Description of different types of gonioscopy

1. Gonioscopy TechniqueGonioscopy Technique
And InterpretationAnd Interpretation
Hira Nath DahalHira Nath Dahal

2. ReferencesReferences
 Diagnosis and therapy of the glaucomaDiagnosis and therapy of the glaucoma
 77thth
edition Becker-Shaffer’sedition Becker-Shaffer’s
 Duane’s clinical ophthalmology CD ROM 2005Duane’s clinical ophthalmology CD ROM 2005
 Sheilds’ Text book of glaucoma 5Sheilds’ Text book of glaucoma 5thth
editionedition
 AAO 2005-2006 section 10 GlaucomaAAO 2005-2006 section 10 Glaucoma

3. Presentation layoutPresentation layout
 IntroductionIntroduction
 Optics of gonioscopyOptics of gonioscopy
 Methods of gonioscopyMethods of gonioscopy
 DirectDirect
 IndirectIndirect
 InterpretationInterpretation
 NormalNormal
 AbnormalAbnormal

4.  Gonioscopy refers to the techniques used forGonioscopy refers to the techniques used for
viewing the anterior chamber angle of the eye forviewing the anterior chamber angle of the eye for
evaluation, management and classification ofevaluation, management and classification of
normal and abnormal angle structures.normal and abnormal angle structures.
 Term was coined by Trantas, who in 1907Term was coined by Trantas, who in 1907
visualized the angle in an eye with keratoglobus byvisualized the angle in an eye with keratoglobus by
indenting the limbus.indenting the limbus.
(Gonio:Angle, Scopy: Examination)(Gonio:Angle, Scopy: Examination)

5.  Salzmann in 1944 determined visualization ofSalzmann in 1944 determined visualization of
anterior chamber angles is impossible withoutanterior chamber angles is impossible without
special optical instrument due to total internalspecial optical instrument due to total internal
reflection and design his own lensreflection and design his own lens
 Troncoso ,Koeppe, Goldmann modifiedTroncoso ,Koeppe, Goldmann modified
gonioscopic techniquegonioscopic technique

6. Snell’s LawSnell’s Law
Total internal reflectionTotal internal reflection

7. IndicationIndication
 Suspected angle-closure diseaseSuspected angle-closure disease
 Any sign of angle-closure diseaseAny sign of angle-closure disease
(glaucomflecken, iritis, iris atrophy)(glaucomflecken, iritis, iris atrophy)
 Family member with angle-closure diseaseFamily member with angle-closure disease
 Positive van HerickPositive van Herick
 History of any type of glaucoma, field loss, or discHistory of any type of glaucoma, field loss, or disc
damagedamage
 Elevated IOPElevated IOP
 Pigment dispersion syndromePigment dispersion syndrome
 Ocular blunt trauma or history of foreign bodyOcular blunt trauma or history of foreign body

8.  Pseudoexfoliation syndromePseudoexfoliation syndrome
 Retinal vascular occlusionRetinal vascular occlusion
 History of ocular tumorHistory of ocular tumor
 Unexplained hypotony to look for a cyclodialysisUnexplained hypotony to look for a cyclodialysis
cleftcleft

9. CONTRAINDICATIONSCONTRAINDICATIONS
 Patients with known recurrent corneal erosionPatients with known recurrent corneal erosion
 Patients with corneal abrasionsPatients with corneal abrasions
 Patients with keratopathy (i.e., bullous, band,Patients with keratopathy (i.e., bullous, band,
punctate, etc.)punctate, etc.)
 Perforating eye injuriesPerforating eye injuries

10. Gonioscopic methodGonioscopic method
 Indirect methodIndirect method
 Goldmann lens--- surface is slightly larger than the corneaGoldmann lens--- surface is slightly larger than the cornea
and that require gonioscopic geland that require gonioscopic gel
 Zeiss four mirror lens---surface is smaller than the cornea andZeiss four mirror lens---surface is smaller than the cornea and
that use the patient’s tear film as a coupling agentthat use the patient’s tear film as a coupling agent
 Posner four mirror, Sussmann four mirror, Thorpe fourPosner four mirror, Sussmann four mirror, Thorpe four
mirrormirror
 Direct methodDirect method
 Koeppe lens--- surface is quite large ,that use saline as aKoeppe lens--- surface is quite large ,that use saline as a
coupling agent ,and the patient should be in supinecoupling agent ,and the patient should be in supine
 Swan Jacob, Barkan, Richardson-ShafferSwan Jacob, Barkan, Richardson-Shaffer

