GONIOSCOPYDr. Rashmi Ranjan
Greek : gṓ nḗ : angle , Ộs’k-pḗ : view
Alexois Trantas:(1907) First visualized angle in an eye
with Keratoglobus
Maximilian Salsmann:(1914) Father of Gonioscopy. First
introduced Goniolens
HISTORY
Koeppe : Designed improved Contact lens and gave the
method biomicroscopy of angle of anterior Chamber with slit lamp.
Manuel Uribe Troncoso: Developed Gonioscope for magnification &
illumination of Angle. First to write a Comprehensive book on
Gonioscopy
Otto Barkan: Established use of Gonioscopy
in Management of Glaucoma.
Goldmann:(1938) Introduced Gonioprism.
Critical Angle: Cornea Air Interface~46degree Light rays from Angle exceeds Critical angle so rays reflected
back into AC,preventing direct visualisation of Angle
PRINCIPLE
PRINCIPLEINDIRECT DIRECT
LENS DESCRIPTIONKOEPPE Prototype Diagnostic LensRICHARDSON SHAFFER Small Koeppe Lens used for
InfantsLAYDEN For Gonioscopic Examination
of Premature InfantsBARKAN Prototype Surgical GoniolensTHORPE Surgical & Diagnostic lens for
Operating RoomsSWAN JACOB Surgical Goniolens used in
Children
CONTACT LENSES FOR GONIOSCOPYDIRECT
Used with Handheld Biomicroscope (15x to 20x) with separate light source
KOEPPE
BARKAN
SWAN JACOB
LENS DESCRIPTIONGOLDMANN SINGLE MIRROR Mirror inclined at 62 degreesGOLDMANN THREE MIRROR One mirror for gonioscopy, two for
retina; coated front surface for laser useZEISS FOUR MIRROR All 4 mirrors inclined at 64 degrees for
gonio;requires holder;fluid bridge not required.
POSNER FOUR MIRROR Modified Zeiss four mirror gonioprism with attached handle
SUSSMAN FOUR MIRROR Handheld Zeiss type GonioprismTHORPE FOUR MIRROR Four gonioscopy mirrors; inclined at 62
degrees;requires fluid bridgeRITCH TRABECULOPLASTY LENS
Four gonioscopy mirrors; two inclined at 59 degrees & two at 62 degrees with convex lens over two
LATINA TRABECULOPLASTY LENS
One mirror for Trabeculoplasty
INDIRECT
GOLDMANN SINGLE MIRROR
GOLDMANN THREE MIRROR
All 4 mirrors inclined at 64 degrees for gonio
ZEISS FOUR MIRROR
POSNER FOUR MIRROR
HandheldSUSSMAN FOUR MIRROR
Four gonioscopy mirrors; inclined at 62 degrees;requires fluid bridge
THORPE FOUR MIRROR
RITCH TRABECULOPLASTY LENS
One mirror for Trabeculoplasty
LATINA TRABECULOPLASTY LENS
INDIRECT TECHNIQUE
DIRECT
ADVANTAGE DISADVANTAGE
Observer’s height can be changed
Done on sedated, comatosed & Children
Panoramic view of Angle Less distortion of AC Useful in examining fundus
with small pupil
Inconvinient Special equipments required Difficult to master Does not Stabilize globe
INDIRECTADVANTAGE DISADVANTAGE
Quick & Convinient No special equipment
required Allows differentiation B/w
Appositional & Synechial closure
Can create corneal wedge
Inadverent Pressure on Cornea
Mirror image is confusing
DIRECT V/S INDIRECTDIRECT INDIRECT
Panoramic view of iridocorneal angle with ability to adjust view by examiner.
Both eyes can be examined simultaneously.
No viscous [ coupling ] material required.
Direct view for surgery e.g. Goniotomy
DISADV: Inability to perform indentation, low magnification, assistance.
Segmental View
One Eye at a time
Viscous required
Mirror Image seen Excellent optics with Slit
Lamp Indentation Can be Done
Classification : Open or Closed angle glaucoma To assess AC angle recess & risk of angle closure. To identify plateau iris. To look for Abnormal angle pigmenatation, PEX , angle recession, cyclodialysis, foreign body, Neoplasm, copper deposition , blood in Schlemm’s canal.
