Guidelines for Disinfection of Applanation Tonometers: A Position Statement from the American Glaucoma Society and the American Academy of Ophthalmology.

Glaucoma is the leading cause of irreversible blindness in the United States and across the globe. Accurate measurement of intraocular pressure (IOP) is essential for management. As such, equitable access to accurate and high-quality tonometry to measure IOP is critical. In the 1950s, the Goldmann applanation tonometer (GAT) replaced the Schiotz tonometer as the clinical reference standard for measuring IOP. Current disinfection guidelines, using a categorization system devised in the 1930s, place tonometers in the same category as tonometers with instruments such as endoscopes and bronchoscopes, the latter of which contact the mucous membranes, as semi-critical instruments, requiring them to undergo high-level disinfection (HLD). Available clinical evidence has not shown an increased risk of disease transmission with low-level disinfection (LLD) of tonometers. At the same time, HLD for GAT may give rise to potential patient safety concerns. HLD chemicals can cause corneal burns and can damage instrumentation by dissolving the glue holding the applanation tip together, causing the tip to swell and crack. The damaged tip can both harm patients' corneas and produce inaccurate intraocular pressure readings. To circumvent the inconvenience, error and cost associated with HLD, many healthcare systems have adopted disposable tonometer tips, which generate large amounts of plastic waste and impose unsustainable costs. Because LLD has been effective in preventing disease transmission in practice, we propose that tonometers be reclassified as a non-critical-use item under the Spaulding classification system. As a non-critical item, tonometers would not require HLD, but rather low-level disinfection. Patients at increased risk of developing an infection, for example, those with corneal abrasions or a history of ocular trauma, signs of possible ocular infection such as erythema or discharge, or a history of chronic viral infection, can be evaluated with single-use tonometer tips or other acceptable methods of tonometry, facilitating more efficient utilization of resources while ensuring high-quality patient care.