1. Dr. Rashmi Ranjan

2.  Greek : gṓ nḗ : angle , Ộs’k-pḗ :
view
 Alexois Trantas:(1907)
First visualized angle in an eye
with Keratoglobus
 Maximilian Salsmann:(1914)
Father of Gonioscopy. First
introduced Goniolens

3.  Koeppe :
Designed improved Contact lens and gave the
method biomicroscopy of angle of anterior
Chamber with slit lamp.
 Manuel Uribe Troncoso:
Developed Gonioscope for magnification &
illumination of Angle.
First to write a Comprehensive book on
Gonioscopy

4.  Otto Barkan:
Established use of Gonioscopy
in Management of Glaucoma.
 Goldmann:(1938)
Introduced Gonioprism.

5.  Critical Angle: Cornea Air Interface~46degree
Light rays from Angle exceeds Critical angle so rays
reflected back into AC,preventing direct visualisation of
Angle

6. INDIRECT DIRECT

8. LENS DESCRIPTION
KOEPPE Prototype Diagnostic Lens
RICHARDSON SHAFFER Small Koeppe Lens used for
Infants
LAYDEN For Gonioscopic Examination
of Premature Infants
BARKAN Prototype Surgical Goniolens
THORPE Surgical & Diagnostic lens for
Operating Rooms
SWAN JACOB Surgical Goniolens used in
Children

9.  Used with Handheld Biomicroscope (15x to 20x) with
separate light source

12. LENS DESCRIPTION
GOLDMANN SINGLE MIRROR Mirror inclined at 62 degrees
GOLDMANN THREE MIRROR One mirror for gonioscopy, two for retina;
coated front surface for laser use
ZEISS FOUR MIRROR All 4 mirrors inclined at 64 degrees for
gonio;requires holder;fluid bridge not
required.
POSNER FOUR MIRROR Modified Zeiss four mirror gonioprism
with attached handle
SUSSMAN FOUR MIRROR Handheld Zeiss type Gonioprism
THORPE FOUR MIRROR Four gonioscopy mirrors; inclined at 62
degrees;requires fluid bridge
RITCH TRABECULOPLASTY
LENS
Four gonioscopy mirrors; two inclined at
59 degrees & two at 62 degrees with
convex lens over two
LATINA TRABECULOPLASTY
LENS
One mirror for Trabeculoplasty

16.  All 4 mirrors inclined at 64 degrees for gonio

18.  Handheld

19.  Four gonioscopy mirrors; inclined at 62 degrees;requires fluid
bridge

21.  One mirror for Trabeculoplasty

23. ADVANTAGE DISADVANTAGE
 Observer’s height can be
changed
 Done on sedated, comatosed
& Children
 Panoramic view of Angle
 Less distortion of AC
 Useful in examining fundus
with small pupil
 Inconvinient
 Special equipments required
 Difficult to master
 Does not Stabilize globe

24. ADVANTAGE DISADVANTAGE
 Quick & Convinient
 No special equipment
required
 Allows differentiation B/w
Appositional & Synechial
closure
 Can create corneal wedge
 Inadverent Pressure on
Cornea
 Mirror image is confusing

25. DIRECT INDIRECT
 Panoramic view of
iridocorneal angle with
ability to adjust view by
examiner.
 Both eyes can be examined
simultaneously.
 No viscous [ coupling ]
material required.
 Direct view for surgery e.g.
Goniotomy
 DISADV: Inability to
perform indentation, low
magnification, assistance.
 Segmental View
 One Eye at a time
 Viscous required
 Mirror Image seen
 Excellent optics with Slit
Lamp
 Indentation Can be Done

26.  Classification : Open or Closed angle glaucoma
 To assess AC angle recess & risk of angle closure.
 To identify plateau iris.
 To look for Abnormal angle pigmenatation,
PEX ,
angle recession,
cyclodialysis,
foreign body,
Neoplasm,
copper deposition ,
blood in Schlemm’s canal.

