Update Your Anterior Chamber Angle Skills: How To Best Examine, Grade, and Treat

Update Your Anterior
Chamber Angle Skills: How to

Best Examine, Grade, and Treat
Senior Instructor: Ronald Leigh Fellman MD OCS
Course: 263
Sunday, November 15, 2015
3:15 PM - 5:30 PM
Room: MURANO 3303
Published: 9/8/15 7:50 PM
Join the conversation #aao2015
© 2015 American Academy of Ophthalmology. All rights reserved.

The Anterior Chamber Angle: Fellman, Gross, Neelakantan, Orengo-Nania, Samuelson, Sherwood, Simmons, Spaeth 1
American Academy of Ophthalmology 2015 Las Vegas, Nevada
Update Your Chamber Angle Skills: How to Best

Examine, Grade, and Treat
Course Faculty
Ronald L. Fellman, M.D.

Glaucoma Associates of Texas
Clinical Associate Professor Emeritus
Dept of Ophthalmology Thomas W. Samuelson M.D.
University of Texas Professor of Ophthalmology
Southwestern Medical Center Dallas University of Minnesota
Dallas, TX Minneapolis, Minnesota
Ronald Gross, M.D. Mark B. Sherwood, M.D.

Chairman, Dept of Ophthalmology Daniels Professor of Ophthalmology
West Virginia University Department of Ophthalmology
Morgantown, West Virginia University of Florida, Gainesville
Silvia Orengo-Nania, MD
Professor of Ophthalmology George L. Spaeth, M.D.
Cullen Eye Institute Professor of Ophthalmology
Baylor College of Medicine Wills Eye Hospital
Houston, TX Philadelphia, PA
Steven T Simmons, MD
Associate Professor of Ophthalmology
Director, Glaucoma Service
Albany Medical College
Albany, N.Y.
Chamber Angle Quiz Answers on page 97
• What is the most important gonioscopic angle landmark?
• What is the best way to differentiate appositional from synechial
angle closure? (appositional = hidden but not closed)
• Does a normal angle vessel cross the scleral spur?
• What type of slit lamp illumination is best for gonioscopy?
• Does it matter if the room lights are on or off during gonioscopy?
• What structure should you avoid illuminating during gonioscopy?
• If the patient has bilateral angle closure, think of?
• Is iridoplasty useful for acute angle closure glaucoma?
• Iris processes are more prominent in blue or brown eyes?
• Are normal angle vessels more common in blue or brown eyes?
• Normally, especially in Caucasians, the iris root inserts onto the
scleral spur? (T or F)
Update Your Chamber Angle Skills: How to Best Examine, Grade and Treat
Table of Contents page
1) Faculty………………………………. 1
2) Chamber angle Quiz 2
3) Table of Contents ………………………. 3
4) Course Objectives 4
5) Introduction……………………………. Fellman 5
6) Minimum Indications for Gonioscopy ...... 9
7) Essential Optic for the Gonioscopists …… 10
8) Can Gonioscopy be Replaced….................… 11
9) Grade the Angle……………….........................Spaeth 12
10) Additional Information regarding Classification Systems 36
11) The Normal Angle ……………………………. Sherwood 41
12) Gonioscopy in a Busy Clinical Practice………Samuelson 53
13) Pathology of the Chamber angle…………………Simmons 56
14) Technique of Zeiss Gonioscopy………………….Fellman 59
15) Angle closure disease …………. Gross 62
16) Table, Indications for Peripheral Iridotomy 75
17) Laser trabeculoplasty……………………Orengo-Nania 77
18) Answers to Gonioscopy Quiz……………….. 97
19) Notes……………………………. 99
REVIEW OF COURSE OBJECTIVES
Reduce blindness through the information gained from proficient

gonioscopy and its related diagnostic and therapeutic disciplines.
How to update your chamber angle skills:
1. Select the correct gonioprism.
2. Use the best method to evaluate the angle? (indentation, slit lamp and
room lighting)
3. Accomplished gonioscopists, become proficient at gonioscopy, easily
differentiate normal from abnormal.
4. Integrate gonioscopy into your busy practice on a daily basis
5. Indentation Gonioscopy is a must!
6. Accurately record your findings, use a classification system
7. Correlate your findings and with the history and classify the type of
glaucoma along with follow-up gonioscopy
8. Gonioscopic driven treatment (PI, iridoplasty, trabeculoplasty)
9. Learn to code 92020 (do you need a modifier, unilateral or bilateral code? Bundled?
10. Study www.gonioscopy.org

Update your Anterior Chamber

Angle Skills: How to Best
Examine, Grade and Treat
Fellman
Gross
Neelakantan
Orengo-Nania
Samuelson
Sherwood
Simmons
Spaeth
A recent study of initial office visits

for glaucoma found that gonioscopy
was documented in 46% of cases
while evaluation of the disc was
noted in 94% of cases.[i]
[i] Fremont AM, Lee PP, Mangione CM, et al: Patterns of care for open-angle glaucoma in
managed care. Arch Ophthalmol, June 2003, 777-83.
Van Herick
vanHerick is only a
is only a
screen
guestimate
of the true
angle
anatomy
Rethink and update chamber angle skills.

Objective: Reduce blindness through the
information gained from proficient gonioscopy and
its related diagnostic and therapeutic disciplines.
Upgrade our chamber angle skills

1. Correct gonioprism for the task at
hand.
2. Best method to evaluate and treat
angle.
3. Strive to be an accomplished
gonioscopists
4. Integrate gonioscopy into daily practice
5. Learn indentation gonioscopy
Upgrade anterior chamber skills

6. Record your findings (classify)
7. Correlate clinical findings and repeat
gonio
8. Refine angle treatment (PI,
trabeculoplasty)
9. Learn code 92020 (? Bilateral, modifier?)
10. Study web site www.gonioscopy.org,
www.gonioscopy.org, review
gonioscopy chapters
When we upgrade we develop Anterior

Chamber Organizational Skills
? gonioscopy
technique
Normal from
abnormal
Clinic efficiency:
efficiency: Chamber organizational skills Look at
table 1,
page 10,
? gonioscopic
opportunities,
Be as Facile
as this
fritillary
landing on a
Gulf Fritillary
flower with
your
gonioprism!
Definition of gonioscopy: The procedure whereby the examiner visualizes the