11. Direct gonioscopyDirect gonioscopy
 The Koeppe lens is an exampleThe Koeppe lens is an example
of a direct goniolens.of a direct goniolens.
 It is placed directly on the corneaIt is placed directly on the cornea
along with lubricating fluid, toalong with lubricating fluid, to
avoid damaging its surface.avoid damaging its surface.
 The index of refraction of aThe index of refraction of a
Koeppe lens is approximately 1.4,Koeppe lens is approximately 1.4,
almost exactly that of thealmost exactly that of the
cornea(1.37).cornea(1.37).

12.  The incident ray travels through the goniolensThe incident ray travels through the goniolens
practically unalteredpractically unaltered
 The ray escapes because the angle of incidenceThe ray escapes because the angle of incidence
at the new Koeppe air boundary is now less thanat the new Koeppe air boundary is now less than
the critical angle.the critical angle.
 Unfortunately it requires the patient to be lyingUnfortunately it requires the patient to be lying
down, and so it cannot be so easily used with andown, and so it cannot be so easily used with an
ordinary slit lampordinary slit lamp

13. Examination of a supine patient using Koeppe gonioscopy

14. Swan Jacob surgical goniolensSwan Jacob surgical goniolens

15. Indirect gonioscopyIndirect gonioscopy
 Goldmann goniolens:Goldmann goniolens: this utilisesthis utilises
mirrors to reflect the light from themirrors to reflect the light from the
iridocorneal angle into the direction of theiridocorneal angle into the direction of the
observerobserver
 While the view obtained is smaller thanWhile the view obtained is smaller than
that of the Koeppe goniolens, it can bethat of the Koeppe goniolens, it can be
used with the patient sitting uprightused with the patient sitting upright
positionposition

16.  Zeiss indirect goniolens:Zeiss indirect goniolens:
 Similar to the Goldmann, but employs prisms in theSimilar to the Goldmann, but employs prisms in the
place of mirrors.place of mirrors.
 Its four symmetrical prisms allow visualisation of theIts four symmetrical prisms allow visualisation of the
iridocorneal angle in four quadrants of the eyeiridocorneal angle in four quadrants of the eye
simultaneously, and works well with a slit lampsimultaneously, and works well with a slit lamp
 Does not require lubricating fluid, only the patient's tearDoes not require lubricating fluid, only the patient's tear
film - allows for indentation gonioscopyfilm - allows for indentation gonioscopy

20. Indentation GonioscopyIndentation Gonioscopy
 Essential in distinguishing appositional angle closure from synechialEssential in distinguishing appositional angle closure from synechial
angle closure.angle closure.
 Done with goniolenses that have contact diameters smaller than theDone with goniolenses that have contact diameters smaller than the
corneal diameter.E.g. Ziess, Posner and Sussman lenses.corneal diameter.E.g. Ziess, Posner and Sussman lenses.
 Lens is placed centrally on the cornea and pushed posterior, so thatLens is placed centrally on the cornea and pushed posterior, so that
aqueous is pushed into the angle which will deepen the appositionallyaqueous is pushed into the angle which will deepen the appositionally
closed angle.closed angle.

21.  Angles having synechial closure either open withAngles having synechial closure either open with
indentation, or partially open with synechiae beingindentation, or partially open with synechiae being
tethered to the cornea or trabecular meshwork.tethered to the cornea or trabecular meshwork.
 Also helpful in diagnosing iridodialysis, cyclodialysisAlso helpful in diagnosing iridodialysis, cyclodialysis
and foreign bodies in the angle.and foreign bodies in the angle.

