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==Overview==
==Overview==


'''Intraocular pressure''' (IOP) is the fluid [[pressure]] inside the [[eye]].
'''Intraocular pressure''' ('''IOP''') is the fluid [[pressure]] inside the [[human eye|eye]]. [[Ocular tonometry|Tonometry]] is the method [[eye care professional]]s use to determine this. IOP is an important aspect in the evaluation of patients at risk from [[glaucoma]]. Most tonometers are calibrated to measure pressure in millimeters of mercury ([[mmHg]]).
 
==Physiology==
Intraocular pressure is mainly determined by the coupling of the production of [[aqueous humor]] and the drainage of aqueous humor mainly through the [[trabecular meshwork]] located in the [[anterior chamber]] angle.
 
An important quantitative relationship is provided below:
:IOP = F / C + PV
Where F = aqueous fluid formation rate, C = outflow rate, PV = episcleral venous pressure.
The above factors are those that drive IOP.
 
==Measurement==
Intraocular pressure is measured with a [[Ocular tonometry|tonometer]] as part of a comprehensive [[eye examination]].
 
Measured values of intraocular pressure are influenced by [[cornea]]l thickness and rigidity.<ref name=Grieshaber>{{Cite journal|author=Grieshaber MC, Schoetzau A, Zawinka C, Flammer J, Orgul S|title=Effect of Central Corneal Thickness on Dynamic Contour Tonometry and Goldmann Applanation Tonometry in Primary Open-angle Glaucoma|journal=Arch Ophthalmol.|volume=125|issue=6|pages=740–44|date=June 2007|url=http://archopht.ama-assn.org/cgi/content/full/125/6/740|pmid=17562982|doi=10.1001/archopht.125.6.740}}</ref><ref name=Tanaka>{{Cite journal|author=Tanaka GH|title=Corneal pachymetry: a prerequisite for applanation tonometry?|journal=Arch Ophthalmol.|volume=116|issue=4|pages=544–5|date=April 1998|url=http://archopht.ama-assn.org/cgi/content/full/116/4/544|pmid=9565063}}</ref> As a result, some forms of [[refractive surgery]] (such as [[photorefractive keratectomy]]) can cause traditional intraocular pressure measurements to appear normal when in fact the pressure may be abnormally high.
 
==Classification==
Current consensus among ophthalmologists and optometrists define normal intraocular pressure as that between 10 [[mmHg]] and 20 mmHg.<ref>[http://www.webmd.com/hw/lab_tests/hw201323.asp webMD - Tonometry]</ref><ref>[http://www.emedicinehealth.com/articles/14545-1.asp Glaucoma Overview] from eMedicine</ref> The average value of intraocular pressure is 15.5 mmHg with fluctuations of about 2.75 mmHg.<ref name=Janunts>{{Cite web|url=http://www.uniklinikum-saarland.de/de/einrichtungen/kliniken_institute/experimentelle_ophthalmologie/forschung/iop_sensing/| title=Optical remote sensing of intraocular pressure by an implantable nanostructured array
|author=Janunts E|work=Medizinische Fakultät der Universität des Saarlandes}}</ref>
 
[[Ocular hypertension]] (OHT) is defined by intraocular pressure being higher than normal, in the absence of [[optic nerve]] damage or [[visual field]] loss.<ref name="Vieira">{{cite journal |author=Viera GM, Oliveira HB, de Andrade DT, Bottaro M, Ritch R |title=Intraocular Pressure Variation During Weight Lifting |journal=Arch Ophthalmol. |volume=124 |issue=9 |pages=1251–54 |date=September 2006 |url=http://archopht.ama-assn.org/cgi/content/full/124/9/1251 |pmid=16966619 |doi=10.1001/archopht.124.9.1251}}</ref><ref>[http://www.aoa.org/ocular-hypertension.xml American Optometric Association - Ocular Hypertension]</ref>


