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Corneal Hysteresis

Policy Number: MP-354

Latest Review Date:  December 2019

Category: Medicine                                                               

Policy Grade: Active Policy but no longer scheduled for regular literature reviews and updates.


Corneal hysteresis measurement is considered not medically necessary and investigational.


Corneal hysteresis (CH) measurement assesses corneal resistance to deformation. CH has been proposed as a possible indicator of the viscoelastic properties in the cornea. The Ocular Response Analyzer® (ORA) is an instrument that measures CH by using a rapid air impulse to apply force to the cornea. An advanced electro-optical system then monitors the deformation. Two independent pressure values are derived from the inward and outward applanation events. The difference between these two pressure values is CH. Low CH demonstrates that the cornea is less capable of absorbing (damping) the energy of the air pulse. Abnormalities in CH have been detected in a variety of corneal diseases, including keratoconus, Fuchs' dystrophy, and in individuals who have had laser in situ keratomileusis (LASIK). Glaucoma is another potential indication for CH measurement. The preferred method of measuring intraocular pressure (IOP) is using a contact applanation method such as a Goldmann tonometer (GAT).


Literature review through December 2019.


The available evidence reviewed for the measurement of corneal hysteresis is insufficient to determine the effects of the technology on health outcomes.


Glaucoma, corneal hysteresis, corneal, intraocular pressure, IOP, primary open angle glaucoma, POAG, keratoconus, Goldmann tonometer, Reichert Ocular Response Analyzer, ORA, Ocular Response Analyzer


On January 20, 2004, the Ocular Response Analyzer® (ORA) by Reichert Inc. received FDA clearance for the intended use to measure intra-ocular pressure of the eye and the biomechanical response of the cornea for the purpose of aiding in the diagnosis and monitoring of glaucoma. More information is available at: (Accessed December 30, 2019)


Coverage is subject to member’s specific benefits.  Group specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP contracts: FEP does not consider investigational if FDA approved and will be reviewed for medical necessity. Special benefit consideration may apply.  Refer to member’s benefit plan.


CPT Codes:

92145              Corneal hysteresis determination, by air impulse stimulation, unilateral or bilateral, with interpretation and report