anterior chamber of the eye by redirecting light rays with a prism or lens placed on
the cornea. (a gonioprism reflects light rays and a goniolens refracts light rays)
Clinical implications: New surgical procedures require that eye surgeons be intimately
familiar with angle anatomy in order to successfully place new devices and/or perform
canal surgery. Minimally invasive glaucoma surgery has created a renaissance in
gonioscopy.
Scope of the problem
Primary open angle and angle closure glaucoma remain a major health problem and
continue to be the leading causes of irreversible blindness afflicting at least 60 million
people worldwide with over 7 million legally blind. A recent study of initial office visits
for glaucoma in the United States found gonioscopy documented in only 46% of cases
while evaluation of the disc was noted in 94%. A similar study in Britain documented
gonioscopy in only 23 % of glaucoma subjects even though the majority of
ophthalmologists thought it was necessary. Why? The chamber angle may sustain
considerable damage without any obvious ocular manifestation. For example, eighty
percent of angle closure glaucoma cases are asymptomatic and chronic in nature; only
20% have the acute symptomatic variant. The eye has an astounding anterior chamber
angle reserve that may hide disease for years; ultimately delaying the correct
diagnosis..
Lack of routine gonioscopy may culminate in misdiagnosis, maloccurence, and
maltreatment. Routine gonioscopy (Table 1) detects early angle compromise in time to
preserve vision in most patients (e.g. fellow eye of acute angle closure). Course synopsis.
1. Indications for gonioscopy
2. Different angle classification systems
3. Normal from abnormal angle structures
4. Integrating gonioscopy into a busy practice
5. Indentation gonioscopy
6. Management of angle closure glaucoma, indications for LPI
7. Iridoplasty
8. Laser trabeculoplasty (ALT vs SLT)
Table 1. Minimum Indications for Gonioscopy

Patient’s History reveals:
1. Family member with angle closure or open angle disease
2. Symptoms compatible with angle closure disease
3. High-risk angle closure heritage (Asian, Alaskan, Indian heritage)
4. History of any type of glaucoma, field loss or disc damage
5. Ocular blunt trauma or history of foreign body
6. Diabetes mellitus or proliferative retinopathy
7. Ocular tumor
8. Failing vision
9. Topamax usage or history of acute myopia
10. Prior ocular surgery especially scleral buckle, penetrating keratoplasty, laser
therapy, glaucoma surgery and cataract surgery
11. New patient exam (need for dilation with unknown angle status) or absence of
gonioscopy for 2 to 4 years
12. Chart review reveals the absence of baseline gonioscopy
Patient exam reveals:
13. Any sign of angle closure disease (glaucomflecken, iritis, iris atrophy)
14. Any iris lesion, vessel, coloboma, or cyst deserves gonioscopy
15. Positive van Herick or “shallow chamber”
16. Elevated IOP, especially a significant change from baseline
17. Hyperopia
18. History of nanophthalmos
19. Radial iris transillumination or any sign of pigment dispersion syndrome
20. Pseudoexfoliation syndrome
21. Anticipated trabeculoplasty
22. Retinal vascular occlusion
23. Hyphema
24. Posterior embryotoxon (prominent Schwalbe’s line)
25. Inflammation with flare and cell
26. Hypotony to look for cyclodialysis cleft
Miscellaneous
27. prior non-penetrating glaucoma surgery
28. Preoperative cataract or glaucoma surgery to look for PAS
29. Following laser peripheral iridotomy or iridoplasty
30. After addition of pilocarpine
31. Post trabeculectomy or nonpenetrating glaucoma surgery
32. IOP rise greater than 6 mm Hg post dilation
(from Gonioscopy, Duane’s Clinical Ophthalmology, Fellman RL, Spaeth GL,:Vol.
3, Chap 44, 2005, eds. Tasman, Jaeger, Lippincott, Philadelphia, PA
Essential optics of gonioscopy: from

Gonioscopy, Fellman and Spaeth, Duane’s Clinical Ophthalmology, chapter 44, vol
3, 2005, Harper and Row, eds Tasman and Jaeger
Total internal reflection of light rays explains

the inability to naturally see the chamber
angle. When the critical angle is exceeded, the
light rays are reflected back in to the anterior
chamber.
A gonioprism changes the index of refraction at
the cornea creating a new boundary that allows
the light from the chamber angle to be seen
indirectly (Goldmann or Zeiss) by the examiner
or directly (with a Koeppe type lens).
Critical angle = 46.5º
Can Gonioscopy be Replaced?
Angle closure glaucoma (ACG) accounts for approximately a quarter of all cases
of glaucoma worldwide. However the number of patients blind with ACG is nearly equal
to those with open angle glaucoma. There are large variations in the prevalence of ACG
across the world, with over 80% of these in Asia, largely China and India.1
In a large proportion of these patients the disease is silent and chronic, with no
attacks of acute glaucoma. Proper detection and prophylactic treatment can potentially
help prevent ACG. Identifying persons at risk for acute angle closure attacks, as well as
those prone to develop more chronic forms of angle closure is a challenge.
Gonioscopy remains the gold standard for diagnosis of angle closure.
Unfortunately, gonioscopy is not an integral part of the clinical exam in many established
clinical practices, more so in developing countries2, where large pockets of patients with
ACG exist. Gonioscopy relies on subjective assessment of the anterior chamber angle
findings in real time and is difficult to master3.
Newer technologies are currently available that can potentially improve our
ability to assess and monitor the anterior chamber angle. These include Ultrasound
biomicroscopy (UBM) and anterior segment optical coherence tomography (AS-OCT),
among others. The problem with many imaging devices such as anterior segment OCT
is finding the scleral spur. The spur is easy to see with gonioscopy, but difficult with
imaging. These imaging devices will continue to improve, but for now, the gonioprism
remains the gold standard to see the variable configuration of the angle. However, UBM
is excellent for imaging posterior to the iris, the ciliary body and suprachoridal space
behind the ciliary body. These areas are difficult to see with gonioscopy.
Quigley HA, Broman AT. The number of people with glaucoma worldwide in 2010 and 2020. Br J
Ophthalmol 2006:90:262-267.
2
Thomas R, Muliyil J, George R. Glaucoma in southern India[letter]. Ophthalmology 2001;108:1173-1175.
3
Friedman DS, He M. Anterior chamber angle assessment techniques. Surv Ophthalmol 2008;53:250-273.
The Anterior Chamber Angle:

How to Examine, Grade and Treat:
Spaeth Classification System
George L. Spaeth, M.D.

Louis J. Esposito Research Professor
Director, Glaucoma Service
Wills Eye Hospital/Jefferson Medical College
How to Best grade the

anterior chamber angle
Aspects needing for grading:
• Configuration
• Character
Gonioscopy
Conceptual Advances
• 1900 Trantas Greece View Structure

• 1913 Salzmann Austria Direct Contact Lens
• 1936 Thorburn Sweden Open-Closed Angles
photography
• 1939 Goldmann Switzerland Indirect Contact Lens
• 1941 Gradle United States Quantitation
Shaffer – angularity of approach

Zeiss 4-mirror Gonioprism
Configuration: 3 aspects
• Iris attachment
• Angular approach
• Iris curvature
The iris has a

variable attachment
to the inner wall of
the eye
Iris attaches at
scleral spur
Iris Attachment
• Related to age, race disease
– Age – moves posteriorly
– Race – Yellow, Black, White
– Diseases – PAA present?
Cyclodialysis?
Configuration: Angularity
• Estimate in 5 degree increments

• Related to anterior chamber
depth – usually
• Decreases with age (after age 2)
• Less than ten degrees a concern
f for flat iris Curvature