==Physiology and measurement==
Hypotony, or ocular hypotony, is typically defined as intraocular pressure equal to or less than 5 mmHg.<ref>[http://emedicine.medscape.com/article/1207657-overview eMedicine - Ocular Hypotony - Author: Sheila P Sanders, MD]</ref><ref name="Henderer">{{cite journal |author=Henderer JD, Budenz DL, Flynn HW Jr, Schiffman JC, Feuer WJ, Murray TG |title=Elevated Intraocular Pressure and Hypotony Following Silicone Oil Retinal Tamponade for Complex Retinal Detachment: Incidence and Risk Factors |journal=Arch Ophthalmol. |volume=117 |issue=2 |pages=189–95 |date=February 1999 |url=http://archopht.ama-assn.org/cgi/content/abstract/117/2/189 |pmid=10037563 |doi=10.1001/archopht.117.2.189}}</ref> Such low intraocular pressure could indicate fluid leakage and deflation of the eyeball.
Intraocular pressure is mainly determined by the coupling of the production of [[aqueous humor]] from the eye's [[ciliary body]] and its drainage through the [[trabecular meshwork]] and [[Schlemm's canal]] located in the [[anterior chamber]] angle.  


Intraocular pressure is measured with a tonometer.
==Influencing factors==


===Influencing factors===
=== Daily variation ===
Intraocular pressure measurement is also influenced by corneal thickness and rigidity.<ref>Effect of Central Corneal Thickness on Dynamic Contour Tonometry and Goldmann Applanation Tonometry in Primary Open-angle Glaucoma by Matthias C. Grieshaber, MD; Andreas Schoetzau, MS; Claudia Zawinka, MD; Josef Flammer, MD; Selim Orgul, MD in Arch Ophthalmol. 2007;125:740-744.</ref><ref>Corneal Pachymetry: A Prerequisite for Applanation Tonometry? by Tanaka in Arch Ophthalmol.1998; 116: 544-545</ref>
Intraocular pressure varies throughout the night and day. The diurnal variation for normal eyes is between 3 and 6 mmHg and the variation may increase in glaucomatous eyes. During the night, intraocular pressure may not decrease<ref>{{cite journal|last=Liu JHK|author2=Weinreb RN|title=Monitoring intraocular pressure for 24 h|journal=Br J Ophthalmol|year=2011|volume=95|issue=5|pages=599–600}}</ref> despite the slower production of aqueous humour.<ref>{{cite journal|last=Brubaker RF|title=Flow of aqueous humor in humans|journal=Invest Ophthalmol Vis Sci|year=1991|volume=32|issue=13|pages=3145–3166}}</ref> In the general population, IOP ranges between 10 and 21&nbsp;mm Hg with a mean of about 15 or 16&nbsp;mm Hg (plus or minus 3.5&nbsp;mm Hg during a 24-hour cycle).{{Citation needed|date=November 2011}}


===Significance===
=== Fitness and exercise ===
[[Ocular hypertension]] (OHT) is defined by intraocular pressure being higher than normal, in the absence of [[optic nerve]] damage or [[visual field]] loss.<ref>[http://archopht.ama-assn.org/cgi/content/full/124/9/1251 Archives of Opthalmology]</ref><ref>[http://www.aoa.org/x1799.xml American Optometric Association]</ref> Current consensus in [[ophthalmology]] defines normal introcular pressure as that between 10 [[mmHg]] and 20 mmHg.<ref>[http://www.webmd.com/hw/lab_tests/hw201323.asp webMD]</ref><ref>[http://www.emedicinehealth.com/articles/14545-1.asp Glaucoma Overview] from eMedicine</ref>
There is some inconclusive research that indicates that exercise could possibly affect IOP (some positively and some negatively).<ref>[http://journals.tubitak.gov.tr/medical/issues/sag-00-30-2/sag-30-2-20-9907-19.pdf Studies have also been conducted on both healthy and sedentary individuals to determine if intraocular pressure could be reduced with other types of exercise. Some forms of exertion have been found to result in a decrease in intraocular pressure. Exercises studied included; walking, jogging, and running. Acute Dynamic Exercise Reduces Intraocular Pressure, Departments of Ophthalmology, Physiology, Faculty of Medicine, Atatürk University, Erzurum- Turkey. July 1999.]</ref><ref>[http://informahealthcare.com/doi/abs/10.1080/03014469500004202 Qureshi IA. Effects of mild, moderate and severe exercise on intraocular pressure of sedentary subjects. Rawalpindi Medical College, Rawalpindi, Pakistan]</ref> However, some other forms of exercise may raise IOP.<ref name="Vieira" />


