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Gonioscopy
Dr Vijayasree SDr Arjun S (PG )
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Definition :
Gonioscopy describes the
use ofgoniolens to gain
the view of anatomical
angle formed between the
eye s cornea & iris
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Purpose
Whydo I need to perform gonioscopy ?
Fundamental part of comprehensive
examination Most imp factor in correct diagnosis (its
omission is a common cause of misdiagnosis )
Done in all glaucoma pts & suspects Repeated periodically in pts with angle closure
glaucoma
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WhatcanIachievewithgonioscopy?
1) visualization of anterior chamber angle
2) view of peripheral iris
3) differentiation between angle closure ,
occludable & secondary glaucomas
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Other ways of evaluating the
anterior chamber angle
Scheimpflug photography
Ultrasound biomicroscopy
Anterior segment OCT
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Gonioscopy -History
Trantas (1907 ) coined the term gonioscopy
Salsmann (1914) first performed gonioscopy
Goldmann (1938 ) first introdused gonioprism
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Indications
Diagnostic IncreasedIOP
Normal IOP ; AC shallow ( Von Herricks ) orhistorical evidence of angle closure
Dx e/w as glaucoma or using anti glaucomamedications
Family h/o glaucoma
Patent /partially patent PIdone e/w withincreased / normal IOP
Classification of glaucoma( primary/secondary
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Blunt ocular trauma (angle recession ,
cyclodialysis )
extent of rubeosis iridis ( CRVO, CRAO, PDR)
PXF & pigmentary glaucomas
Visualisation of congenital anomalies
Neoplastic invasion into angle ( ciliary body
tumor )
FB in the angle after open globe injury
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THERAPEUTIC
Laser trabeculoplasty.
Excimer laser trabeculotomy.
Goniotomy./ gonioplasty
Laser gonio photocoagulation.
Indentation gonioscopy to break an acute
attack PACG.
Reopening of a blocked trabeculectomy
opening.
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Contraindications :
Open globe injury Fresh concussion injury
Hyphema
Early post operative period Corneal edema
Infections
Corneal epithelial defect
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.it is not possible to view theirido corneal angle , because
light from the angle strikes thecornea at an angle of incidence> 46* , which is the critical angle(cornea air interface ) for total
internal reflection And there by light from the
angle are reflected back into theanterior chamber
Rare exceptions are keratoconus, keratoglobus angle structuresare directly visualized
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Gonioscope helps to neutralize the air cornea
interface and allows visualization of the angle
structures
Gonioscopy types
Direct
Indirect without indentation
with indentation
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Types of gonioscopes
Direct:angle directly viewed
Indirect :angle viewed in mirror mounted on agonioprism
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Direct goniolens
LENSES DESCRIPTION/USE
Koeppe prototype diagnostic goniolens
Richardson schaffer small koeppe lens forinfants
Layden forpremature infants
Barkan prototypesurgical goniolens
Thorpe surgical and diagnostic lens forOT
Swan jacob Surgical goniolens for children
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Techniques
Koeppe (50 D concavelens ) is the proto type
direct gonio lens
Pt is in recumbent position
Placed on anaesthetised pts cornea
Saline or viscous gel is used to fill the interface
Slit lamp or binocular magnifier used for viewing
Direct lens is nowadays only employed in
congenital glaucoma Sx
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Koeppe Barkans
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Swan jacob Thorpe
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Indirect Gonioscopy
Technique :
Pt is positioned on slit lamp with
anaesthetized
cornea Pt is asked to look down or upward and
quickly lens is tipped forward against cornea
Slit lamp is placed
perpend
icular to the pupil SL beam should have least possible
illumination & magnification
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Advantages
Convenient to use
Manipulation & indentation
possible
Optical corneal wedge can
identify angle structures
Lasers can be applied
Streoscopical view ofONH
disadvantages
Inverted image, opposite
angle viewed
Inability to see both angles
simultaneously
Needs pt cooperation
Visco make cornea hazy
Scleral type lens falsely
close angle by pressure
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Indirect gonioscopy
Types :scleral type & corneal type
Scleral type ( gold mann )- large area(12mm ),
steep convex surface (7.38mm )
Viscous substance needed ( methyl cellulose )
Cannot be used for indentation gonioscopy
Perimetry, ophthalmoscopy, fundus
photography should be performed prior tothis
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INDIRECT GONIOSCOPY
INSTRUMENTS : gonioprism &slitlamp
GOLDMANN singlemirroris a prototype
mirrorhas a heightof 12mm
posteriorradiusof 7.38mm
GOLDMANN 3 MIRROR: has 3 mirrors
twomirrors forexamination of fundus
(67 deg , 73 deg)
and one forant. Chamberangletilted at59 degrees
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The center lens is the contact Hruby Lens used for viewing the posterior pole,nerve head, and macula.