• Usually healthy
• Not necessarily healthy
– Neovascular closure
– Recession
b = Anterior Bowing
• Grade 1 – 4+
• 4+ = severe iris bombé always
pathological
• Related to pupillary block
c = Posterior Curving
• Seen in myopes, posterior bow
• Seen in aphakes and dislocated lens
• Seen in pigment dispersion syndrome
(? More than myopes)
p = Plateau
• Sudden anterior curve: a bend not a
“bowing”
• Not related to angularity
bows concave
nd
y bo dy ba
ciliar
flat plateau
Peripheral iris configuration: b, c, f, p
Optically closed
indent
Appositional
closure
Synechial
closure
What do you do if you

can’t see the
meshwork?
Preindentation
gonioscopy
(A)D40p3+ptm
View with
indentation
gonioscopy
Pigmentation
1. Where?
2. How much?
3. What color?
Pigmentation – Where?
• In PTM – pigment dispersion
syndrome
• On PTM – exfoliation syndrome
• Anterior to Schwalbe’s – exfoliation
syndrome
• On Schwalbe’s - routine
Pigmentation – Where?
• 12 o’clock normally not less than 6
o’clock
• 12 o’clock less than 6 o’clock
– Brown iris
– Trauma
– Exfoliation syndrome
Pigmentation – How Much?

• Grade 0-4+
• 3+ or 4+ usually pathologic
• Pigment dispersion syndrome
• Exfoliation syndrome
• Trauma
Pigmentation – Color?
• Brown – usual
• Black –
– Exfoliation syndrome
– Megalocornea
– Radiation
– Sometimes with pigment dispersion
syndrome
Grading Angle Summary

• 3 aspects regarding configuration
– Iris insertion (A-E)
– Geometric angle in degrees (0-40)
– Curvature (f, b, c, p)
• 3 aspects regarding pigmentation
– Where
– How much
– What color
• Then clinical conclusion
Routine Exam
• Identify a clear-cut landmark: scleral spur
or PTM
• Name iris insertion (A-E), geometric
angularity (0-40°) and iris configuration
(f,b,c,p)
• Grade pigment 6 & 12 and note color
• Make clinical conclusion
Routine Exam
• 6 & 12 o’clock (6 > 12)
• If folds – NO!
• 1 minute at most
Grading Angle
• Must move lens – helps to have eye
move
• Must see clearly
• Use low power
• Firm, then gentle, indent when
necessary
Notation
• Iris insertion
– (parenthesis if not real insertion)
• Angularity
• Curvature
• PTM
• Draw circle if not the same 360º
Additional information regarding classification systems

George L. Spaeth, MD
I. Previous classification systems of the anterior chamber angle
a. Penlight:
i. Iris bowing casts a shadow across the iris
b. Van Herick – proposed system comparing peripheral anterior chamber.
(PAC) depth to corneal thickness (CT)
i. Grade 4: PAC > CT
ii. Grade 3: PAC = ¼ to ½ CT
iii. Grade 2: PAC = ¼ CT
iv. Grade 1: PAC < ¼ CT
c. Scheie (1957) – proposed system based on the extent of the anterior
chamber structures which could be visualized
i. Wide Open: all structures visible
ii. Grade 1: hard to see over iris root
iii. Grade 2: ciliary body obscured
iv. Grade 3: posterior trabecular obscured
v. Grade 4: only Schwalbe’s line visible
d. Shaffer (1960) – proposed a system using the angular width of the angle
recess at the trabecular meshwork
i. Wide open Grade 3 to 4, 30° to 45°, closure improbable
ii. Moderately narrow Grade 2, closure possible, 20°
iii. Extremely narrow, Grade 1, 10°, closure probable
iv. Partly or totally closed, Grade 0, closure present.
e. Becker (1972) – proposed combining an estimation of anterior chamber
angle width and the height of iris insertion
f. Spaeth (1977) – proposed a system that does not rely on any single
denominator, but one of at least three variables
i. The point where the iris attaches (iris insertion)
ii. Configuration of the peripheral iris curvature
iii. The angular approach of the iris to the iris recess at 1/3 distance
from angle
1. also noted are:
a. presence or absence of iris processes
b. pigmentation of posterior trabecular meshwork
c. presence of PAS
d. degree of iris bowing
e. pigment puddling in inferior angle
f. irregularity of pigmentation
SYSTEM SYSTEM BASIS ANGLE STRUCTURES CLASSIFICATION
Scheie Extent of angle all structures seen Wide open

1957 structures iris root not seen Grade I narrow
visualized ciliary body band not seen Grade II narrow
posterior trabeculum obscured Grade III narrow
only Schwalbe’s line visible Grade IV narrow
Shaffer Angular width of wide open (30° -45°) Grade 3-4, closure improbable
1960 the recess moderately narrow (20°) Grade 2 closure possible
extremely narrow (10°) Grade 1 closure probable
partly or totally closed Grade 0 closure present
Spaeth Three variables: 1. Level of iris insertion
1971 1.Angular Anterior to Schwalbe’s line
approach to the
A
recess Behind (posterior) to B
2. Configuration Schwalbe’s
of peripheral iris sCleral spur
C
3. Insertion of iris
root Deep into ciliary body band D
Extremely deep E
2. Angular approach to recess 0° - 40°
3. Peripheral iris configuration
flat approach f
bowing (forward bow, 1 to 4
plus) b
concave (post. bow, 1 to 4 c
plus)
p = plateau p
From Atlas of Glaucoma, Ed Choplin and Lundy, Chapter: Gonioscopy, Fellman

Grover
Grade this angle. Where does the iris insert? Angular approach? Peripheral
configuration? A40f Only a few circumstances present this picture, what comes
to mind? ICE, PPD, prior surgery, epithelial downgrowth, NVG.
Grade this angle. Where does the iris insert (A, B, C, D, E)? Angular approach? 40 º
Peripheral configuration f, c, b, p? f D40f3+ptm
D D40f2+ptm
Grade this angle.

1. Where does the iris insert?
2. What is the angular approach?
3. What is the peripheral configuration?
1. inserts? D
2. angular approach? 40º
3. configuration ? f
answer: D40f tr ptm

arrow= Blood vessels are normally visible in the
angle in 62% of individuals with blue eyes and 9%
What is this?
with brown eyes. These circular vessels are nestled
in the face of the ciliary body and do not cross the
scleral spur.
Grade this angle.