INDICATIONSDIAGNOSTIC
Evaluation of trabeculectomy fistula , glaucoma drainage devices
Congenital anomalies- aniridia, iris processes.
Laser trabeculosplasty/ goniophtocoagulation
Goniotomy/ Gonioplasty/ Trabectome sxReopening of blocked trabeculectomy
opening.Laser of suture around tube of G.D.D.Indentaion Gonioscopy to break an attack
of Ac. ACG
THERAPEUTIC
NORMAL ANGLE STRUCTURES
This structural portion of ciliary body is visible in the A.C. as a result of iris insertion into ciliary body
Width depends on level of iris insertion
Wider in myopes and narrow in hyperopia
Color: grey to dark brown
CILIARY BODY BAND
This is the post. Lip of scleral sulcus which is attached to the ciliary body posteriorly and corneo-scleral meshwork anteriorly
Color : prominent white line
SCLERAL SPUR
Pigmented band anterior to scleral spur Although extent of TMW is from root of iris to
schwalbe’s line it is considered as 2 portions
a) Anterior - between schwalbe’s line and ant. Edge of schlemm’s cannal
Involved in lesser degree of aqueous out flowb) Posterior – Functional part , primary site of aqueous out
flow Appearance of funtional TMW depends on
amount of pigment deposition
TRABECULAR MESHWORK
At birth no pigment and with age from faint to dark brown
Pigment deposition may be homogeneous or irregular
When lightly pigmented blood reflex in schlemm’s cannal may be seen as a red band
TRABECULAR MESHWORK
When a thin slit of light hits the irido-corneal angle at an angle of 10 -15 , two light reflections are seen from ⁰ ⁰the external and internal corneal surfaces which pipe down at the sclero-corneal junction (Schwalbe’s line) marking the anterior border of trabecular meshwork.
Corneal wedge is a useful technique to identify the trabecular meshwork in eyes that are either nonpigmented or excessively pigmented its diff. to mark trabecular meshwork begins
CORNEAL WEDGE
SCHWALBE LINE Junction between
anterior chamber angle structures and cornea where the descement’s membrane terminates
Fine ridge ant. to TMW identified by a small built up of pigment
Landmark for TMW in narrow angle
SAMPAOLESI'S LINE
POSTERIOR EMBRYOTOXON
Contour
Flat- Deep AC Concave- Shallow AC , Hyperopia Convex- High Myopia, Pigment Dispersion Syndrome Abnormal Rolling- Plateau iris
IRIS
IRIS PROCESS PAS
Fine Extend into scleral Spur Follow concavity of Recess Underlying Structures are
seen Iris moves with indentation Broken with angle
Recession
Broad Extend Beyond Scleral Spur Bridge concavity of Recess Obscures the View Resists Movement Intact in Recession
ANGLE BLOOD VESSELS
NORMAL NEOVASCULARIZATION
Radial Orientation Thick Non Branching Do not cross Scleral Spur
Fine Arborising Crosses Scleral Spur
MANUPULATIVE GONIOSCOPY Over the Hill Corneal Wedging Indentation
It’s a special maneuver to view over a steep iris.
It is done by asking the patient to look in the direction of the mirror or moving the mirror towards the angle being viewed
OVER THE HILL/DIVE BOMBER’S VIEW
INDENTATION GONIOSCOPY When iris covers the trabecular meshwork
(TM) its easy to mistake:◦The non-pigmented TM for scleral spur◦Pigmented Schwalbe’s line for TM◦Apposition from synechiae
Indentation Gonioscopy is particularly useful in these cases
Useful when iris surface is convex◦Done when recognition of angle structures is
difficult Performed in all glaucoma cases
◦Differentiates appositional vs synechial closure in pupillary block
◦Measures extent of angle closure◦Identifies plateau iris config.◦Identifies lens induced angle closure
INDENTATION:PLATAEU IRIS
If posterior [ pigmented ] part of trabecular meshwork is not visible in more than 180 degrees of angle without indentation or manipulation, this is known as an ‘ occludable angle’.