The average value of intraocular pressure is 15 mmHg with fluctuations of about 0.25 mmHg. Intraocular pressure varies throughout the night and day. The diurnal variation for normal eyes is between 3 and 6 mmHg and the variation may increase in glaucomatous eyes. During the night, intraocular pressure usually decreases due to the slower production of aqueous humour. Intraocular pressure also varies with a number of other factors such as heart rate, respiration, exercise, fluid intake, systemic medication and topical drugs. Alcohol consumption leads to a transient decrease in intraocular pressure and caffeine may increase intaocular pressure. <ref>Intaocular pressure measure on normal eyes by Pardianto G et al., in Mimbar Ilmiah Oftalmologi Indonesia.2005;2: 78-9.</ref>
=== Musical instruments ===


Ocular hypertension is the most important risk factor for [[glaucoma]].
Playing some musical wind instruments has been linked to increases in intraocular pressure. One 2011 study focused on brass and woodwind instruments observed "temporary and sometimes dramatic elevations and fluctuations in IOP".<ref>
{{cite journal
| title = Intraocular Pressure Fluctuations in Professional Brass and Woodwind Musicians During Common Playing Conditions
| author1 = Gunnar Schmidtmann
| author2 = Susanne Jahnke
| author3 = Egbert J. Seidel
| author4 = Wolfgang Sickenberger
| author5 = Hans-Jürgen Grein
| journal = Graefe's Archive for Clinical and Experimental Ophthalmology
| volume = 249
| number = 6
| pages = 895–901
| year = 2011
| doi = 10.1007/s00417-010-1600-x
}}
</ref>
Another study found that the magnitude of increase in intraocular pressure correlates with the intraoral resistance associated with the instrument, and linked intermittent elevation of intraocular pressure from playing high-resistance wind instruments to incidence of visual field loss.<ref>
{{cite journal
| title = Increased Intraocular Pressure and Visual Field Defects in High Resistance Wind Instrument Players
| author1 = J. S. Schuman
| author2 = E. C. Massicotte
| author3 = S. Connolly
| author4 = E. Hertzmark
| author5 = B. Mukherji
| author6 = M. Z. Kunen
| journal = Ophthalmology
| volume = 107
| number = 1
| pages = 127–133
|date=January 2000
| doi=10.1016/s0161-6420(99)00015-9
}}
</ref>
The range of intraoral pressure involved in various classes of ethnic wind instruments, such as [[Native American flute]]s, has been shown to be generally lower than Western classical wind instruments.<ref name="IOP_Ethnic">
{{cite journal
| title = Intraoral Pressure in Ethnic Wind Instruments
| author = Clinton F. Goss
|date=August 2013
| url = http://www.Flutopedia.com/refs/Goss_2013_IntraoralPressureInEthnicWindInstruments.pdf
| format = PDF
| layurl = http://www.Flutopedia.com/breath_pressure.htm
| accessdate = 22 Aug 2013
| arxiv = 1308.5214
}}
</ref>


Differences in pressure between the two eyes is often clinically significant, and potentially associated with certain types of glaucoma, as well as  [[iritis]] or [[retinal detachment]].
=== Other factors ===
Intraocular pressure also varies with a number of other factors such as [[heart]] rate, [[Respiration (physiology)|respiration]], fluid intake, systemic medication and topical drugs. [[Alcohol]] consumption leads to a transient decrease in intraocular pressure and [[caffeine]] may increase intraocular pressure.<ref>Intraocular pressure measure on normal eyes by Pardianto G et al., in Mimbar Ilmiah Oftalmologi Indonesia.2005;2:78-9.</ref>


Because of the effect of corneal thickness and rigidity on measured value of intraocular pressure, some forms of [[refractive surgery]] (such as [[photorefractive keratectomy]]) can cause traditional intraocular pressure measurements to appear normal when in fact the pressure may be abnormally high.
Taken orally, [[glycerol]] (often mixed with fruit juice to reduce its sweet taste) can cause a rapid, temporary decrease in intraocular pressure.  This can be a useful initial emergency treatment of severely elevated pressure.<ref>Effect of Oral Glycerol on Intraocular Pressure in Normal and Glaucomatous Eyes, S. M. Drance, MD, FRCS (ENG) ''Arch Ophthalmol.'' 1964;72(4):491-493. doi:10.1001/archopht.1964.00970020491009</ref>