22. Indentation gonioscopy
Differentiates ‘appositional’ from ‘synechial’ angle closure
Press Zeiss lens posteriorly
against cornea
Aqueous is forced into
periphery of anterior chamber

23. • Part of angle is forced open
During indentation
• Complete angle closure
Before indentation

25. The gonioscopy processThe gonioscopy process
 Briefly explaining the procedure to the patientBriefly explaining the procedure to the patient
 Cleaning and sterilising the front (curved)Cleaning and sterilising the front (curved)
surface of the goniolenssurface of the goniolens
 Applying lubricating fluid to the front surface ifApplying lubricating fluid to the front surface if
appropriateappropriate
 Anaesthetising the patient's cornea with topicalAnaesthetising the patient's cornea with topical
anaestheticanaesthetic
 Preparing the slit lamp for viewing through thePreparing the slit lamp for viewing through the
goniolensgoniolens

26.  Gently moving the patient's eyelids away from theGently moving the patient's eyelids away from the
corneacornea
 Slowly applying the goniolens to the ocular surfaceSlowly applying the goniolens to the ocular surface
 Fine-tuning the slit lamp to optimise the viewFine-tuning the slit lamp to optimise the view
 Interpreting the gonioscopic imageInterpreting the gonioscopic image
 Moving the goniolens to view each section of theMoving the goniolens to view each section of the
iridocorneal angleiridocorneal angle
 Cleaning the instruments and irrigating the patient'sCleaning the instruments and irrigating the patient's
eyeseyes

27. Gonioscopic procedureGonioscopic procedure

28. Angle structures

29. (1) pupil border; (2) peripheral
iris; (3) ciliary body band; (4)
scleral spur; (5) trabecular
meshwork; and (6) Schwalbe's
line.

30. Pupil and IrisPupil and Iris
 Glaukomflecken and posterior synechiaeGlaukomflecken and posterior synechiae
 Dandruff like particlesDandruff like particles
 If posterior chamber pathology such as tumors,If posterior chamber pathology such as tumors,
suspected, the pupil should dilated and gonioscopysuspected, the pupil should dilated and gonioscopy
repeated.repeated.
 NeovascularizationNeovascularization

31. Iris configurationIris configuration
 Myopes –concaveMyopes –concave
 Hyperopes –convexHyperopes –convex
 Abnormal convexity (pupillary block)Abnormal convexity (pupillary block)
 Abnormal concavity (pigment dispersion)Abnormal concavity (pigment dispersion)
 Abnormal last roll (Plateau iris)Abnormal last roll (Plateau iris)

32. Plateau iris configurationPlateau iris configuration

34. Ciliary Body BandCiliary Body Band
 The band is usually tan, gray, or dark brown,The band is usually tan, gray, or dark brown,
pigmented and typically narrow in hyperopespigmented and typically narrow in hyperopes
and wide in myopes.and wide in myopes.
 In angle recession they are broadly exposedIn angle recession they are broadly exposed
 The root of the iris normally inserts onto theThe root of the iris normally inserts onto the
ciliary body band.ciliary body band.
 If the iris inserts directly into the scleral spur,If the iris inserts directly into the scleral spur,
the ciliary body band is not seen easily.the ciliary body band is not seen easily.

35. Angle blood vesselsAngle blood vessels

36.  The normal angle has three types of vessels:The normal angle has three types of vessels:
 (1) circular ciliary body band vessels(1) circular ciliary body band vessels
 (2) radial iris vessels(2) radial iris vessels
 (3) radial ciliary body band vessels(3) radial ciliary body band vessels
 If angle vessel that bridges the scleral spur is seen, it is probablyIf angle vessel that bridges the scleral spur is seen, it is probably
abnormal.abnormal.

37. Scleral spurScleral spur
 Posterior border of TMPosterior border of TM
 Attachment of ciliary bodyAttachment of ciliary body
 Insertion of longitudinal muscles of ciliary bodyInsertion of longitudinal muscles of ciliary body
 May be obscured by:May be obscured by:
 Iris processIris process
 Iris bombeIris bombe
 PASPAS
 PigmentsPigments

38. Trabecular MeshworkTrabecular Meshwork
 Extends from the scleral spur to Schwalbe's lineExtends from the scleral spur to Schwalbe's line
 Pigment in the meshwork usually accumulates in thePigment in the meshwork usually accumulates in the
posterior divisionposterior division
 Posterior meshwork is the favored location forPosterior meshwork is the favored location for
trabeculoplasty.trabeculoplasty.
 More pigmented with ageMore pigmented with age
 Aqueous flow is through posterior TMAqueous flow is through posterior TM
 More pigment inferiorlyMore pigment inferiorly

