- 1.2 to 0.545 +/- 0.78 (P < 0.0001). Complications included transient hypotony (three eyes-two of them without tube ligature), transient choroidal effusion (three eyes) and an intermediate increase in IOP (seven eyes). Tube exchange was performed in one eye and needling/bleb excision in two patients. CONCLUSIONS: Pars plana-modified Ahmed Valve implantation is effective and safe in advanced glaucoma. Partial ligature of the tube is necessary to prevent early hypotony. Close follow-up of patients is needed to monitor variations of IOP within the first year.

[Subconjunctival anaesthesia using cocaine or mepivacaine for cyclocryotherapy in advanced glaucoma]. / Subkonjunktivale Anästhesie mit Kokain oder Mepivacain bei der Zyklokryokoagulation zur Behandlung fortgeschrittener Glaukome.

BACKGROUND: Retro- or peribulbar anaesthesia are the standard procedures for cyclodestructive surgery. Because these methods of anaesthesia may further compromise optic nerve function, especially in advanced glaucoma, subconjunctival anaesthesia was evaluated as an alternative procedure in cyclocryotherapy. PATIENTS AND METHODS: 1. To evaluate the current methods of anaesthesia a questionnaire was sent to all University Eye Clinics in Germany in 2001. 2. A prospective, consecutive study concerning cyclocryotherapy in advanced glaucoma was started using subconjunctival anaesthesia with 5 % cocaine or, alternatively, 2 % mepivacaine in 25 eyes of 25 patients in each group. Pain during cyclocryotherapy was recorded using a 10-point rating-scale (1 = no pain to 10 = intolerably severe pain) and adverse events were also recorded. RESULTS: 1. 88.6 % of the University Eye Clinics in Germany replied to our questionnaire. In 2001 cyclocryotherapy was performed in 80.6 % of the University Eye Clinics in Germany (Tübingen not included), 16.1 % among them solely used cyclocryotherapy for the treatment of advanced glaucoma. 2. Using 5 % cocaine for subconjunctival anaesthesia - 92 % of patients experienced no pain and 8 % of patients reported very mild pain during cyclocryotherapy. One patient reported nausea, 4 patients mouth dryness. After anaesthesia with mepivacaine - 80 % experienced no pain, 12 % very mild pain, and 8 % mild pain. There were no systemic side effects. CONCLUSION: Most of the patients experienced no pain during cyclocryotherapy using subconjunctival anaesthesia with cocaine or mepivacaine. Therefore, risks and side effects of retro- or parabulbar anaesthesia can be successfully avoided by this simple modification.

[Spontaneous, bifocal rupture of the limbus in secondary angle closure glaucoma after open globe injury]. / Spontane, bifokale Limbusruptur bei sekundärem Winkelblockglaukom nach penetrierender Augenverletzung.

PURPOSE: To report on a case of bifocal rupture of the limbus that developed in a young male with secondary angle closure glaucoma 7 months after penetrating eye injury. CASE REPORT: A 20-year old male suffered from severe polytrauma due to a car accident. Examination revealed an open globe injury of the left eye due to corneal penetration by a foreign body (glass). After primary wound closure a pars plana vitrectomy with lens extraction and removal of the foreign body was performed. Five months later IOP increased markedly and could neither be controlled by antiglaucomatous medication nor by cyclophotocoagulation. Seven months after the injury a bifocal, closed rupture of the upper nasal and temporal corneoscleral limbus occurred. IOP of the eye was elevated despite the rupture. The limbal dehiscence was readapted and IOP increased again. A new limbal rupture occurred and a tectonic keratoplasty was performed. Because a marked thinning of the transplanted cornea occurred accompanied by strong evidence of advanced epithelial ingrowth the eye was enucleated. Histologic examination of the excised tissue and enucleated eye showed diffuse epithelial ingrowth. CONCLUSION: This is first reported case of delayed, spontaneous, bifocal rupture of the corneoscleral limbus after primary open globe injury. It may be speculated that severe contusion of the eye with structural damage of the corneoscleral limbus preceded the penetrating injury and that the later limbal rupture was caused by a marked elevated IOP due to epithelial ingrowth.