  1. Bayer A, Sahin A, Hürmeric V, et al. Intraocular pressure values obtained by ocular response analyzer, dynamic contour tonometry, and Goldmann tonometry in keratokonic corneas.  J Glaucoma.  2010 Oct-Nov; 19(8):540-5.
  2. Bayoumi NH, Bessa AS, El Massry AA.  Ocular response analyzer and Goldmann applanation tonometry: a comparative study of findings.  J Glaucoma. 2010 Dec; 19(9):627-31.
  3. Bochmann F, Ang GS and Azuara-Blanco A.  Lower corneal hysteresis in glaucoma patients with acquired pit of the optic nerve (APON).  Graefes Arch Clin Exp Ophthalmol, May 2008; 246(5): 735-738.
  4. Carbonaro F, Andrew T, Mackey DA, et al.  Comparison of three methods of intraocular pressure measurement and their relation to central corneal thickness. Eye (Lond). 2010 Jul;24(7):1165-70.
  5. Congdon NG, Broman AT, et al.  Central corneal thickness and corneal hysteresis associated with glaucoma damage.  American Journal of Ophthalmology, May 2006, Vol. 141, Issue 5.
  6. ECRI Institute. Hotline Response. Central Corneal thickness measurement for the diagnosis of glaucoma and ocular hypertension.  April 2010.
  7. Elsheikh A, Wang D, Rama P, et al.  Experimental assessment of human corneal hysteresis.  Curr Eye Res, March 2008; 33(3): 205-213.
  8. Fontes BM, Ambrósio R Jr, Velarde GC, et al. Ocular response analyzer measurements in keratoconus with normal central corneal thickness compared with matched normal control eyes.  J Refract Surg, 2011 Mar;27(3):209-15.
  9. Gatinel D, Chaabouni S, Adam PA, Munck J, et al.  Corneal hysteresis, resistance factor, topography, and pachymetry after corneal lamellar flap.  J Refract Surg, January 2007; 23(1): 76-84.
  10. Hager A, Loge K, Kutschan A and Wiegand W.  [The effect of cataract and vitreoretinal surgery on central corneal thickness and corneal hysteresis].  Klin Monatsbl Augenheilkd, March 2008; 225(3): 207-211.
  11. Hayes, Inc. Medical Technology Directory. Measurement of Corneal Hysteresis for the Diagnosis and Management of Glaucoma. Lansdale, PA: Hayes, Inc.; December 6, 2018.
  12. Jorge JM, Gonzalez-Meijome JM, et al.  Correlations between corneal biomechanical properties measured with the ocular response analyzer and ICare rebound tonometry.  J Glaucoma, Sept 2008; 17(6): 442-448.
  13. Kirwan Caitriona, O’keefe Michael and Lanigan Bernadette.  Corneal hysteresis and intraocular pressure measurement in children using the Reichert Ocular Response Analyzer.  American Journal of Ophthalmology, December 2006, Vol. 142, Issue 6.
  14. Kopito R, Gaujoux T, Montard R, et al.  Reproducibility of viscoelastic property and intraocular pressure measurements obtained with the Ocular Response Analyzer.  Acta Ophthalmol. 2010 Aug 25.
  15. Kotecha A, Elsheikh A, Roberts CR, et al.  Corneal thickness- and age-related biomechanical properties of the cornea measured with the ocular response analyzer.  IOVS, December 2006, Vol. 47, No. 12.
  16. Kotecha A.  What biomechanical properties of the cornea are relevant for the clinician?  Surv Ophthalmol, November 2007; 52 Suppl 2: S109-114.
  17. Lam A, Chen D, Chiu R and Chui WS.  Comparison of IOP measurements between ORA and GAT in normal Chinese.  Optom Vis Sci, September 2007; 84(9): 909-914.
  18. Lau W, Pye D.  Changes in corneal biomechanics and applanation tonometry with induced corneal swelling.  Invest Ophthalmol Vis Sci. 2011 Feb 23.
  19. Lu F, Xu S, Qu J, Shen M, Wang X, et al.  Central corneal thickness and corneal hysteresis during corneal swelling induced by contact lens wear with eye closure.  Am J Ophthalmol, April 2007; 143(4): 616-622.
  20. Mangouritsas G, Morphis G, Mourtzoukos S, et al.  Association between corneal hysteresis and central corneal thickness in glaucomatous and non-glaucomatous eyes.  Acta Ophthalmol.  2009 Nov;87(8):901-5.
  21. Martinez-de-la-Casa J, Garcia-Feijoo J, et al.  Ocular response analyzer versus Goldmann applanation tonometry for intraocular pressure measurements.  IOVS, October 2006, Vol. 47, No. 10.
  22. Medeiros FA and Weinreb RN.  Evaluation of the influence of corneal biomechanical properties on intraocular pressure measurements using the ocular response analyzer.  J Glaucoma 2006; 15(5): 364-370.
  23. Murphy ML, Pokrovskaya O, Galligan M, et al. Corneal hysteresis in patients with glaucoma-like optic discs, ocular hypertension and glaucoma. BMC Ophthalmol. 2017 Jan 10;17(1):1.
  24. Ortiz D, Shabayek MH, et al.  Corneal biomechanical properties in normal, post-laser in situ keratomileusis, and keratoconic eyes.  Cataract Refract Surg, August 2007; 33(8): 1371-1375.
  25. Pepose JS, Feigenbaum SK, Qazi MA, et al.  Changes in corneal biomechanics and intraocular pressure following LASIK using static, dynamic, and noncontact tonometry.  American Journal of Ophthalmology, January 2007, Vol. 143, Issue 1.
  26. Renier C, Zeyen T, Fieuws S, et al.  Comparison of ocular response analyzer, dynamic contour tonometer and Goldmann applanation tonometer Int Ophthalmol. 2010 Dec; 30(6):651-9.
  27. Saad A, Lteif Y, Azan E, et al.  Biomechanical properties of keratoconus suspect eyes.  Invest Ophthalmos Vis Sci. 2009 Dec 30.
  28. Schweitzer C, Roberts CJ, Mahmoud AM, et al.  Screening of forme gruste keratoconus with the ocular response analyzer. Invest Ophthalmol Vis Sci.  2010 May;51(5):2403-10.
  29. Shah S, Laiquzzaman M, Cunliffe I and Mantry S.  The use of the Reichert ocular response analyser to establish the relationship between ocular hysteresis, corneal resistance factor and central corneal thickness in normal eyes.  Cont Lens Anterior Eye, December 2006; 29(5): 257-262.
  30. Shah S, Laiquzzaman M, Bhojwani R, Mantry S and Cunliffe I.  Assessment of the biomechanical properties of the cornea with the ocular response analyzer in normal and keratoconic eyes.  Investigative Ophthalmology & Visual Science, July 2007; 48(7): 3026-3031.
  31. Shah S, Laiquzzaman M, Mantry S and Cunliffe I.  Ocular response analyser to assess hysteresis and corneal resistance factor in low tension, open angle glaucoma and ocular hypertension.  Clin Experiment Ophthalmol, August 2008; 36(6): 508-513.
  32. Sullivan-Mee M, Gerhardt G, Halverson KD, et al.  Repeatability and reproducibility for intraocular pressure measurement by dynamic contour, ocular response analyzer and Goldmann applanation tonometry. J Glaucoma.  2009 Dec:18(9):666-73.
  33. Sullivan-Mee M, Billingsley SC, Patel AD, Halverson KD, et al.  Ocular Response Analyzer in subjects with and without glaucoma.  Optom Vis Sci, June 2008; 85(6): 463-470.
  34. Sun L, Shen M, Wang J et al.  Recovery of corneal hysteresis after reduction of intraocular pressure in chronic primary angle-closure glaucoma.  Am J Ophthalmol.  2009 Jun:147(6):1061-6., 1066.e1-2.
  35. Susanna CN, Diniz-Filho A, Daga FB, et al. A Prospective Longitudinal Study to Investigate Corneal Hysteresis as a Risk Factor for Predicting Development of Glaucoma. Am J Ophthalmol. 2018 Mar;187:148-152.
  36. Touboul D, Roberts C, Kerautret J, Garra C, et al.  Correlations between corneal hysteresis, intraocular pressure, and corneal central pachymetry.  J Cataract Refract Surgery 2008; 34(4): 616-622.
  37. Vandewalle E, Vandenbroeck S, Stalmans I, et al. Comparison of ICare, dynamic contour tonometer, and ocular response analyzer with Goldmann applanation tonometer in patients with glaucoma,  Eur J Ophthalmol. 2009 Sep-Oct;19(5):783-9.


Medical Policy Group, April 2009 (1)

Medical Policy Administration Committee, May 2009

Available for comment May 12-June 24, 2009

Medical Policy Group, July 2011; Updated Key Points and References

Medical Policy Group, September 2012: Effective September 14, 2012 this policy is no longer scheduled for regular literature reviews and updates.

Medical Policy Group, November 2014: 2015 Annual Coding update. Added code 92145 to current coding and added Previous Coding section to include deleted code 0181T.

Medical Policy Group, December 2019 (6): Updates to Description, Key Points, Governing Bodies, Key Words (Goldmann tonometer) and References. No change to policy intent.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.