1. Where does the iris insert?
2. What is the angular approach?
3. What is the peripheral
configuration?
4. D
5. 40º
6. f
answer: D40f 1+ptm

Narrow angle seen through

a Goldmann lens,
indentation gonioscopy is
difficult because the contact
area of the lens is large, the
Zeiss contact is only 9 mm.
(A)C25b4+
Angle post PI has deepened and

is now a C40f
THE NORMAL ANGLE The

APPEARANCE AND VARIATIONS Normal
Angle
Mark
Mark Sherwood MD Sherwood MD
University of Florida
Gainesville
THE NORMAL ANGLE

• Wide Range of Variability in :
Ø Angle width
Ø Site of iris insertion
Ø Peripheral iris convexity
Ø Pigmentation
Ø Iris processes
Ø Vessels
• Helpful to examine many normals to recognize

angle pathology
IRREGULAR PERIPHERAL IRIS CONTOUR

NORMAL ANGLE
Iris Processes
• Branch and entwine on surface of CB
• Bridge angle recess – variable size and
color
• Usually insert at or near scleral spur
• Occasionally climb angle wall to
Schwalbe’s line
• Can be mistaken for PAS
ANTERIOR FINE BRANCHED PROCESSES
MORE POSTERIOR BRANCHED IRIS PROCESSES

NORMAL ANGLE
Ciliary Body
• Iris root inserts on the CB in most eyes
• Portion of CB visible on gonioscopy is from the

iris root to scleral spur
• This CB is covered by reflected iris stroma
which may be condensed into bands – iris
processes
• CB & iris processes gray – white in light irides

–
pigmented in eyes with darker irides
NORMAL ANGLE
Scleral Spur
• White to yellowish line anterior to CB

• Internal projection of the sclera
• Schlemm’s canal lies just anterior to it
• Schlemm’s canal usually a grayish line
but occasionally may contain blood
NORMAL ANGLE
Trabecular Meshwork
• Roughened appearance due to pores on

surface
• Semitransparent white / grey in youth

• Pigmentation common with age ( and
pathology)
NORMAL ANGLE
Schwalbe’s Line
• Most anterior angle structure identifiable

• Peripheral termination of Decemet’s membrane
• Condensation of collagen fibers
• Change from corneal to scleral curvature
• Pigment granule accumulation especially inferiorly
CORNEAL WEDGE
POINTS TO
SCHWALBE’S LINE
From Alward WLM, Color Atlas of Gonioscopy

NORMAL ANGLE
Angle Recess
• Not present in newborn

• Hollowing out of CB first year
• Defined by iris insertion
• Circumferential & radial vessels may be seen

NORMAL ANGLE
Angle Width
• Related to:
Ø Age
Ø Refractive Error
Ø Inheritance
Ø Corneal curvature
• Narrowest superiorly; widest inferiorly
• Angle width 10 deg. or less in 6% (elderly)
SUPERIOR
ANGLE
SHALLOWER
INFERIOR ANGLE
DEEPER
NORMAL ANGLE
Variability - Factors
• Age
• Race
• Inheritance
• Iris color
• Sex
ANGLE CHANGES WITH

INCREASING AGE
• Iris insertion anterior in young, esp. blacks
• Variability of iris insertion common in
Caucasian children (54% in brown eyed) –
less common later (10% overall)
• ‘Translucent membrane’ covering the
depth of angle recess in 100% newborn;
perforated membrane 25% of 10-15 yrs;
membrane not seen over age 52.
ANGLE CHANGES WITH

INCREASING AGE
• Initial widening and later (after 30) narrowing
of angle approach
• More frequent “s” type angulation of
peripheral iris
• Decreased # of iris processes
• Increased pigmentation of PTM & scattered
inferior pigment
ANGLE VARIABILITY
(Ref: Francois J 1948)
< 30 yrs 30-50 yrs > 50 yrs
Angle Approach
Wide 38 34 16
Medium 57 52 52
Narrow 4 13 31
PTM pigment 0 0 19
ANGLE DIFFERENCES WITH IRIS

COLOR
• Iris processes more common in brown
eyes
(visible in 78% versus 17%)
• Iris insertion possibly more anterior in

brown eyes
ANGLE VARIABILITY
Iris Processes – Relation to Iris Color
% Eyes (Caucasian)
90
80
83
70
60
50 None
53 Few
40
30 39 39 Many
33
20
22
10 15
11 6
0
Blue Hazel Brown
Iris Color
Ref: Spaeth GL 1971
ANGLE DIFFERENCES
WITH RACE
• Schaffer grade 2 or less:
Caucasians (>55 yrs) – 3.8%
Eskimos (> 40 yrs) – 61.1%
• Anterior iris insertion:
Asians > Blacks > Caucasians
• Angle width:
Asians / Blacks / Caucasians – no
significant difference
ANGLE DIFFERENCES
WITH GENDER
Women
• Shallower anterior chambers
• Narrower angles generally
• Higher frequency of narrow angle
• PACG 2 to 4 times more common
(Caucasians / Black / Eskimos / Chinese)
ANGLE DIFFERENCES WITH

REFRACTIVE ERROR
Hypermetropia
• Increased incidence of iris convexity

( 85% versus 13% in > 50 yr olds)
• Iris root shorter & thicker; inserted more

anteriorly
ANGLE VARIABILITY
Refractive Error (Age > 50 yrs)
Iris Configuration ( % eyes)
90
80 85
70
60
50 54 Convex
40 46 41 46 Flat
30 Concave
20
10 13 15
0 3 0
Myope (> 5D) Emmetrope Hypermetrope
(> 4D)
Refractive Error
Ref: Busacca A 1964
ANGLE AND INHERITANCE

First Degree Relatives PACG Patients
• Peripheral anterior convexity of iris more

common
• Anterior iris insertion more common
• No increased frequency of narrow approach
COMPARATIVE ANGLE FINDINGS

PACG PACG Control
Relative
Anterior Iris Insertion (%) 38 18 10
Narrow Approach (%) 54 6 6
Peripheral Anterior 69 33 6
Convexity(%)
Ref: Spaeth GL 1978

Identify the six basic landmarks of the chamber

angle.
Gonioscopy in a Busy Clinical Practice

Thomas W. Samuelson, M.D.
I. Introduction:
In an ideal world gonioscopy should be performed on all patients able to cooperate

with the test. You simply cannot be confident of the anatomy of the anterior segment
without gonioscopy. Gonioscopy is helpful for several reasons:
• Unexpected Narrow Angle

o Example: plateau configuration
• Mechanism of Elevated IOP
• Glaucoma Treatment Plan
• Potential Predictive Value for Trabeculoplasty
• R/O Posterior Bow patients with PDS
It is essential to identify chronic angle closure glaucoma, a diagnosis that is more

common than acute angle closure in African Americans, and is especially common in
the Southeast Asian population.
• Angle closure glaucoma is far more likely to cause bilateral blindness than is
POAG
Harry Quigley, M.D.
AAO Annual Meeting
November 13, 2001
II. Obstacles to Gonioscopy

• Perception
• Technique
• Equipment
• Poor Planning
Perception: “Gonioscopy is difficult and time consuming”
Reality: Gonioscopy is easily learned and can be performed in less
than a minute
Technique / Equipment: Gonioscopy with the 4 mirror lens is dynamic, fast,

accurate, and convenient for physician and patient. It is far superior to other
techniques that require a coupling agent. Additionally, many such lenses do not
allow for pressure gonioscopy which is essential in determining whether an angle is
apposition or closed.
Poor Planning: Quite often in a busy clinic, patients have are dilated prior to seeing
the physician. Post dilation gonioscopy, while helpful, is not a substitute for pre
dilation gonioscopy. With proper planning and instruction, a protocol can be devised
that will help continue the efficiencies of pre-dilation for select patients while
postponing dilation for those patients in need of gonioscopy.
New Patients: Standard dilating orders – options:
1. Dilate all new patients

a. This is a poor strategy and should be avoided.
2. Dilate select new patients
Educate Technician / Assistant
• Narrow by Von Herrick
• Known Glaucoma / Suspect
• Elevated IOP
• Pigment Dispersion Syndrome
• Hyperopia
• Retinal Vascular Occlusion
• Hx of PDR or PPDR
• Hx of Significant Ocular Trauma
• Exfoliation
3. Dilate no new patients