[Trabecular aspiration in pseudoexfoliative glaucoma--surgery to primarily reduce intraocular pressure]. / Trabekelaspiration als primär chirurgischer, drucksenkender Eingriff beim Pseudoexfoliationsglaukom.

BACKGROUND: Trabecular aspiration has been discussed during the past few years as a new surgical method in the treatment of pseudoexfoliative glaucoma. In this procedure PEX-material, pigment and detritus are aspirated from the trabecular meshwork. Trabecular aspiration has been evaluated mainly in combination with cataract extraction. This study reports on our first experiences concerning the IOP-reducing effect of trabecular aspiration as a primary surgical method in the management of pseudoexfoliative glaucoma. MATERIALS: 17 eyes of 14 patients (7 m, 7 f; 12 OD, 5 OS; age 71 +/- 6 years) with pseudoexfoliative glaucoma were included in this study and operated on by standardised trabecular aspiration (vacuum max. 200 mm Hg, 180 - 270 degrees, 5 min). Therapy success was defined as an IOP reduction by more than 20 % and less than 21 mm Hg. RESULTS: Therapy success was 82 % (14 out of 17) on the first postoperative day, 50 % after 30 days (8 out of 16) and 23 % after 180 days (3 out of 13). IOP was 26.8 +/- 8.5 mm Hg before surgical intervention, 18.1 +/- 11.4 mm Hg after 1 day, 19.1 +/- 7.9 mm Hg after 30 days and 19.2 +/- 5.2 mm Hg after 180 days. Mean quantity of antiglaucomatous eye drops application was 3.1 +/- 0.9 preoperatively, 0.9 +/- 1.6 after 1 day, 0.8 +/- 1.2 after 30 days and 1.0 +/- 1.3 after 180 days. CONCLUSIONS: Trabecular aspiration achieves a good short-term effect in the reduction of IOP in patients with pseudoexfoliative glaucoma. However, this effect was limited to a few weeks in most patients. Trabecular aspiration as a primary surgical method in the management of pseudoexfoliative glaucoma does not appear to be suitable for long-term IOP reduction.

[Measurement of intraocular pressure using the Tono-Pen in comparison with Goldmann applanation tonometry - a clinical study in 100 eyes]. / Messung des Augeninnendrucks mit dem Tono-Pen im Vergleich zum Applanationstonometer nach Goldmann - eine klinische Studie an 100 Augen.

BACKGROUND: In clinical practice ophthalmologists often need a tonometer which is independent of a slit lamp. Such a hand-held device is the Tono-Pen. We compared the precision of two equal Tono-Pens with Goldmann applanation tonometry. MATERIAL AND METHODS: Measurement of intraocular pressure (IOP) was done in 100 eyes of 51 patients (mean age 63 +/- 15 years) suffering from ocular hypertension or glaucoma. According to a random table either the right or left eye was measured using Goldmann tonometer first and the Tono-Pen second. For the other eye the measurement was reversed. One of the two equal Tono-Pens (Solan/USA) was used according to a second random table. Three measurements were obtained with each instrument on both eyes within 15 minutes subsequently. Patients were placed in an upright position for all measurements. RESULTS: Even for well-trained ophthalmologists a learning curve of approximately 10 measurements was observed using the Tono-Pen. The Tono-Pen measured an average IOP of 16.9 mm Hg in all 100 eyes. The Goldmann tonometer measured an average IOP of 17.7 mm Hg. The difference was not statistically significant. The standard deviation for all measurements was better for the Tono-Pen (4.7 mm Hg vs 5.8 mm Hg for Goldmann tonometer). No reduction of the IOP after Tono-Pen measurement was observed (in contrast to the Goldmann tonometer). The reproducibility of the Tono-Pen on the same eye was inferior to the Goldmann tonometer by a factor of 2. There was an almost significant difference in reproducibility between two equal Tono-Pens. CONCLUSIONS: Measurement of IOP with the Tono-Pen is comparable to Goldmann applanation tonometry if an average of 3 measurements is used. The difference between two equal Tono-Pens indicates the need for improvement of the quality check during production.