Gonioscopy Technique and Interpretation

Gonioscopy Technique
And Interpretation
Hira Nath Dahal

References
 Diagnosis and therapy of the glaucoma
 7th edition Becker-Shaffer’s
 Duane’s clinical ophthalmology CD ROM 2005
 Sheilds’ Text book of glaucoma 5th edition
 AAO 2005-2006 section 10 Glaucoma
Presentation layout
 Introduction
 Optics of gonioscopy
 Methods of gonioscopy
 Direct
 Indirect
 Interpretation
 Normal
 Abnormal
 Gonioscopy refers to the techniques used for
viewing the anterior chamber angle of the eye for
evaluation, management and classification of
normal and abnormal angle structures.
 Term was coined by Trantas, who in 1907
visualized the angle in an eye with keratoglobus by
indenting the limbus.
(Gonio:Angle, Scopy: Examination)
 Salzmann in 1944 determined visualization of
anterior chamber angles is impossible without
special optical instrument due to total internal
reflection and design his own lens
 Troncoso ,Koeppe, Goldmann modified

gonioscopic technique
Snell’s Law
Total internal reflection

Indication
 Suspected angle-closure disease
 Any sign of angle-closure disease
(glaucomflecken, iritis, iris atrophy)
 Family member with angle-closure disease
 Positive van Herick
 History of any type of glaucoma, field loss, or disc
damage
 Elevated IOP
 Pigment dispersion syndrome
 Ocular blunt trauma or history of foreign body
 Pseudoexfoliation syndrome
 Retinal vascular occlusion
 History of ocular tumor
 Unexplained hypotony to look for a cyclodialysis
cleft
CONTRAINDICATIONS
 Patients with known recurrent corneal erosion
 Patients with corneal abrasions
 Patients with keratopathy (i.e., bullous, band,

punctate, etc.)
 Perforating eye injuries

Gonioscopic method
 Indirect method
 Goldmann lens--- surface is slightly larger than the cornea
and that require gonioscopic gel
 Zeiss four mirror lens---surface is smaller than the cornea and
that use the patient’s tear film as a coupling agent
 Posner four mirror, Sussmann four mirror, Thorpe four
mirror
 Direct method
 Koeppe lens--- surface is quite large ,that use saline as a
coupling agent ,and the patient should be in supine
 Swan Jacob, Barkan, Richardson-Shaffer
Direct gonioscopy
 The Koeppe lens is an example
of a direct goniolens.
 It is placed directly on the cornea
along with lubricating fluid, to
avoid damaging its surface.
 The index of refraction of a
Koeppe lens is approximately 1.4,
almost exactly that of the
cornea(1.37).
 The incident ray travels through the goniolens
practically unaltered
 The ray escapes because the angle of incidence
at the new Koeppe air boundary is now less than
the critical angle.
 Unfortunately it requires the patient to be lying
down, and so it cannot be so easily used with an
ordinary slit lamp
Examination of a supine patient using Koeppe gonioscopy
Swan Jacob surgical goniolens
Indirect gonioscopy
 Goldmann goniolens: this utilises

mirrors to reflect the light from the
iridocorneal angle into the direction of the
observer
 While the view obtained is smaller than
that of the Koeppe goniolens, it can be
used with the patient sitting upright
position
 Zeiss indirect goniolens:
 Similar to the Goldmann, but employs prisms in the

place of mirrors.
 Its four symmetrical prisms allow visualisation of the

iridocorneal angle in four quadrants of the eye
simultaneously, and works well with a slit lamp
 Does not require lubricating fluid, only the patient's tear

film - allows for indentation gonioscopy
Indentation Gonioscopy
 Essential in distinguishing appositional angle closure from synechial
angle closure.
 Done with goniolenses that have contact diameters smaller than the
corneal diameter.E.g. Ziess, Posner and Sussman lenses.
 Lens is placed centrally on the cornea and pushed posterior, so that

aqueous is pushed into the angle which will deepen the appositionally
closed angle.
 Angles having synechial closure either open with
indentation, or partially open with synechiae being
tethered to the cornea or trabecular meshwork.
 Also helpful in diagnosing iridodialysis, cyclodialysis

and foreign bodies in the angle.
Indentation gonioscopy
Differentiates ‘appositional’ from ‘synechial’ angle closure
Press Zeiss lens posteriorly Aqueous is forced into

against cornea periphery of anterior chamber
During indentation Before indentation
• Part of angle is forced open • Complete angle closure

The gonioscopy process
 Briefly explaining the procedure to the patient

 Cleaning and sterilising the front (curved)
surface of the goniolens
 Applying lubricating fluid to the front surface if
appropriate
 Anaesthetising the patient's cornea with topical
anaesthetic
 Preparing the slit lamp for viewing through the
goniolens
 Gently moving the patient's eyelids away from the
cornea
 Slowly applying the goniolens to the ocular surface
 Fine-tuning the slit lamp to optimise the view
 Interpreting the gonioscopic image
 Moving the goniolens to view each section of the
iridocorneal angle
 Cleaning the instruments and irrigating the patient's
eyes
Gonioscopic procedure
Angle structures
(1) pupil border; (2) peripheral
iris; (3) ciliary body band; (4)
scleral spur; (5) trabecular
meshwork; and (6) Schwalbe's
line.
Pupil and Iris
 Glaukomflecken and posterior synechiae
 Dandruff like particles
 If posterior chamber pathology such as tumors,