The Trapezoid mirror(73 deg) is used to view the retina slightly posterior to the
equator.
The Half Round mirror (67 deg) is used to view the peripheral retina fromthe equator out to the ora serrata.
The Finger Nail mirror(59deg) is used to view angle and the most anterior retina
and ciliary body.
GOLDMANN 3
MIRROR GONIOSCOPE
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Corneal ( ziess ) type : diameter 9 mm
Radius of curvature =7.72 mm approxcorneal radius of curvature
So can be used for indentation gonioscopy
coupling fluid not needed uses tear film
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LENSES DESCRIPTION/USE
ZEISS 4 MIRROR has a 9mm corneal segment and
Radius of curvature 7.72mm
All 4 mirrors are inclined at 64 degrees
allows examination of 360 deg
No fluid bridge required
requires holder
POSNER 4 MIRROR modified zeiss with attached handle
SUSSMANN hand held zeiss type
THORPE 4 MIRROR 4 gonioscopy mirrors inclined at 62
degrees,requires fluid bridge
RITCH TRABECULOPLASTY
LENS 4 gonioscopy mirrors 2 inclined at 59
degrees and other 2 at 62 degreeswith convex lens over two
Because of smaller diameter used for
Indentation or compressive gonioscopy.
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Suss mann Posners
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Technique (ziess) goniolens Do an external Ex first Perform tonometry before gonioscopy Use topical anaesthesia
Pay attention to Pt comfort Pay attention to alignment
Use dark room pupillary constriction makes a narrow angleappear more open
Position pt at SL with illumination coaxial with viewing system& low magnification ( x 10 )
Lateral canthal marker to center vertical range of slit lamp, No coupling fluid is used
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Use vertical parallelopiped beam which is 2-3
mm wide (fairly short & narrow beam )
Examiner should remember that he is viewing
the opposite angle
The slit beam should not have much
illumination & not cross pupillary margin
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While the looks straight ahead the lens is gentlyguided onto the corneal apex so that the edges
do not indent the cornea
Do not press too hard ,( DM folds appear)
Mirrors should be placed in the 12, 3, 6, 9 o clockposition
If air bubbles appear , slightly rock, rotate or
remove & reapply
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Examine first the inferior quadrant ( widest &
more pigmented , which implies that thestructures are easy to recognize )
Then nasal , superior , temporal (so that atany point the beam should not cross the pupil)
Always compare the findings in one eye withfellow eye before commenting on angle
characteristics
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Sterilization& disinfectionofgoniolens
Washing with soap &water, sodium
hypochlorite
3% H2O
2 1% formaldehyde
70% isopropyl alcohol
Ethylene oxide gas (surgical lens )
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What shouldI look for in gonioscopy ?
Recognize angle land marks & consider:
1. Level of iris insertion
2. Shape & profile of peripheral iris3. Estimated width of angle
4. Degree of trabecular pigmentation
5. Areas of iridotrabecular apposition /synechiae
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Starting from the root of iris the following
structures are present in a normal ad
ult angle1. Ciliary body band
2. Scleral spur
3. PigmentedTM
4. Non pigmentedTM
5. Schwalbe s line
for identification of angle , the scleral
spur & schwalbes line are the mostconsistent land marks
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Sample View of Wide Angle
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ANGLE STRUCTURES
it iseasierto identifythe anglestructures fromposterior(irisside) to
anterior(cornea side).
Start from pupil , follow the plane of iris , identify root of iris
1.) Ciliary body - (CB)
isthemostposteriorstructure in the angle .