Most appropriate for Glaucoma Practice:
-All new patients receive gonio before dilation
Return Patient
• Common RTC Orders:
o Va Ta Dilate
• Consider
o Va Ta Gonio
• In many patients gonioscopy will provide better yield than peripheral fundus
exam.
o Example: Hyperope
§ Especially Asian Heritage
Asian Heritage / Angle Closure OAG : ACG

II. Other Practice Efficiencies:
Consider Scribe
• Very Efficient
• Better Documentation
• Gonio Even Easier
o Example:
(A)D15b Superiorly; Focal PAS @ 12:00
(B)D20b Inferiorly
3+ Pigment PTM
Example of Scribe Documentation
• A & O, calm *
• Ext normal
• LLP clear
• C & S Quiet
• Cornea Clear
• D&Q
• Iris Normal: No TID (Transillumination Defects)
• Lens 2+ NS
• (-) KS, TID, EXF
• Mild Macular
RPE changes
• Flat to periphery
• Etc, etc, etc…
What about Disc Drawings??

• Describing C/D Ratio is ineffective
• Example: Consider C/D of .7
Disc: Describe Rim of same disc with C/D of .7
OD OS
Superior 0.15 0.3
Nasal 0.2 0.15
Inferior 0.15 Notch
Drawing _____ _____

Gonioscopy Documentation:
Description Method Is Cumbersome (Example):
“I see peripheral cornea only, the iris is moderately bowed forward, and the approach is
quite narrow. However, when I push with the goniolens, I can see ciliary body. There
are no PAS and light angle pigment.”
Description using Scribe with Spaeth Classification:
(A)D15b3+, 0 PAS, 1+ PTM (pupil block, narrow angle mechanism)
“I see peripheral cornea only, the iris is moderately bowed forward, and the approach is
moderately deep. However, when I push with the goniolens, I can see ciliary body.
There are no PAS and light angle pigment.”
Description using Scribe with Spaeth Classification:
(A)D30p, 0 PAS< 1+ PTM (plateau iris)
Pathology of the Anterior Chamber Angle
Steven T. Simmons, M.D.
I. Pigmentary Dispersion Syndrome & Pigmentary Glaucoma

a. Pigment dispersion from iris pigmented epithelium
b. Densely pigmented trabecular meshwork
c. Pigment deposits on lens, corneal endothelium and iris
d. Angle appearance
i. Homogenous densely pigmented trabecular meshwork
ii. Mid peripheral concave configuration of iris (q)
iii. Speckled ring of pigment at or anterior to Schwalbe’s line
iv. Pigment on lens zonules, anterior iris stroma, lens capsule
II. Exfoliation Syndrome
a. Whitish-gray deposits on lens, iris, zonular fibers, ciliary body, anterior
chamber angle
b. Angle appearance
i. Increased non-homogenous pigmentation of trabecular meshwork
ii. Inferior > superior pigmentation
iii. Asymmetry between eyes in TM pigmentation
iv. 91% > 2 + PTM @ 12:00 vs. 12% normal and 26% POAG
v. Sampaolesi line – wavy pigmented line anterior to Schwalbe’s line
vi. Propensity toward narrow angle – 30% in PXF vs. 4% in N1
III. Uveitis
a. Peripheral anterior synechiae
i. Adhesions between iris and trabecular meshwork caused by
1. swelling of peripheral iris (choroidal)
2. protein transudation, exudation
3. bridging of angle by keratic precipitates
ii. angle appearance
1. peripheral anterior synechiae
a. not uniform in shape, height – often alternating with
open areas of the angle
b. greatest inferiorly
2. various degrees of TM pigmentation
3. blood in Schlemm’s canal
IV. Fuch’s Heterochromic Iridocyclitis
a. Angle appearance
i. Iris heterochromia, atrophy
ii. Multiple fine blood vessels which cross over TM in radial,
concentric patterns not associated with PAS
iii. Few synechiae
iv. Keratic precipitates
v. Filiform hemorrhage
V. Neovascularization
a. Angle appearance:
i. Tufts at papillary margin, meander over iris surface, cross scleral
spur and TM
ii. Arborize over trabecular meshwork
iii. Best seen under high magnification, bright light with no
indentation
iv. PAS with contraction of fibrovascular membrane – STOP at
Schwalbe’s line
v. Ectropion uveae
VI. Iridocorneal Endothelial Syndrome (ICE)
a. Progressive (essential) iris atrophy, Chandler’s syndrome, Cogan-Reese
syndrome (iris nevus)
b. Unilateral condition
c. High peripheral anterior synechiae which extend anterior to Schwalbe’s
line.
d. Iris holes, corectopia, ectropion uveae
VII. Megalocornea
a. Corneal enlargement (14.0-16.0 mm)
b. No tears in Descemet’s membrane
c. Iridodonesis
d. Angle appearance
i. Normal
ii. Prominent iris processes, minimal angle recess
iii. Broad, densely pigmented trabecular meshwork
iv. Pigment dusting on anterior surface of iris
VIII. Axenfeld-Rieger Syndrome
a. Angle appearance
i. Prominent, anteriorly displaced Schwalbe’s line (posterior
embryotoxon)
ii. Iridocorneal adhesions
1. broad to threadlike in nature
2. anterior to Schwalbe’s line
iii. obscured scleral spur, TM
iv. iris stromal thinning to actual hole formation, corectopia, ectropion
uveae
IX. Angle Tumors
a. Iris pigment cyst
b. Melanoma
c. Ciliary body, iris
d. Epithelial inclusion cysts
X. Trauma
a. Iridodialysis
i. Tear in peripheral iris
ii. Ciliary processes seen through injury
b. Angle Recession (Cleavage)