Intraocular pressure may become elevated due to anatomical problems, [[inflammation]] of the eye, genetic factors, as a [[Adverse effect (medicine)|side-effect]] from [[medication]], or during exercise.<ref>Intraocular Pressure Variation During Weight Lifting by Vieira et al., in Arch Ophthalmol.2006; 124: 1251-1254.</ref> Intaocular pressure usually increases with age and is genetically influenced.<ref>Intaocular pressure measure on normal eyes by Pardianto G et al., in Mimbar Ilmiah Oftalmologi Indonesia.2005;2: 80.</ref>
==Significance==
Ocular hypertension is the most important risk factor for [[glaucoma]].
Hypotony, or ocular hypotony, is typically defined as intraocular pressure equal to or less than 5 mmHg.<ref>http://www.emedicine.com/oph/topic579.htm</ref><ref>http://archopht.ama-assn.org/cgi/content/abstract/117/2/189</ref> Such low intraocular pressure could indicate fluid leakage and deflation of the eyeball.


==Case History==
Intraocular pressure has been measured as a secondary outcome in a systematic review comparing the effect of neuroprotective agents in slowing the progression of open angle glaucoma.<ref name="Sena">{{cite journal |author= Sena DF, Lindsley K |title= Neuroprotection for treatment of glaucoma in adults |journal=Cochrane Database Syst Rev|volume=2 |pages= CD006539 |year=2013 |pmid= 20166085 |doi= 10.1002/14651858.CD006539.pub3}}</ref>
One of the most extensive intraocular pressure case history records assembled to date is available online.<ref>[http://fiteyes.com/blogs/dave/ fiteyes.com/blogs/dave]</ref> As of December 29, 2006, this case history included over 12,755 intraocular pressure measurements over a period of 170 days under a wide variety of real life situations.


Additional intraocular pressure measurements are continuing to be recorded at a rate of up to 100 per day and this case history web site is updated regularly. The size of the data set and the frequency with which measurements are recorded may lead to additional insights into intraocular pressure changes in response to a diverse number of factors. One interesting recent discussion that arose directly from data mining the large data set involved the timing of using glaucoma eye drop medications.<ref>[http://fiteyes.com/blogs/dave/2006/12/12/Interesting-Results-Of-Combining-Timoptic-and-Xalatan Combining-Timoptic-and-Xalatan]</ref>
Differences in pressure between the two eyes is often clinically significant, and potentially associated with certain types of glaucoma, as well as  [[iritis]] or [[retinal detachment]].


Another question that is extensively discussed in the patient's commentary at the Case History site is the relationship between psychological stress and intraocular pressure. According to conventional wisdom, a patient's stress (e.g. nervousness or anxiousness) does not increase the patient's intraocular pressure the way it might increase their blood pressure. <!--For a discussion of this topic with Dr. Elliot Werner, a glaucoma specialist, see [http://www.wills-glaucoma.org/supportgroup/20050720.htm "Stress and Glaucoma"] at the Wills Glaucoma support group web site.--> The data of the Case History challenges this convention wisdom, although a single case history will certainly not settle the question. What can be said at this point is that stress can seemingly increase intraocular pressure in at least the one individual being followed in this ambitious Case History project. Researchers will have to continue investigating the connection between stress and intraocular pressure.
Intraocular pressure may become elevated due to anatomical problems, [[inflammation]] of the eye, genetic factors, or as a [[Adverse effect (medicine)|side-effect]] from [[medication]]. Intraocular pressure usually increases with age and is genetically influenced.<ref>Intraocular pressure measure on normal eyes by Pardianto G et al., in Mimbar Ilmiah Oftalmologi Indonesia.2005;2: 80.</ref>


==References==
==References==
{{reflist|2}}
{{Reflist|2}}


==External links==
==External links==
* [http://www.eyemdlink.com/Test.asp?TestID=16 EyeMDLink]
* [http://www.allaboutvision.com/eye-exam/expect.htm www.allaboutvision.com] What To Expect During a Comprehensive Eye Exam
* [http://www.emedicinehealth.com/articles/37513-1.asp eMedicine]
* [http://www.emedicinehealth.com/ocular_hypertension/article_em.htm www.emedicinehealth.com] Ocular Hypertension
* [http://www.opt.indiana.edu/riley/HomePage/NonContact/TEXT_Non_Contact.html Tonometry]
* [http://www.opt.indiana.edu/riley/HomePage/NonContact/TEXT_Non_Contact.html www.opt.indiana.edu] Non-Contact Tonometry


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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Synonyms and keywords: IOP

Overview

Intraocular pressure (IOP) is the fluid pressure inside the eye. Tonometry is the method eye care professionals use to determine this. IOP is an important aspect in the evaluation of patients at risk from glaucoma. Most tonometers are calibrated to measure pressure in millimeters of mercury (mmHg).