It appears as a grey or dark brown bandIts width Dependsupon thelevelof iris insertion it is widerin myopes
and narrowerin hypermetropes
2.) Scleral spur - (SS)
istheposteriorportion ofscleral sulcus
Appears as a prominent whitelinebetween CBB and functional TMW.
finepigmented strandsseen crossing thespurfrom irisrootto
TMW are irisprocesses.
Blood in schlems canallies just anttothescleral spur. 38
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3.TRABECULAR MESH WORK: is seen as a band just anterior to scleral spur
posterior pigmented functional TMW band
anterior non pigmented TMW band seen
.
it has no pigment at birth and develops pigmentwith increasing age and appears faint tan to dark brown.
4 SCHWALBES LINE: it forms the anterior limit of the angle structures
formed by prominent end of descemets membrane of cornea.
it appears as a faint dark line.
An optical cut through the cornea with
Slitlamp beam has 2 reflections from
Bowmans and descemets they meet at
Schwalbes line. Corneal wedge technique
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Normal angle
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Dynamic gonioscopy
Indentation gonioscopy
Manipulative gonioscopy
Biometric gonioscopy
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INDENTATION GONIOSCOPY
1.SHALLOW AC
2.OPEN ANGLE
3.CLOSED ANGLE WITHPAS.
Increased pressure
indents centralcornea anddisplaces
fluid in to the angle
opening it wider
should the angle be
closed it
differentiates
between
appositional (
reversed )&
synechial
(irreversible )closure
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When no angle is directly visible before
indentation , the closure can be due to 3
reasons 1) synechial
2) appositional
3) optical ( apparent closure due to steepcurvature of peripheral iris )- a moretangential viewing of the angle aids inidentification of angle .Ask the pt to look
in thed
irection of the mirror /move themirror towards the angle being viewed manipulative gonioscopy
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Sample View of Narrow Angle
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Steep iris , narrow angle
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When no angle structure is directly before
indentation , 4 things can happen on
indentation
1) iris moves peripherally backwards ,assumes a
concave conf & angle recess widens
- appositional closure
2) The angle widens but iris strands remain
attached to the outer wall of angle- synechial closure
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Sample View of Anterior Synechiae
with Indentation Gonioscopy
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3) the iris moves peripherally backwards, but
the periphery of the iris bulges out & assumes
a concave configuration , this represents ananteriorly displaced ciliary body & iris root
- plateau iris
4) Iris moves only slightly & evenly backwards ,
but retains a convex profile , this can occur in
anteriorly displaced lens / large diameter lens
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VAN HERICKS GRADING :
Is a slit lamp technique use
dforEstimating the depth of PAC by
Comparing it with the adjacent
Cornel thickness.
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SHAFFERS GRADING: based on the angular width of angle recess.
GRADE ANGLE WIDTH CONFIG. CHANCES OF CLOSURE
IV 35-45 WIDE OPEN NIL
III 20-35 OPEN ANGLE NIL
II 20 MODERATELY
NARROW POSSIBLE
I 10 VERY NARROW HIGH
SLIT ANGLE
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SCHEIES GONIOSCOPIC CLASSIFICATION :
Based on the extent of visible angle structures
CLASSIFICATION GONIOSCOPIC APPEARANCE
Wide open all structures visible
GRADE I hard to see over iris root
in to recess
GRADE II ciliary body band obscured
GRADE III posterior trabecula obscured
GRADE IV (closed) only schwalbes line visible
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SPAETH SYSTEM OF GRADING b d 3 i bl
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SPAETH SYSTEM OF GRADING:based on 3 variables
a.