i. Tear in ciliary body between longitudinal and circular fibers
ii. 70-100% have associated hyphema
iii. injury often involves a tear in the trabecular meshwork
iv. angle appearance
1. deepened angle recess with atrophy of circular fibers
2. torn or absent iris processes
3. whitening or increased visibility of scleral spur
4. localized depression in trabecular meshwork
5. irregular pigmentation of meshwork, pigment dusting
6. PAS at edge of recession
c. Cyclodialysis
i. Separation of ciliary body from its insertion into scleral spur
ii. Angle appearance
1. irregular pigmentation overlying cyclodialysis
2. torn, absent iris processes
iii. when surgically performed also look for torn Descemet’s
membrane
XI. Surgical Trauma
a. Filtration site
i. Location
ii. Blockage by blood, vitreous, lens remnants, ciliary processes
b. Cataract extraction
i. Vitreous, iris to wound
ii. Torn Descemet’s membrane
iii. Capsular remnants
c. Intraocular lens location
d. Location of cyclodestructive procedures
XII. Sturge-Weber Syndrome
a. Angle appearance
i. Poorly developed scleral spur
ii. Anterior iris insertion
iii. Incomplete angle cleavage
iv. Reflux blood Schlemm’s canal
XIII. Aniridia
a. Angle appearance
i. Small rudimentary iris stump
ii. Progressive angle closure over first 2 decades of life
Technique of Zeiss Compression Gonioscopy Ronald L Fellman MD
The Zeiss, or equivalent, four-mirror gonioprism is constructed with glass and is

a very durable instrument attached to the metal Unger handle. The lens has a contact
surface of 9 mm and a 7.85 mm radius of curvature. The Zeiss lens does not require a
viscous solution, only a capillary tear film bridge, and therefore does not interfere with
further exam.
After instillation of a topical anesthetic, the lens should be applied to the eye
oriented in a square configuration, not the diamond shape. To accomplish this for the left
hand, the thumb should be placed on the bottom flat side of the handle along the
serrations and the second and third fingers on the top curved side. When the lens is held
in the right hand, the thumb is positioned on the bottom curved side and the second and
third fingers on the top flat serrated side. With the handle at a 45º angle to the eye and
the prism in the square configuration, the elbow should rest on the slit lamp stand. While
holding the prism in the aforementioned position, momentarily look away from the slit
lamp and position the prism directly in front of the patient’s eye. To aid in
proprioception, the little finger should rest on the vertical headrest bar, which facilitates
stabilizing the alignment and allows for kinesthetic realignment as you look through the
microscope. Gently touch the lid and while looking through the microscope, apply a
gentle forward rocking motion with the gonioprism to push the upper lid away.
Simultaneously, barely touch the cornea until the pre-corneal capillary tear film is evenly
disbursed. Adjust the slit lamp microscope for fine focus and look through each one of
the mirrors to evaluate the chamber angle. If unable to see into the depths of the chamber
angle, have the patient look into the direction of the mirror being viewed.
The Challenge of the Narrow Angle
Additional skills and corneal indentation techniques are necessary to view the crowded or
narrow angle. Even with “routine” gonioscopy there are still unseen vital angle
structures. To adequately diagnose and treat the narrow-angled eye, the gonioscopist
must understand the relationship of the chamber angle to the viewing mirror and master
indentation gonioscopy.
Indentation gonioscopy consists of a temporary deepening of the chamber periphery due

to posterior displacement of aqueous by corneal indentation with the Zeiss lens. The goal
of the technique is to differentiate appositional from synechial angle closure. By using
the aforementioned techniques, the addition of indentation gonioscopy is a simple task.
This only needs to be carried out in eyes with narrow angles when you suspect angle
closure disease and is also helpful when looking for cyclodialysis clefts. With the
gonioprism in the normal position, apply enough force to gently indent the cornea. The
amount and force of corneal indentation will vary depending on the level of IOP,
shallowness of the chamber, and lens thickness. As the iris bows backwards, identify
landmarks and remember this is a dynamic process and can be repeated several times. If
the iris falls back for 360º and there are no synechiae noted, then optical closure exists
and one must decide on proper therapy. If synechiae are identified as the iris bows
backwards, then the diagnosis of angle closure disease has been made.
The most common method of viewing the chamber angle is indirect gonisocopy with the
Goldmann lens. This lens is excellent for initial learning of angle landmarks and for laser therapy of the
angle, but is cumbersome and time consuming for routine use on a busy >50 patient day. In addition,
patients are not pleased with the discomfort and blurred vision from the goniogel. Learn an efficient
rapid method of examining and grading the chamber angle.
Palmberg P, Gonioscopy. In Ritch R, Shields MB, Krupin T, eds, The Glaucomas,

Second edition (Mosby, 1996) 457.
Campbell DG, A comparison of diagnostic techniques in angle-closure glaucoma, Am J
Ophthalmol (1979) 88:197-204.
Sugar HS, Concerning the chamber angle, Am J Ophthalmol (1940) 23: 853-866).
Fellman RL, Spaeth GL, Starita RJ, Gonioscopy: Key to Successful management of
Glaucoma, Focal Points 1984: Clinical Modules for Ophthalmologists, American
Academy of Ophthalmology, San Francisco, Ca.
Scheie H, Width and pigmentation of the angle of the anterior chamber. A system of
Grading by gonioscopy, Arch Ophthalmol (1957) 58:510-512.
Shaffer, RN, Gonioscopy, ophthalmoscopy and perimetry, Trans Am Acad Ophthalmol
Otolaryngol (1960) 64: 112-115.
Spaeth GL< The normal development of the human anterior chamber angel: A new
System of descriptive grading, Trans Opthalmol Soc UK (1971) 91:709-739.
Forbes M, Gonioscopy with corneal indentation. A method for distinguishing between
Appositional closure and synechial closure Arch Opthalmol (1966) 76: 488-492).
Lichter PR, Iris processes in 340 eyes, Am J Ophthalmol (1969) 68: 872-878.
Henkind P, Angle vessels in normal eyes. A gonioscopic evaluation and anatomic
Correlation, Br J Ophthalmol (!964) 48: 441-447.
Fellman RL, Spaeth GL. Gonioscopy, Duane’s Clinical Ophthalmology, :Vol. 3, Chap
44, 2005, eds. Tasman, Jaeger, Lippincott, Philadelphia, PA
Fellman RL. Gonioscopy. Atlas of Glaucoma, eds, Choplin N, Gundy D. in press

Slide 1
The Anterior Chamber:
How to Examine, Grade, and
Treat
Acute Angle Closure
Ronald L. Gross, M.D.

