Gonioscopy

Dr. Chandra Shekhar Kumar

GONIOSCOPY
Gonioscopy refers to the technique to evaluate the anterior chamber angle. Developed and discovered by TRANTAS and SALZMANN independently in early 1900.

Principle of gonioscopy
Anterior chamber angle cannot be visualized directly through intact cornea because the light emitted from the angle structures undergo total internal reflection at the anterior surface of the precorneal tear film.

Types of gonioscopy

Direct gonioscopy: steep convex lens permits light from angle to exit from the angle

Koeppe Hoskin Barkans Swan-Jacobs lens

Koeppe

Swan-Jacobs lens

Indirect gonioscopy: uses mirrors/prism to overcome the phenomenon of total internal reflection. Also uses the magnification of slitlamp

Goldmanns gonioscope

Zeiss goniolens

Other indirect goniolenses: Posner and Sussmann lenses.

Which gonioscope to use and why?

Direct gonioscopes
Advantages: Panoramic view of the angle Viewing angle can be manipulated by examiner Both eyes can be visualized simultaneously Good binocularity Very little distortion of the angle Disadvantages : Requires supine position of the patient Requires operating microscopes Gives poor detailed anatomy

Common use of direct gonioscopes nowadays 1) for angle evaluation during EUA in children. 2)for surgical procedures like Goniotomy (Swan-Jacobs lens)

Indirect gonioscope Advantages Slitlamp magnification ,illumination, stereopsis, and convenience Allows localization of angle structures. More convenient for patients and examiner

Disadvantages Reflected image is seen. Image is inverted and of opposite angles Small aperture lens may cause distortion of the angle (following indentation).

Goldmann 3 Mirror Lens

Dimensions 12mm diameter, 3 mm flange width. Mirror View 180 degrees away from mirror (inverted reversed)
Trapezoid - 73 degrees, from posterior pole to equator, Rectangular- 67 degrees, equator to beginning of ora, Thumbnail- 59 degrees, Anterior chamber angle (10 - 12 mm height, 9 mm wide, 7 mm from the center.

Radius of curvature 7.4mm

59 degrees, anterior chamber, ora serrata Thumbnail At 55*

73 degrees, from posterior pole to equator Trapezoid At 73* 67 degrees, equator to beginning of ora Rectangular At 63*

Indications of gonioscopy
Diagnostic : To visualize the anterior chamber angle Forms basis for classification of glaucoma To note extent of iris neovascularization History or evidence of Trauma Assess Angle Recession Evidence of neoplastic activity in the Anterior Chamber To assess Peripheral Anterior Syncheiae (PAS)

Therapeutic indication: ALT Laser goniotomy Reopening of trabeculectomy os

Contraindication of gonioscopy
Post-traumatic patients

Post-surgical patients

Technique

Explain the procedure Anesthetize with paracaine Position patient at slit lamp

Illumination lamp and microscope at 0 degrees (perpendicular to pupil) Low magnification and low illumination (6-10X) Parallelopiped (2 mm width and maximum height) Orient beam parallel to the axis of the mirror Clean goniolens Instill goniolens fluid. (Goniosol or other viscous fluid)

Technique

Dynamic gonioscopy

Indentation gonioscopy Manipulation gonioscopy

Indentation gonioscopy

Indentation gonioscopy
Synechial Vs appositional closure Difficult >40mm Hg Sliding the lens towards the angle reduces folds and improves view

Manipulation gonioscopy
Mirror height and distance from centre of cornea (zeiss/Posner advantageous) Tilting or sliding lens towards angle or having pt look into the mirror Avoid indentation (Zeiss) or compression (Goldmann) Tilt astigmatism shortened TM

Manipulation to see angle

Angle view when pt. looks up

Clearing of edematous cornea

Clearing of edematous cornea done with 1) topical glycerin: painful procedure so cornea should be anesthetized before the procedure. 2)ethanol (70%) can be used during surgery to scrape the edematous epithelium.

Guidelines for disinfection of gonioscopes

70% ethyl alcohol sponge for 10 seconds. 1:10 household bleach (sodium hypochlorite) for 5 mins. 3% hydrogen peroxide. 1% formaldehyde Operating gonioscopes -ethylene oxide (sterilisation of tonometers and gonioscopes--Indian j. Ophthalmol.1998;46:113-16 )

Normal angle structures

Schwalbe's line (SL): Is the termination of the descemet's membrane. Schwalbe's line is identified easily with help of parallelepiped made of slit(2mm wide and of max. length ) In most it is a smooth transition zone between trabecular and corneal endothelium.

