Q:

I would like to streamline my exam in every way possible and heard from a colleague that they don’t use fluorescein to obtain Goldmann pressures. What’s your take on this?

A:

Sam Quintero, OD, adjunct associate professor at University of Houston College of Optometry, says he hasn’t used fluorescein in years and experiences excellent results when performing tonometry—and forgoing it saves him a step in the process. He encourages students to aperform Goldmann tonometry without it. He notes that “students don’t challenge the modalities as taught,” but he encourages them to question longstanding practices. “For instance, the sole purpose of the dye in Goldmann tonometry is to enhance the observation of the tear film,” which can be accomplished without dye, with practice, he says.

Overcoming Assumptions

When Dr. Quintero presents the concept of going without fluorescein to students, he tells them I don’t use fluorescein when I measure IOP with the Goldmann tonometer, and I will have the students look through the teaching tube and emphasize that they look for the tear layer. “I like to seek out new ways to arrive at the same answer in a more efficient manner,” says Dr. Quintero. “I am an efficiency fanatic and spend as little time arriving at the correct answer as possible.”

Here is the typical with-dye scenario, according to Dr. Quintero:

“Some students take too long to measure IOP in the first eye; by the time they get to the second eye, you guessed it, they now have to instill the fluorescein again and, as a consequence, it can take as much as seven to eight extra minutes to complete this procedure—one that should have lasted approximately one minute total,” says Dr. Quintero. Another problem he sees with students: On occasion, they spill a drop on the patient’s clothing. “And now you have an unhappy patient, no matter what you say or how much you reassure them” that the dye won’t permanently stain

Nevertheless, Dr. Quintero tells his students to be aware of the expectations from other attending ODs and not to engage in quarrels. However, he also cautions them to “do as the National Board requires and perform tonometry as described on the skills assessments for this technique—one must use the dye or else you fail this skill on Part III.”

Flush the Fluress

Dr. Quintero suggests Fluress (fluorescein sodium and benoxinate hydrochloride ophthalmic solution, USP, 0.25%/0.4%, Akorn) contains too much fluorescein to be of value in tonometry. “Invariably, the mires are huge and distorted, requiring a delay for the solution to dissipate and the mires to thin, rendering it ineffective and a big waste of time.”

Recent research reveals IOP is lower—a mean difference of 1.4mm Hg—when tonometry is used without fluorescein.1 Older literature shows much greater differences—up to 7mm Hg—than anecdotal data.2

Andrea Knouff, OD, founder of Eyeclectic Vision Source in Atlanta, hasn’t used fluorescein in clinical practice for a number of years either. “I find a high correlation between results with and without dye, and so have chosen to do without it,” eliminating a step and saving valuable chair time, says Dr. Knouff. “If I ever have a question, or the mires are too faint, I can always put a dry strip in the eye and light up the mires a bit,” she says. Forgoing fluorescein also preserves the patient’s contact lenses when they are reinserted at exam’s end.

Dr. Knouff advises ODs rely on our other tried-and-true methods and tests of detecting glaucoma. “Use careful stereoscopic nerve evaluations, pachymetry, fields and OCTs for glaucoma diagnosis, instead of putting too much emphasis on IOP readings alone.” 

1. Arend N, Hirneiss C, Kernt M. Differences in the measurement results of Goldmann applanation tonometry with and without fluorescein. Ophthalmologe. 2014 Mar;111(3):241-6.
2. Bright DC, Potter JW, Allen DC, Spruance RD. Goldmann applanation tonometry without fluorescein. Am J Optom Physiol Optom. 1981 Dec;58(12):1120-6.