27. Evaluation of trabeculectomy fistula ,
glaucoma drainage devices
Congenital anomalies- aniridia, iris processes.

28. Laser trabeculosplasty/
goniophtocoagulation
Goniotomy/ Gonioplasty/ Trabectome sx
Reopening of blocked trabeculectomy
opening.
Laser of suture around tube of G.D.D.
Indentaion Gonioscopy to break an attack
of Ac. ACG

30.  This structural portion
of ciliary body is visible
in the A.C. as a result of
iris insertion into ciliary
body
 Width depends on level
of iris insertion
 Wider in myopes and
narrow in hyperopia
 Color: grey to dark
brown

32.  This is the post. Lip of
scleral sulcus which is
attached to the ciliary
body posteriorly and
corneo-scleral
meshwork anteriorly
 Color : prominent
white line

33.  Pigmented band anterior to scleral spur
 Although extent of TMW is from root of iris to
schwalbe’s line it is considered as 2 portions
a) Anterior - between schwalbe’s line and ant. Edge of
schlemm’s cannal
 Involved in lesser degree of aqueous out flow
b) Posterior – Functional part , primary site of aqueous out
flow
 Appearance of funtional TMW depends on
amount of pigment deposition

34.  At birth no pigment and
with age from faint to
dark brown
 Pigment deposition may
be homogeneous or
irregular
 When lightly pigmented
blood reflex in
schlemm’s cannal may
be seen as a red band

35.  When a thin slit of light hits the irido-corneal angle at
an angle of 10⁰-15⁰, two light reflections are seen from
the external and internal corneal surfaces which pipe
down at the sclero-corneal junction (Schwalbe’s line)
marking the anterior border of trabecular meshwork.
 Corneal wedge is a useful technique to identify the
trabecular meshwork in eyes that are either
nonpigmented or excessively pigmented its diff. to
mark trabecular meshwork begins

39.  Junction between
anterior chamber angle
structures and cornea
where the descement’s
membrane terminates
 Fine ridge ant. to TMW
identified by a small
built up of pigment
 Landmark for TMW in
narrow angle

42. Contour
 Flat- Deep AC
 Concave- Shallow AC , Hyperopia
 Convex- High Myopia, Pigment Dispersion Syndrome
 Abnormal Rolling- Plateau iris

43. IRIS PROCESS PAS
 Fine
 Extend into scleral Spur
 Follow concavity of Recess
 Underlying Structures are
seen
 Iris moves with indentation
 Broken with angle
Recession
 Broad
 Extend Beyond Scleral Spur
 Bridge concavity of Recess
 Obscures the View
 Resists Movement
 Intact in Recession

44. NORMAL NEOVASCULARIZATION
 Radial Orientation
 Thick
 Non Branching
 Do not cross Scleral Spur
 Fine
 Arborising
 Crosses Scleral Spur

46.  Over the Hill
 Corneal Wedging
 Indentation

47.  It’s a special maneuver
to view over a steep iris.
 It is done by asking
the patient to look in
the direction of the
mirror or moving the
mirror towards the
angle being viewed

48.  When iris covers the trabecular meshwork
(TM) its easy to mistake:
◦ The non-pigmented TM for scleral spur
◦ Pigmented Schwalbe’s line for TM
◦ Apposition from synechiae
 Indentation Gonioscopy is particularly useful
in these cases

50.  Useful when iris surface is convex
◦ Done when recognition of angle structures is
difficult
 Performed in all glaucoma cases
◦ Differentiates appositional vs synechial
closure in pupillary block
◦ Measures extent of angle closure
◦ Identifies plateau iris config.
◦ Identifies lens induced angle closure

54.  If posterior [ pigmented ] part of trabecular
meshwork is not visible in more than 180
degrees of angle without indentation or
manipulation, this is known as an ‘ occludable
angle’.