39. Schwalbe's LineSchwalbe's Line
 Termination of Descemet's membrane and is the most anteriorTermination of Descemet's membrane and is the most anterior
angle structureangle structure
 Marks the forward limit of the trabecular meshworkMarks the forward limit of the trabecular meshwork
 Landmark for identification of TM in narrow anglesLandmark for identification of TM in narrow angles
Pigmented –Sampaolesi’s linePigmented –Sampaolesi’s line

41. 4+ pigmented posterior4+ pigmented posterior
trabecular meshworktrabecular meshwork

42. Schlemm's CanalSchlemm's Canal
 The canal is located directly anterior to the scleral spurThe canal is located directly anterior to the scleral spur
and is normally not seen.and is normally not seen.
 However, during gonioscopy, blood may reflux intoHowever, during gonioscopy, blood may reflux into
the canalthe canal
 Blood in the canal is more common under conditionsBlood in the canal is more common under conditions
of elevated episcleral venous pressure( eg Sturge –of elevated episcleral venous pressure( eg Sturge –
Weber syndrome ) ,active uveitis or scleritisWeber syndrome ) ,active uveitis or scleritis
 Hypotony may also cause blood to reflux into the canal.Hypotony may also cause blood to reflux into the canal.

43. Blood in schlemm’s canalBlood in schlemm’s canal

44. Angle PigmentationAngle Pigmentation
 A minimal amount of angle pigment is expectedA minimal amount of angle pigment is expected
 Excessive may be caused by pigmentary glaucoma,Excessive may be caused by pigmentary glaucoma,
pseudoexfoliation, trauma, uveitis, or tumors.pseudoexfoliation, trauma, uveitis, or tumors.
 Excessive trabecular pigment at the 12 o'clock position occurs inExcessive trabecular pigment at the 12 o'clock position occurs in
only 2.5% of individuals and is usually pathologic.only 2.5% of individuals and is usually pathologic.

45. Grading of chamber anglesGrading of chamber angles

46. Van HerickVan Herick
Grade 4Grade 4
Grade 3Grade 3
Grade 2Grade 2
Grade 1Grade 1
PAC>CTPAC>CT
PAC=1/4-1/2 CTPAC=1/4-1/2 CT
PAC=1/4 CTPAC=1/4 CT
PAC<1/4 CTPAC<1/4 CT
Angle is wide openAngle is wide open
Angle is narrowAngle is narrow
Angle is dangerously narrowAngle is dangerously narrow
Angle is dangerously narrow or closedAngle is dangerously narrow or closed

47. Open angleOpen angle
Close angleClose angle

48. Shaffer grading
• Ciliary body easily visible
Grade 4 (35-45 )
• At least scleral spur visible
Grade 2 (20 )
Grade 3 (25-35 )
Grade 1 (10 )
• Only trabeculum visible
• Only Schwalbe line and perhaps
top of trabeculum visible
• High risk of angle closure
• Iridocorneal contact present
• Apex of corneal wedge not visible
• Angle closure possible but unlikely
• Use indentation gonioscopy
3 2 1
04
Grade 0 (0 )

49. Scheie classificationScheie classification

50. Spaeth gradingSpaeth grading

52.  Myopic eye with pigment dispersion syndromeMyopic eye with pigment dispersion syndrome
 E 40 q/4+TMP= An extremely deeply inserting irisE 40 q/4+TMP= An extremely deeply inserting iris
root ,in a 40 degree angle recess ,with posteriorroot ,in a 40 degree angle recess ,with posterior
bowing of the peripheral iris and extensive TMPbowing of the peripheral iris and extensive TMP

53. Gonioscopy flow diagramGonioscopy flow diagram

54. Closed angleClosed angle

55. Open angle

56. Open
angle

57. Iris melanoma

58. Neovascularization

59. Neovascularization

60. Microhyphema following traumaMicrohyphema following trauma

61. Foreign bodyForeign body

62. Foreign bodyForeign body

63. Note relative deepening of the iris insertionNote relative deepening of the iris insertion
Post traumatic angle recessionPost traumatic angle recession

64. Peripheral anterior synechiaePeripheral anterior synechiae

65. Haptic in ACHaptic in AC

66. PEXPEX
pigments in pupillary margin and anglepigments in pupillary margin and angle

68. Normal Iris processesNormal Iris processes

69. Thank youThank you