Corneal wedge to localize the Schwalbe's line

Schwalbe's line

PIGMENTATION ANTERIOR TO SCHWALBE LINE

PIGMENTATION

Trabecular meshwork (TM): lies between Schwalbe's line and scleral spur. non-pigmented (anteriorly and nonfiltering ) pigmented part (posteriorly placed and filtering) *In cases of heavy pigmentation of angle structures corneal wedge is helpful in its identification.

Totally open angle showing TM

TM

Heavily pigmented angle in nevus of ota

Scleral spur (SS) : Continuation of the sclera into the AC. Attached anteriorly to the TM and posteriorly to the sclera Scleral spur is seen as thin band of white or light grey color .

Angle showing scleral spur

scleral spur

Cilliary body band (CBB): Light brown to dark brown in appearance visible anterior to the iris. Look for asymmetry of CCB width and depth in both eyes sign of angle recession, cyclodialysis or unilateral high myopia .

Iris process: uveal extention from the iris to the trabecular meshwork . Extend into the inferior portion of the trabecular meshwork. Usually follow the concavity of the angle recess. Do not inhibit posterior movement of iris on indentation also not to the movement of aqueous. .

Iris process

Blood vessels in the angle :

Radially oriented or looping branch from the major arterial circle. Short segment of major arterial circle may also be visible. Abnormal vessels are fine, irregularly oriented ,cross the scleral spur.

Normal blood vessels in the angle

blood vessels

Scheie system
Grade 0 (wide open) Grade I Grade II Grade III Grade IV (closed) CBB CBB narrow CBB not seen, SS Post TM not seen goinioscopically closed no angle closure no angle closure rarely closure possible closure likely

Shaffer system
Grade 4 (35-45) Grade 3 (25-35) Grade 2 (20) Grade 1 (10) Grade S (<10) (slit angle) Grade 0 (0) CBB SS TM Sch. Line no iridocorneal contact no corneal wedge incapable of closure incapable of closure cl. possible but unlikely high risk of closure imminent closure

Indentation gonioscopy

Grading systems for angle width

Grade number 4 3 2 1 slit 0

1)Shaffer system Angle width Description Risk of closure 45*-35* 35*-20* 20* <10* slit 0* Wide open Wide open Narrow Extremely narrow Narrow to slit Closed Impossible Impossible Possible Possible Probable Closed

Spaeth system
Iris configuration
q -- concave peripheral iris r -- regularly straight iris s --steeply convex iris

Angular width -10, 20, 30, 40

Spaeth system contd..

Level of iris insertion
A B C d e U V W (Anterior to schwalbes line) ( just behind schwalbes line) (at the Scleral spur) (deep angle CBB seen) (extremely deep angle) along angle recess upto TM upto schwalbes line

Iris processes

RPC System
Grade 0 -Grade 1 -Grade 2 -Grade 3 -Grade 4 -Grade 5 -Grade 6 -Closed Schwalbes line Anterior (non pigmented) TM Posterior pigmented TM Scleral spur Ciliary body band Root of iris

Steep iris

Regular

Queer

Common findings

Peripheral anterior synechia

PAS

Typical appearance of PAS

PAS

Neovascular glaucoma

new vessels

Neovascular iris

new vessels

NVG (showing ectropion uveae +PAS+ cilliary processes

cilliary processes

cilliary processes

Angle recession- broadening of the cilliary body band

Angle recession-

Angle recession- broadening of the cilliary body band

Angle recession-

Silicon oil in angle

Silicon oil

Pigment dispersal syndrome

Heavily pigmented TM

Closed angle

Iris cyst

Heavy pigmentation of angle in nevus of ota

Angle in a failed trabeculectomy patient

closed opening

Glaucoma implant visible in the angle

Gonioscopy showing patent internal opening post trab.

internal opening

Melanoma

Foreign bodies

Posterior embryotoxon

Posterior embryotoxon

Axenfield anomaly Posterior embryotoxon( ) Bridging iris strands

Thank you