OCCLUDABLE ANGLE
SCHEMATIC REPRESENTATION OF GONIOSCOPIC FINDINGS
SCHEIE SYSTEM: most posterior structure visible. SHAFFER’S SYSTEM : assess geometric angle width in 4 grades . angle potential for occlusion. SPAETH SYSTEM : three dimentional structure of angle - level of iris insertion and peripheral iris
configuration. RPC GRADING
GRADING
GRADE STRUCTURE SEEN PROBABILITY
0 CBB Seen No angle closure
I CBB Narrow No angle closure
II CBB not seen, SS Seen Rarely closure possible
III Posterior TM Not seen Closure likely
IV Schwalbe’s Line not seen Gonioscopicaly closed
SCHEIE SYSTEM
SHAFFER’S SYSTEM
Angular width Iris Configuration Level of Iris Insertion Iris Processes Pigmentation of posterior Trabecular
Meshwork
SPAETH SYSTEM
SPAETH SYSTEM
SPAETH SYSTEMIRIS PROCESSES PIGMENTATION OF TBM
U – along angle recess
V – upto trabecular meshwork
W – upto Scwalbe’s Line
0 no pigmentation 1+ just perceptible 2+ definite but mild 3+ moderately dense 4+ dense black pigmentation
GRADE STRUCTURE SEEN
0 CLOSED
1 SCHWALBE’S LINE
2 ANTERIOR(NON PIGMENTED) TM
3 POSTERIOR PIGMENTED TM
4 SCLERAL SPUR
5 CILIARY BODY BAND
6 ROOT OF IRIS
RPC System of Grading
Angle is Deep Flat Iris inserted posterior to Scleral Spur Translucent Trabecular Meshwork Normal CBB
In Congenital Glaucoma: Anterior insertion of iris directly on TBM Thin CBB Congenital vessels in ‘’Hair Pin’’ Configuration
ANGLES IN INFANTS
ANGLE ANOMALIES
CLOSED ANGLE
FOREIGN BODY IN ANGLE
PIGMENTARY GLAUCOMA
IOL HAPTIC IN ANGLE
HYPHEMA
CYCLODIALYSIS
DRAINAGE IMPLANT
IRIS MELANOMA
IRIS NEVUS
Wash with soap & water Soaking the lens for 5-10 min in fresh solution of Sod.
Hypochlorite [ 1:10 household bleach : water] Rinsing with sterile water Air drying 3% H2O2 or 1% Formaldehyde can also be used. Direct surgical gonioscopes [ Koeppe, Swan Jacob] can
be sterilized with ethylene oxide.
STERILIZATION & DISINFECTION
Contact investigation patient discomfort. Conjunctival infection. Artefactual angle closure Slit lamp illumination-> pupil constriction-> opens up
the angle Wide interobserver variations. Indentation corneal folds, distorted view of angle
structures, epithelial injury.
LIMITATIONS
Painful inflamed eye
Acute glaucoma with edematous cornea
Mydriatic drugs- obscure angle by bunching up iris
Suspected open globe injury or early in course of suspected closed globe injury with hyphaema as pressure may precipitate rebleed.
CONTRAINDICATION
OTHER IMAGING MODALITIES
High Frequency (50 – 100 Mhz)B Scan system
Ocular structures anterior to Pars Plana
Lateral Resolution 50mm Axial Resolution 25mm Depth of penetration 4-5mm Field of View 4x4mm
ULTRASOUND BIOMICROSCOPY
PUPILLARY BLOCK
High Resolution Anterior Segment Imaging Modality
Spatial Resolution of 10-20µm Uses 1310 nm of Infra Red light Works on Principle of Low
Coherence Interferometry Measures: Echotime delay &
Intensity of Back Scattered light & Back Reflected Light
Anterior Segment OCT
APPLICATIONS Imaging of Anterior Chamber Evaluation of Structural Causes of Angle
Closure Effects of Interventions like Iridotomy Imaging of Trabeculectomy Blebs Tube Position in Glaucoma Drainage Implants Angle Assesment in Corneal Opacities Pachymetry Large Scale Screening of Angle Closure &
Angle Closure Glaucoma
Anterior Synechiae
AS OCT UBM
Non Contact Axial Resolution 10-20µm Light Energy 90 degree patient
Technician Set up Precise Scanning Location (Degrees) Posterior Chamber not Well
Delineated No distortion of Angle All 4 quadrants at a time
Contact Axial Resolution 50µm Sound Energy Supine
Scanning Location less precise(Quadrants)
Posterior Chamber Well Delineated
Distortion of Angle 1 Quadrant at a time
SCHEIMPFLUG PHOTOGRAPHY
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