57.  SCHEIE SYSTEM:
most posterior structure visible.
 SHAFFER’S SYSTEM :
assess geometric angle width in 4 grades .
angle potential for occlusion.
 SPAETH SYSTEM :
three dimentional structure of angle -
level of iris insertion and peripheral iris
configuration.
 RPC GRADING

58. GRADE STRUCTURE SEEN PROBABILITY
0 CBB Seen No angle closure
I CBB Narrow No angle closure
II CBB not seen, SS Seen Rarely closure
possible
III Posterior TM Not seen Closure likely
IV Schwalbe’s Line not seen Gonioscopicaly
closed

60.  Angular width
 Iris Configuration
 Level of Iris Insertion
 Iris Processes
 Pigmentation of posterior Trabecular
Meshwork

62. IRIS PROCESSES PIGMENTATION OF TBM
 U – along angle recess
 V – upto trabecular
meshwork
 W – upto Scwalbe’s Line
 0 no pigmentation
 1+ just perceptible
 2+ definite but mild
 3+ moderately dense
 4+ dense black
pigmentation

63. GRADE STRUCTURE SEEN
0 CLOSED
1 SCHWALBE’S LINE
2 ANTERIOR(NON
PIGMENTED) TM
3 POSTERIOR PIGMENTED
TM
4 SCLERAL SPUR
5 CILIARY BODY BAND
6 ROOT OF IRIS

64.  Angle is Deep
 Flat Iris inserted posterior to Scleral Spur
 Translucent Trabecular Meshwork
 Normal CBB
In Congenital Glaucoma:
 Anterior insertion of iris directly on TBM
 Thin CBB
 Congenital vessels in ‘’Hair Pin’’
Configuration

66. CLOSED ANGLE

83.  Wash with soap & water
 Soaking the lens for 5-10 min in fresh solution of Sod.
Hypochlorite [ 1:10 household bleach : water]
 Rinsing with sterile water
 Air drying
 3% H2O2 or 1% Formaldehyde can also be used.
 Direct surgical gonioscopes [ Koeppe, Swan Jacob] can
be sterilized with ethylene oxide.

84.  Contact investigation patient discomfort.
 Conjunctival infection.
 Artefactual angle closure
 Slit lamp illumination-> pupil constriction-> opens up
the angle
 Wide interobserver variations.
 Indentation corneal folds, distorted view of angle
structures, epithelial injury.

85.  Painful inflamed eye
 Acute glaucoma with edematous cornea
 Mydriatic drugs- obscure angle by bunching up iris
 Suspected open globe injury or early in course of
suspected closed globe injury with hyphaema as
pressure may precipitate rebleed.

87.  High Frequency (50 – 100
Mhz)B Scan system
 Ocular structures anterior to
Pars Plana
 Lateral Resolution 50mm
 Axial Resolution 25mm
 Depth of penetration 4-5mm
 Field of View 4x4mm

94.  High Resolution Anterior
Segment Imaging Modality
 Spatial Resolution of 10-20µm
 Uses 1310 nm of Infra Red light
 Works on Principle of Low
Coherence Interferometry
 Measures: Echotime delay &
Intensity of Back Scattered light
& Back Reflected Light

98.  Imaging of Anterior Chamber
 Evaluation of Structural Causes of Angle
Closure
 Effects of Interventions like Iridotomy
 Imaging of Trabeculectomy Blebs
 Tube Position in Glaucoma Drainage Implants
 Angle Assesment in Corneal Opacities
 Pachymetry
 Large Scale Screening of Angle Closure &
Angle Closure Glaucoma

104. AS OCT UBM
 Non Contact
 Axial Resolution 10-20µm
 Light Energy
 90 degree patient
Technician Set up
 Precise Scanning Location
(Degrees)
 Posterior Chamber not Well
Delineated
 No distortion of Angle
 All 4 quadrants at a time
 Contact
 Axial Resolution 50µm
 Sound Energy
 Supine
 Scanning Location less
precise(Quadrants)
 Posterior Chamber Well
Delineated
 Distortion of Angle
 1 Quadrant at a time