Chair of Ophthalmology
West Virginia University
Morgantown, West Virginia
Slide 2
Financial Disclosure
I have the following financial interests or relationships to
disclose:
§ Alcon
§ Allergan
§ Merck
§ Pfizer
§ Ista
§ Lumenis
§ Alacrity Biosciences
§ Glaucos
Slide 3
Acute Angle Closure
Definition
• Marked increase in IOP
• Significant concomitant symptoms
• Gonioscopic closure of angle
• One of the few true ocular emergencies
• Potentially blinding condition
• Early treatment better outcome
• Prevention of an attack is the goal
Slide 4
Acute Angle Closure
Classification
• Primary: No identifiable etiology
– Elderly
– Hyperopic
– Pupillary Block mechanism
– Treatment: PI
• Secondary: Specific underlying cause
– Neovascular, Inflammatory, Ciliary body rotation
– Often not pupillary block mechanism
– Treat the underlying abnormality, PI may not help
Slide 5
Acute Angle Closure
Primary
Pupillary Block:
• Obstruction of aqueous flow through the pupil
• Increased posterior chamber pressure
• Forward bowing of the peripheral iris
• Trabecular Meshwork covered
• Forms:
– Acute
– Sub-acute
– Chronic
Slide 6
Acute Angle Closure
Primary
Plateau Iris
• Rare
• Flat Anterior Iris Plane
• Anatomical cause: Ciliary Body
• Often Diagnosed only after PI rules out PAC
Combined Mechanism
• Follows PAC attack where open angle is
present, but IOP elevated
Slide 7
Primary Acute Angle Closure
Patients at Risk
• Age: increasing
– Increase in anterior-posterior lens
– Looser zonules
• Race:
– Whites: Acute
– Blacks: Chronic
– Asian: depends
– Eskimos
• Gender: female
• Refractive Error: hyperopic
• Family History: 20% of family members of attack
patients have occludable angles
Slide 8
Primary Acute Angle Closure
Examination
Identify Those at Risk
• IOP normal unless current or previous attack
• Slit lamp: small anterior segment, AC more
shallow in the periphery than centrally
• Gonioscopy
– Look superiorly first
– Compression Gonioscopy
• Apposition vs. PAS
• Provocative testing
Slide 9
Acute Angle Closure
• Precipitating Factors
– Dim illumination
– Illness
– Emotional stress
– Drugs
• Anticholinergics
• Adrenergics
– Topomirate
(Topomax)
Slide 10
Acute Angle Closure
Examination
During an Acute Attack
• History
– Classic symptoms: “rainbow colored haloes”
– May be only one
• Red eye
• Nausea & vomiting
• Headache
• Pain
• Blurred vision
Slide 11
Acute Angle Closure
Examination
• External & Slit Lamp
– Conjunctival Injection and hyperemia
– Corneal clouding- epithelial and stromal edema
– Shallow AC- peripheral > central
– May need to clear cornea
with glycerine to rule out
secondary causes
– Mid-dilated pupil
Slide 12
Slide 13
Acute Angle Closure
Examination
• Gonioscopy
– Compression (Indentation)
• Diagnostic: Apposition vs. PAS
• Therapeutic
– Rule out secondary causes
– Fellow Eye- don’t forget
Slide 14
Acute Angle Closure
Examination
• Fundus
– Optic Nerve: initially edematous, later pallor
with cupping if chronic IOP elevation
– Nerve Fiber Layer Defects
– Vascular Occlusion
• Visual Fields: nonspecific constriction
Slide 15
Acute Angle Closure

Treatment
• Reduce the elevated IOP
– Medications
– Compression Gonioscopy
– Laser Iridotomy
• Relieve the angle closure
– The attack is not broken until the TM is seen on
gonioscopy
Slide 16
Slide 17
Acute Angle Closure
Medical Treatment
• Miotics – reduce the size of the pupil
• Antiglaucoma medications
– Beta-blocker
– Carbonic anhydrse inhibitors
– Alpha agonist
– Hyperosmotics
Slide 18
Acute Angle Closure
Surgical Treatment
• Peripheral iridotomy
– Laser
– Surgical
• Lens extraction
• Trabeculectomy
Slide 19
Occludable Angle
DO AN IRIDOTOMY
• Superior angle not visible
• Schaeffer: Grade I or 0
• Spaeth: A-B 20 S
• Superior angle visible with indentation and
few PAS present
• If you think they need a PI
Slide 20
Iridotomy
Contraindications:
• Corneal edema
• Flat anterior chamber
• Completely sealed angle
• Secondary angle closure
• Uncooperative patient
Slide 21
Iridotomy
Set-up: Argon and Nd:YAG Lasers

• Topical anesthetic
• Miotic
• Alpha agonist
• Contact lens
Slide 22
Iridotomy
Abraham Lens:
• Holds lids apart
• Gonioscopy solution acts as heat sink
• Anti-reflective coating
• 66 diopter plano convex button
* greater magnification
* narrow beam width: 1/2
* increase power density: 4
Slide 23
Iridotomy
Site:
• Crypt or fold
• Peripheral 1/3rd of iris
• Superior covered by lid
• ?? Avoid 12 o’clock or
temporal areas
• Avoid blood vessels
Slide 24
Iridotomy
Argon Technique: Settings

• 50 Microns
• 0.1 seconds
• 600 – 1200 mWatts
• 50 – 100 spots
Slide 25
Iridotomy
Argon Settings: Modification

• Pale blue iris
– Increase power
– Increase duration
• Dark brown iris
– Increase power
– Decrease duration
Slide 26
Iridotomy
Argon Technique:Modification
• Contraction burns Contraction
with
• Stretch burns penetrating
burn
• Penetrating burns
Stretch
• Preparation for Nd:YAG burn
Slide 27
Iridotomy
Nd:YAG laser: Settings
• Contact lens
• 3 burst per shot
• Offset- posterior
• 2-6 MJ
Slide 28
Iridotomy
End Point
• Anterior lens capsule visualized
• Excessive Debris
• Ineffective Application
• Corneal Burn
Slide 29
Iridotomy
Laser Comparison: Advantages

• Nd:YAG:
– Fewer Applications
– Independent of iris color
• Argon
– Little risk of hemorrhage
– Larger PI
Slide 30
Iridotomy
Laser Comparison: Disadvantages

• Nd:YAG:
– Possible hemorrhage
– Smaller PI
• Argon
– More applications and debris
– Difficult in light blue or dark brown iris
Slide 31
Iridotomy
Postoperative Care:
• Steroids
• Glaucoma medications
• Slit lamp evaluation
• Gonioscopy evaluation
• Dilate patient at 1 week post op visit
to break any adhesions formed by
inflammation
Slide 32
Iridotomy
Success: Peripheral Iridotomy
• Angle open on gonioscopy
• Anterior lens capsule visualized
• Dilation does not cause an increase in IOP
Slide 33
Bombe Iris
Slide 34
Iridotomy
Complications: Increase in IOP

• Greater than 10 mmHg (30-35%)
• Risk in patients with advanced optic nerve
damage
• Can be prevented with pretreatment
• Monitor for one hour after procedure
Slide 35
Iridotomy
Complications:
• Blurred vision
• Pupil abnormalities
• Diplopia and glare
• Corneal damage
• Anterior uveitis
Slide 36
Iridotomy
Complications:
• Posterior synechiae
• Hemorrhage
• Lens opacity
• Closure
• Retinal damage
Slide 37
Narrow Angle
Do a PI
– Intermittent symptoms of angle closure
– Gonioscopically no angle is visible, but with
indentation it opens
– PAS noted superiorly in a narrow angle patient
– If you think about doing it!!!
• Avoid antihistamines
• Diabetes or retinal disease
• Lifestyle
• Personality
The effects of iridotomy size and position on

symptoms following laser peripheral iridotomy.
Spaeth GL, et al., J Gl, Oct 2005
• 7/172 eyes developed disturbing symptoms or