Angularwidth of
angle
recess
b.Periph
eral iris
Configuration
c.Appare
nt
insertion
Of the irisroot
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Iris
Normal iris has radial markings with crypts Featureless iris past attack of ant uveitis
Asymmetric appearance FHIC
Peripheral concentric rolls May obscure angle plateau iris
Abnormal convexity pupillary block , thick
lens , tumors / cysts of iris pigment epithelium& ciliary body
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The three major features that must be examined
include Contour of the iris ( concave , convex , flat )
Site of iris insertion
Angular width of angle recess
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Normal angle
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Concave iris conf
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Narrow angle
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Ciliary body bandCBB
Iris inserts into concave face ofCB leavingsome portion visible
Usually gray /dark brown
The width of the band level of iris insertion
Wider myopia
Narrow hypermetropia
Broadened ciliary body band ( compared to
fellow eye ) angle recession
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Schlemm s canal
Not normally visibleBlood in schlems canal is seen in
supine posture
with increased episcleral venous pressure
hypotony
struge weber syndrome
or if gonioscopy lens compress the limbal vessels
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Iris processesNormal in 30 % population
Fine , finger like , gray/ brown ,
Extensions of the peripheral iris , follow theconcavity , insert into SS or PTM
Mostly in nasal Q, do not interfere with aqueousout flow
Contract on light stimulus
Do not block the movement of iris on IND GonioAngle recession iris processes may be broken
Often confused with PAS
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P i h l i hi PAS
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Peripheral anterior synechiae PAS
Irregular , broader , tent shaped
Bridge angle recess , instead of following it
Do not follow the concavity
Obscures angle structures
Inhibit post movement of iris on IND G
Drag normal radial iris vessels
Ass with anterior pigmentation angle closure
& uvietis
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Location of PAS
Superiorly first in ACG Inferiorly in uveitis
Anterior to SL in ICE syndrome
Any location in post traumatic case Rubeosis iridis
Delayed reformation of AC after penetrating
corneal injury
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PAS
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ICE syndrome
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axenfeld rieger anomaly
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Plateau iris
Axially normal central ACdepth , flat iris
plane on direct Ex , but narrow angle on
gonioscopy in eye with angle closure
Anteriorly positioned ciliary processes , push
peripheral iris forward & block the angle
Pupillary block & bunching up of peripheral
iris blocking the TM when pupil dilates
Acute / chronic angle closure
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Suspect 1.when angle closure occurs , despite
a patent iridotomy due to peripheral iris conf
2.If angle closure occurs in younger ptswith myopia
confirmed on gonioscopy & UBM
PAS extend posteriorly from SL to TM , SS,CBB ( reverse is seen in pupillary block
glaucoma extend from post to anterior )
May be missed if one relies solely on SLE / vonherricks method of angle Ex
Rx : long term miotic
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Iridodialysis
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FB in angle
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Angle recession
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Angle recession
Blunt injury
Tear in longitudinal & circular muscles ofCB BroadenedCBB ( compared to fellow eye )
Per se does not cause glaucoma , only marker
for trabecular injury Glaucoma ,when recession > 180,270 *
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Angle recession
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I d i t ti l
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Increased pigmentation , angle
recession
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Pi t l
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Pigmentary glaucomaliberation of iris pigment as it rubs against zonules , deposited thru out
anterior segment
Angle-open , deep
Iris marked concave configuration , mid
periphery Pig ant to schwalbes line ( sampaolesi line)
Homogenous , dense pig ,very dark band
(mascara line ) covering TM
Severity of glaucoma related to amt of pig of
angle
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Pigmentary glaucoma
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Pseudo exfoliative glaucoma
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Pseudo exfoliative glaucomaPXF material deposited on endothelium , lens, iris , pupillary margin zonules
ciliary body
Open , (narrow 30 % with PAS in 20%)
Flecks of PXF on TM
pigm TM uneven , blotchy, less black ,segmented
Glaucoma severity does not correlate with
amt of PXF
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Pseudo exfoliative glaucoma
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Uveitic glaucoma
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Uveitic glaucoma
O
pen / closed
inflammatory ppts on TM
PAS broad based , closed angle , inferior
Iris bombe pupillary block NV of angle (chronic )
FHIC fine vessels , bleed on gonioscopy , no
PAS
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Silicon bubbles in angle
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Summary
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y
Gonioscopic Ex is an imp tool in Examining pts
with ocular disorders
Must be incorporated as routine ophthalmic
evaluation as a standard protocol
It provides a clear insight into the
pathogenesis of glaucoma & facilitatesappropriate medical , laser , surgical Rx
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M t i i i l
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Mastering gonioscopy is also a necessary
requirement for the performance of laser
procedures on the angle structures
It is an art & science aquired only thru
experience as it requires considerable hand eye co ordination & a knowledge of the
normal & abnormal gonioanatomy & the
abitily to avoid artifactual observations
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