Physiology

Intraocular pressure is mainly determined by the coupling of the production of aqueous humor and the drainage of aqueous humor mainly through the trabecular meshwork located in the anterior chamber angle.

An important quantitative relationship is provided below:

IOP = F / C + PV

Where F = aqueous fluid formation rate, C = outflow rate, PV = episcleral venous pressure. The above factors are those that drive IOP.

Measurement

Intraocular pressure is measured with a tonometer as part of a comprehensive eye examination.

Measured values of intraocular pressure are influenced by corneal thickness and rigidity.[1][2] As a result, some forms of refractive surgery (such as photorefractive keratectomy) can cause traditional intraocular pressure measurements to appear normal when in fact the pressure may be abnormally high.

Classification

Current consensus among ophthalmologists and optometrists define normal intraocular pressure as that between 10 mmHg and 20 mmHg.[3][4] The average value of intraocular pressure is 15.5 mmHg with fluctuations of about 2.75 mmHg.[5]

Ocular hypertension (OHT) is defined by intraocular pressure being higher than normal, in the absence of optic nerve damage or visual field loss.[6][7]

Hypotony, or ocular hypotony, is typically defined as intraocular pressure equal to or less than 5 mmHg.[8][9] Such low intraocular pressure could indicate fluid leakage and deflation of the eyeball.

Influencing factors

Daily variation

Intraocular pressure varies throughout the night and day. The diurnal variation for normal eyes is between 3 and 6 mmHg and the variation may increase in glaucomatous eyes. During the night, intraocular pressure may not decrease[10] despite the slower production of aqueous humour.[11] In the general population, IOP ranges between 10 and 21 mm Hg with a mean of about 15 or 16 mm Hg (plus or minus 3.5 mm Hg during a 24-hour cycle).[citation needed]

Fitness and exercise

There is some inconclusive research that indicates that exercise could possibly affect IOP (some positively and some negatively).[12][13] However, some other forms of exercise may raise IOP.[6]

Musical instruments

Playing some musical wind instruments has been linked to increases in intraocular pressure. One 2011 study focused on brass and woodwind instruments observed "temporary and sometimes dramatic elevations and fluctuations in IOP".[14] Another study found that the magnitude of increase in intraocular pressure correlates with the intraoral resistance associated with the instrument, and linked intermittent elevation of intraocular pressure from playing high-resistance wind instruments to incidence of visual field loss.[15] The range of intraoral pressure involved in various classes of ethnic wind instruments, such as Native American flutes, has been shown to be generally lower than Western classical wind instruments.[16]

Other factors

Intraocular pressure also varies with a number of other factors such as heart rate, respiration, fluid intake, systemic medication and topical drugs. Alcohol consumption leads to a transient decrease in intraocular pressure and caffeine may increase intraocular pressure.[17]

Taken orally, glycerol (often mixed with fruit juice to reduce its sweet taste) can cause a rapid, temporary decrease in intraocular pressure. This can be a useful initial emergency treatment of severely elevated pressure.[18]

Significance

Ocular hypertension is the most important risk factor for glaucoma.

Intraocular pressure has been measured as a secondary outcome in a systematic review comparing the effect of neuroprotective agents in slowing the progression of open angle glaucoma.[19]

Differences in pressure between the two eyes is often clinically significant, and potentially associated with certain types of glaucoma, as well as iritis or retinal detachment.

