Gonioscopy

Dr Vijayasree S Dr Arjun S (PG )

Definition : Gonioscopy describes the use of goniolens to gain the view of anatomical angle formed between the eye s cornea & iris

Purpose
Why do 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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What can I achieve with gonioscopy ? 1) visualization of anterior chamber angle 2) view of peripheral iris 3) differentiation between angle closure , occludable & secondary glaucoma s

Other ways of evaluating the anterior chamber angle

Scheimpflug photography Ultrasound biomicroscopy Anterior segment OCT

Gonioscopy -History
Trantas (1907 ) coined the term gonioscopy Salsmann (1914) first performed gonioscopy Goldmann (1938 ) first introdused gonioprism

Indications
Diagnostic
Increased IOP Normal IOP ; AC shallow ( Von Herricks ) or historical evidence of angle closure Dx e/w as glaucoma or using anti glaucoma medications Family h/o glaucoma Patent /partially patent PI done e/w with increased / 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

 Vitreous strands incarcerated in surgical wound Dx epithelial down growth To view copper deposition in DM To view peripheral laser iridotomy To view internal ostium of glaucoma drainage devices To view orientation of haptic in AC IOL

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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PRINCIPLE OF GONIOSCOPY
CRITICAL ANGLE:
When light passes from Denser to rarer medium r r i i When r=90 i=critical angle i r

r>i

When i>critical ang.

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 .it is not possible to view the irido corneal angle , because light from the angle strikes the cornea 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 the anterior chamber Rare exceptions are keratoconus , keratoglobus angle structures are 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 a gonioprism

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Direct goniolens
LENSES Koeppe Richardson schaffer Layden Barkan Thorpe Swan jacob DESCRIPTION/USE prototype diagnostic goniolens small koeppe lens for infants for premature infants prototype surgical goniolens surgical and diagnostic lens for OT Surgical goniolens for children

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Direct goniolens
Advantages
Direct visualization of the angle shows erect view View of the entire circumference Good binocularity Easy to look down over the convex iris Used for goniotomy & goniosyneciolysis Both eyes simultaneously examined

Disadvantages Cumbersome Supine position Costly equipment Time consuming Less magnification , poor detail Falsely deep angle as pt in supine

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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 perpendicular 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 of ONH

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 to this
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INDIRECT GONIOSCOPY
INSTRUMENTS : gonioprism & slit lamp GOLDMANN single mirror is a prototype mirror has a height of 12mm posterior radius of 7.38mm

GOLDMANN 3 MIRROR: has 3 mirrors two mirrors for examination of fundus (67 deg , 73 deg) and one for ant. Chamber angle tilted at 59 degrees

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GOLDMANN 3 MIRROR GONIOSCOPE

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 from the equator out to the ora serrata. The Finger Nail mirror(59deg) is used to view angle and the most anterior retina and ciliary body.
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Corneal ( ziess ) type : diameter 9 mm

Radius of curvature =7.72 mm approx corneal radius of curvature So can be used for indentation gonioscopy coupling fluid not needed uses tear film

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LENSES ZEISS 4 MIRROR

DESCRIPTION/USE 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

Because of smaller diameter used for Indentation or compressive gonioscopy. POSNER 4 MIRROR SUSSMANN THORPE 4 MIRROR modified zeiss with attached handle hand held zeiss type 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 degrees with convex lens over two

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Suss mann

Posners

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Goldmann

Zeiss goniolens

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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 angle appear 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 gently guided 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 clock position 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 the structures are easy to recognize ) Then nasal , superior , temporal (so that at any point the beam should not cross the pupil) Always compare the findings in one eye with fellow eye before commenting on angle characteristics
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Sterilization & disinfection of goniolens

Washing with soap &water, sodium hypochlorite 3% H2O2 1% formaldehyde 70% isopropyl alcohol Ethylene oxide gas (surgical lens )

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What should I look for in gonioscopy ?

Recognize angle land marks & consider: 1. Level of iris insertion 2. Shape & profile of peripheral iris 3. 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 adult angle 1. Ciliary body band 2. Scleral spur 3. Pigmented TM 4. Non pigmented TM 5. Schwalbe s line for identification of angle , the scleral spur & schwalbe s line are the most consistent land marks
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Sample View of Wide Angle

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ANGLE STRUCTURES
it is easier to identify the angle structures from posterior (iris side) to anterior (cornea side). Start from pupil , follow the plane of iris , identify root of iris 1.) Ciliary body - (CB) is the most posterior structure in the angle .
It appears as a grey or dark brown band

Its width Depends up on the level of iris insertion it is wider in myopes and narrower in hypermetropes 2.) Scleral spur - (SS) is the posterior portion of scleral sulcus Appears as a prominent white line between CBB and functional TMW. fine pigmented strands seen crossing the spur from iris root to TMW are iris processes. Blood in schlems canal lies just ant to the scleral spur.

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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 pigment with 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

Increased pressure indents central cornea and displaces fluid in to the angle opening it wider should the angle be closed it differentiates between appositional ( reversed )& synechial (irreversible )closure

2.OPEN ANGLE

3.CLOSED ANGLE WITH PAS.

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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 steep curvature of peripheral iris )- a more tangential viewing of the angle aids in identification of angle .Ask the pt to look in the direction of the mirror /move the mirror 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 an anteriorly 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 used for Estimating 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 IV III II ANGLE WIDTH 35-45 20-35 20 CONFIG. WIDE OPEN OPEN ANGLE MODERATELY NARROW VERY NARROW CHANCES OF CLOSURE NIL NIL

POSSIBLE HIGH

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SLIT ANGLE

<10

PORTIONS APPEAR CLOSED CLOSURE PRESENT

CLOSED ANGLE

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SCHEIES GONIOSCOPIC CLASSIFICATION :

Based on the extent of visible angle structures CLASSIFICATION Wide open GRADE I GONIOSCOPIC APPEARANCE all structures visible hard to see over iris root in to recess ciliary body band obscured posterior trabecula obscured only schwalbe s line visible

GRADE II GRADE III GRADE IV (closed)

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SPAETH SYSTEM OF GRADING: based on 3 variables

a. Angular width of angle recess b.Periph eral iris Configur ation

c.Appare nt insertion Of the iris root

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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 band CBB

Iris inserts into concave face of CB leaving some 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 visible
Blood 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 processes
Normal in 30 % population Fine , finger like , gray/ brown , Extensions of the peripheral iris , follow the concavity , insert into SS or PTM Mostly in nasal Q, do not interfere with aqueous out flow Contract on light stimulus Do not block the movement of iris on IND Gonio Angle recession iris processes may be broken Often confused with PAS
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Iris processes

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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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PAS

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ICE syndrome

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axenfeld rieger anomaly

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Plateau iris
Axially normal central AC depth , 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 pts with 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 / von herricks method of angle Ex Rx : long term miotic Laser iridoplasty

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Post traumatic glaucoma

h/o may be more than 20-30 yrs old Defer gonioscopy for 6 weeks after injury Look for signs of concussion trauma Bleeding vessel , fibrin , clot TM tear TM inc pigmentation Goniosynechiae Retro displacement of iris root Rupture of iris process Gray membrane ( fibrosis ) over angle recesss Angle recession FB in the angle
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Iridodialysis

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FB in angle

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Angle recession
Blunt injury Tear in longitudinal & circular muscles of CB Broadened CBB ( 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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Increased pigmentation , angle recession

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Pigmentary glaucoma
liberation 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 schwalbe s 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

PXF 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
Open / 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
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 & facilitates appropriate medical , laser , surgical Rx
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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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