suspected, the pupil should dilated and gonioscopy
repeated.
 Neovascularization
Iris configuration
 Myopes –concave
 Hyperopes –convex
 Abnormal convexity (pupillary block)
 Abnormal concavity (pigment dispersion)
 Abnormal last roll (Plateau iris)
Plateau iris configuration
Ciliary Body Band
 The band is usually tan, gray, or dark brown,

pigmented and typically narrow in hyperopes
and wide in myopes.
 In angle recession they are broadly exposed
 The root of the iris normally inserts onto the

ciliary body band.
 If the iris inserts directly into the scleral spur,
the ciliary body band is not seen easily.
Angle blood vessels
 The normal angle has three types of vessels:
 (1) circular ciliary body band vessels
 (2) radial iris vessels
 (3) radial ciliary body band vessels
 If angle vessel that bridges the scleral spur is seen, it is probably

abnormal.
Scleral spur
 Posterior border of TM
 Attachment of ciliary body
 Insertion of longitudinal muscles of ciliary body
 May be obscured by:
 Iris process
 Iris bombe
 PAS
 Pigments
Trabecular Meshwork
 Extends from the scleral spur to Schwalbe's line

 Pigment in the meshwork usually accumulates in the
posterior division
 Posterior meshwork is the favored location for
trabeculoplasty.
 More pigmented with age
 Aqueous flow is through posterior TM
 More pigment inferiorly
Schwalbe's Line
 Termination of Descemet's membrane and is the most anterior

angle structure
 Marks the forward limit of the trabecular meshwork
 Landmark for identification of TM in narrow angles
Pigmented –Sampaolesi’s line

4+ pigmented posterior
trabecular meshwork
Schlemm's Canal
 The canal is located directly anterior to the scleral spur

and is normally not seen.
 However, during gonioscopy, blood may reflux into
the canal
 Blood in the canal is more common under conditions
of elevated episcleral venous pressure( eg Sturge –
Weber syndrome ) ,active uveitis or scleritis
 Hypotony may also cause blood to reflux into the canal.
Blood in schlemm’s canal
Angle Pigmentation
 A minimal amount of angle pigment is expected
 Excessive may be caused by pigmentary glaucoma,
pseudoexfoliation, trauma, uveitis, or tumors.
 Excessive trabecular pigment at the 12 o'clock position occurs in
only 2.5% of individuals and is usually pathologic.
Grading of chamber angles
Van Herick
Grade 4 Angle is wide open PAC>CT
Grade 3 Angle is narrow PAC=1/4-1/2 CT
Grade 2 Angle is dangerously narrow PAC=1/4 CT
Grade 1 Angle is dangerously narrow or closed PAC<1/4 CT

Open angle Close angle
Shaffer grading
Grade 4 (35-45 )
• Ciliary body easily visible
Grade 3 (25-35 )
• At least scleral spur visible
3 2 1 Grade 2 (20 )
4
•Only trabeculum visible
0 • Angle closure possible but unlikely
Grade 1 (10 )
•Only Schwalbe line and perhaps
top of trabeculum visible
• High risk of angle closure
Grade 0 (0 )
• Iridocorneal contact present
• Apex of corneal wedge not visible
• Use indentation gonioscopy
Scheie classification
Spaeth grading
 Myopic eye with pigment dispersion syndrome
 E 40 q/4+TMP= An extremely deeply inserting iris

root ,in a 40 degree angle recess ,with posterior
bowing of the peripheral iris and extensive TMP
Gonioscopy flow diagram
Closed angle
Open angle
Open
angle
Iris melanoma
Neovascularization
Neovascularization
Microhyphema following trauma
Foreign body
Foreign body
Note relative deepening of the iris insertion
Post traumatic angle recession
Peripheral anterior synechiae
Haptic in AC
PEX
pigments in pupillary margin and angle
Normal Iris processes
Thank you

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Gonioscopy Technique

Hira Nath Dahal

 Troncoso ,Koeppe, Goldmann modified

Total internal reflection

 Patients with corneal abrasions

 Patients with keratopathy (i.e., bullous, band,

 Perforating eye injuries

 Goldmann goniolens: this utilises

 Similar to the Goldmann, but employs prisms in the

 Its four symmetrical prisms allow visualisation of the

 Does not require lubricating fluid, only the patient's tear

 Lens is placed centrally on the cornea and pushed posterior, so that

 Also helpful in diagnosing iridodialysis, cyclodialysis

Press Zeiss lens posteriorly Aqueous is forced into

• Part of angle is forced open • Complete angle closure

 Briefly explaining the procedure to the patient

 Glaukomflecken and posterior synechiae

 Dandruff like particles

 If posterior chamber pathology such as tumors,

 The band is usually tan, gray, or dark brown,

 The root of the iris normally inserts onto the

 If angle vessel that bridges the scleral spur is seen, it is probably

 Extends from the scleral spur to Schwalbe's line

 Termination of Descemet's membrane and is the most anterior

Pigmented –Sampaolesi’s line

 The canal is located directly anterior to the scleral spur

Grade 3 Angle is narrow PAC=1/4-1/2 CT

Grade 2 Angle is dangerously narrow PAC=1/4 CT

Grade 1 Angle is dangerously narrow or closed PAC<1/4 CT

 E 40 q/4+TMP= An extremely deeply inserting iris

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