Intraocular pressure may become elevated due to anatomical problems, inflammation of the eye, genetic factors, or as a side-effect from medication. Intraocular pressure usually increases with age and is genetically influenced.[20]

References

  1. ↑ Grieshaber MC, Schoetzau A, Zawinka C, Flammer J, Orgul S (June 2007). "Effect of Central Corneal Thickness on Dynamic Contour Tonometry and Goldmann Applanation Tonometry in Primary Open-angle Glaucoma". Arch Ophthalmol. 125 (6): 740–44. doi:10.1001/archopht.125.6.740. PMID 17562982.
  2. ↑ Tanaka GH (April 1998). "Corneal pachymetry: a prerequisite for applanation tonometry?". Arch Ophthalmol. 116 (4): 544–5. PMID 9565063.
  3. ↑ webMD - Tonometry
  4. ↑ Glaucoma Overview from eMedicine
  5. ↑ Janunts E. "Optical remote sensing of intraocular pressure by an implantable nanostructured array". Medizinische Fakultät der Universität des Saarlandes.
  6. ↑ 6.0 6.1 Viera GM, Oliveira HB, de Andrade DT, Bottaro M, Ritch R (September 2006). "Intraocular Pressure Variation During Weight Lifting". Arch Ophthalmol. 124 (9): 1251–54. doi:10.1001/archopht.124.9.1251. PMID 16966619.
  7. ↑ American Optometric Association - Ocular Hypertension
  8. ↑ eMedicine - Ocular Hypotony - Author: Sheila P Sanders, MD
  9. ↑ Henderer JD, Budenz DL, Flynn HW Jr, Schiffman JC, Feuer WJ, Murray TG (February 1999). "Elevated Intraocular Pressure and Hypotony Following Silicone Oil Retinal Tamponade for Complex Retinal Detachment: Incidence and Risk Factors". Arch Ophthalmol. 117 (2): 189–95. doi:10.1001/archopht.117.2.189. PMID 10037563.
  10. ↑ Liu JHK; Weinreb RN (2011). "Monitoring intraocular pressure for 24 h". Br J Ophthalmol. 95 (5): 599–600.
  11. ↑ Brubaker RF (1991). "Flow of aqueous humor in humans". Invest Ophthalmol Vis Sci. 32 (13): 3145–3166.
  12. ↑ Studies have also been conducted on both healthy and sedentary individuals to determine if intraocular pressure could be reduced with other types of exercise. Some forms of exertion have been found to result in a decrease in intraocular pressure. Exercises studied included; walking, jogging, and running. Acute Dynamic Exercise Reduces Intraocular Pressure, Departments of Ophthalmology, Physiology, Faculty of Medicine, Atatürk University, Erzurum- Turkey. July 1999.
  13. ↑ Qureshi IA. Effects of mild, moderate and severe exercise on intraocular pressure of sedentary subjects. Rawalpindi Medical College, Rawalpindi, Pakistan
  14. ↑ Gunnar Schmidtmann; Susanne Jahnke; Egbert J. Seidel; Wolfgang Sickenberger; Hans-Jürgen Grein (2011). "Intraocular Pressure Fluctuations in Professional Brass and Woodwind Musicians During Common Playing Conditions". Graefe's Archive for Clinical and Experimental Ophthalmology. 249 (6): 895–901. doi:10.1007/s00417-010-1600-x.
  15. ↑ J. S. Schuman; E. C. Massicotte; S. Connolly; E. Hertzmark; B. Mukherji; M. Z. Kunen (January 2000). "Increased Intraocular Pressure and Visual Field Defects in High Resistance Wind Instrument Players". Ophthalmology. 107 (1): 127–133. doi:10.1016/s0161-6420(99)00015-9.
  16. ↑ Clinton F. Goss (August 2013). "Intraoral Pressure in Ethnic Wind Instruments" (PDF). arXiv:1308.5214. Retrieved 22 Aug 2013. Lay summary.
  17. ↑ Intraocular pressure measure on normal eyes by Pardianto G et al., in Mimbar Ilmiah Oftalmologi Indonesia.2005;2:78-9.
  18. ↑ Effect of Oral Glycerol on Intraocular Pressure in Normal and Glaucomatous Eyes, S. M. Drance, MD, FRCS (ENG) Arch Ophthalmol. 1964;72(4):491-493. doi:10.1001/archopht.1964.00970020491009
  19. ↑ Sena DF, Lindsley K (2013). "Neuroprotection for treatment of glaucoma in adults". Cochrane Database Syst Rev. 2: CD006539. doi:10.1002/14651858.CD006539.pub3. PMID 20166085.
  20. ↑ Intraocular pressure measure on normal eyes by Pardianto G et al., in Mimbar Ilmiah Oftalmologi Indonesia.2005;2: 80.

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