4% with troubling complaints.
• prior to LPI, inform the patient about

postoperative ghost image or visual disturbances
(similar problem to photic phenomena post IOL)
26 % 18 %
9%
Indications for Peripheral Iridotomy

assume pupil block; Optical closure = inability to see anterior trabecular meshwork (iris bowing)
1. Narrow angle, no optical closure, (mild to moderate iris bow), can see all angle
structures 360º, no PAS, and no other worrisome factors….Observe with yearly
gonioscopy
2. Narrow angle, several clock hours of optical closure, (unable or barely able to see
anterior trabecular meshwork for several clock hours), and indentation gonioscopy
reveals no PAS. Options: Observe if no worrisome factors or Iridotomy earlier in
patients at higher risk for angle closure: (Reasons for LPI in absence of PAS)
a. On medications that alter autonomic nervous system (anticholinergics,
parasympathomimetic, sympathomimetics, etc.)
i. Psychiatric medications
ii. Parkinsons disease medications
iii. Peptic ulcer medications
iv. Sleeping medications
v. antihistamines
vi. opiates
vii. understand Topamax signs and symptoms (not pupil block)
b. worrisome family history:
i. sibling with angle closure disease
ii. mother or father with angle closure disease
iii. ethnicity (Eskimo/Inuit, Asian descent, Indian)
iv. family history of glaucoma (type unknown)
c. worrisome patient symptoms
i. rainbows
ii. headache
iii. blurred vision
iv. history of migraines, patient anxiety of problem
d. worrisome patient signs
i.
positive van Herick, does not always correlate with gonioscopy!
ii.
hyperopia
iii.
elevated IOP
iv.
anything that increases pupil block
1. pseudoexfoliation (lax zonules with forward movement of lens and
block)
2. history of POAG on pilocarpine!
3. phacomorphic (mature lens) or microspherophakia
e. need for frequent dilation as in diabetic retinopathy
3. Narrow angle, optically or appositionally closed 360º with no angle structures
visible, volcano look, no PAS seen on indentation gonioscopy………Recommend
iridotomy in spite of no symptoms due to high likelihood of angle closure attack.
4. Narrow angle, optically closed, indentation reveals PAS (do not confuse with iris
processes)…………treat with peripheral iridotomy
5. Narrow angle, PAS without optical closure, high iris insertion
6. History of angle closure disease in fellow eye
7. Angle closure attack

8. Miscellaneous reasons: post surgical PI incomplete, pseudophakic pupil block, etc
Peripheral Iridoplasty.
Iridoplasty is effective in eyes with plateau iris post iridotomy

and in eyes requiring trabeculoplasty when it is difficult to see
the meshwork
o Pilocarpine, pupil miotic, topical anesthetic
o Alpha-agonist, 3 mirror Goldmann lens
o Treat either through periphery of contact lens or angle mirror
o 500 micron spot size
o Range .2 to .5 Watts
o lower energy levels for brown iris
o increase energy for lighter irides
o 0.5 seconds duration
o End point is contraction of peripheral iris
o Treat 360º, recheck angle with gonio
Gonioscopy Quiz
• What is the most important gonioscopic angle landmark?

The scleral spur. If you can’t identify the scleral spur and especially if
you are worried about type of glaucoma, consult a colleague.
• How to tell PAS vs Appositional Closure
Indentation gonioscopy differentiates between appositional and
synechial closure without angle distortion, by deepening the
chamber angle to reveal angle pathology, that otherwise goes unseen.
• Does a normal angle vessel cross the scleral spur?
No, only pathologic vessels cross the scleral spur
• What type of slit lamp illumination is best for gonioscopy?
Initially narrow beam, why? ( a broad beam is less desirable
especially if it enters and constricts the pupil; you can miss a narrow
angle)
• Does it matter if the room lights are on or off during gonioscopy?
Ambient light may constrict the pupil (also, if you are looking
seriously for flare and cell or pigment granules, the room lights must
be out)
• What structure should you avoid illuminating during gonioscopy?
Avoid the pupil initially for the pupil constricts and a narrow angle
may be missed
• If the patient has bilateral angle closure, think of?
Drug induced, an idiosyncratic reaction, usually caused by a sulfa
derivative, Topamax, Wellbutrin, etc., is a likely culprit
• Iris processes are more prominent in blue or brown eyes?
Don’t confuse with PAS, processes are seen more in brown irides
• Are normal angle vessels more common in blue or brown eyes?
more common in blue eyes (62% vs 9%)
• False, iris usually inserts into the ciliary body in Caucasians
Notes
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Update Your Anterior

Chamber Angle Skills: How to

Join the conversation #aao2015

© 2015 American Academy of Ophthalmology. All rights reserved.

American Academy of Ophthalmology 2015 Las Vegas, Nevada

Update Your Chamber Angle Skills: How to Best

Ronald L. Fellman, M.D.

Ronald Gross, M.D. Mark B. Sherwood, M.D.

Chamber Angle Quiz Answers on page 97

• What is the most important gonioscopic angle landmark?

• What is the best way to differentiate appositional from synechial

angle closure? (appositional = hidden but not closed)

• Does a normal angle vessel cross the scleral spur?

• What type of slit lamp illumination is best for gonioscopy?

• Does it matter if the room lights are on or off during gonioscopy?

• What structure should you avoid illuminating during gonioscopy?

• If the patient has bilateral angle closure, think of?

• Is iridoplasty useful for acute angle closure glaucoma?

• Iris processes are more prominent in blue or brown eyes?

• Are normal angle vessels more common in blue or brown eyes?

• Normally, especially in Caucasians, the iris root inserts onto the

Table of Contents page

REVIEW OF COURSE OBJECTIVES

Reduce blindness through the information gained from proficient

3. Accomplished gonioscopists, become proficient at gonioscopy, easily

differentiate normal from abnormal.

4. Integrate gonioscopy into your busy practice on a daily basis

5. Indentation Gonioscopy is a must!

6. Accurately record your findings, use a classification system

glaucoma along with follow-up gonioscopy

8. Gonioscopic driven treatment (PI, iridoplasty, trabeculoplasty)

10. Study www.gonioscopy.org

Update your Anterior Chamber

A recent study of initial office visits

Rethink and update chamber angle skills.

Upgrade our chamber angle skills

Upgrade anterior chamber skills

When we upgrade we develop Anterior

Definition of gonioscopy: The procedure whereby the examiner visualizes the

Table 1. Minimum Indications for Gonioscopy

Essential optics of gonioscopy: from

Total internal reflection of light rays explains

Can Gonioscopy be Replaced?

The Anterior Chamber Angle:

George L. Spaeth, M.D.

How to Best grade the

• 1900 Trantas Greece View Structure

Shaffer – angularity of approach

Zeiss 4-mirror Gonioprism

The iris has a

• Estimate in 5 degree increments

f for flat iris Curvature

What do you do if you

Pigmentation – How Much?

Grading Angle Summary

Additional information regarding classification systems

SYSTEM SYSTEM BASIS ANGLE STRUCTURES CLASSIFICATION

Scheie Extent of angle all structures seen Wide open

From Atlas of Glaucoma, Ed Choplin and Lundy, Chapter: Gonioscopy, Fellman

Drawing _ _