Gonioscopy

Dr. Chandra Shekhar Kumar

 GONIOSCOPY
„ Gonioscopy refers to the technique to evaluate
the anterior chamber angle.

„ Developed and discovered by TRANTAS and

SALZMANN independently in early 1900.
 Principle of gonioscopy
Anterior chamber angle
cannot be visualized
directly through intact
cornea because the light
emitted from the angle
structures undergo total
internal reflection at the
anterior surface of the
precorneal tear film.
 Types of gonioscopy

Direct gonioscopy:
steep convex lens –
permits light from angle
to exit from the angle
9 Koeppe
9 Hoskin Barkans
Koeppe
9 Swan-Jacobs lens

Swan-Jacobs lens
Indirect gonioscopy:
¾ uses mirrors/prism to
overcome the
phenomenon of total
internal reflection.
¾ Also uses the
magnification of slitlamp
Goldmann’s gonioscope
 Zeiss goniolens

Other indirect goniolenses: Posner and Sussmann lenses.

Which gonioscope to use and why?
Direct gonioscopes
Advantages:
Panoramic view of the angle
Viewing angle can be manipulated by examiner
Both eyes can be visualized simultaneously
Good binocularity
Very little distortion of the angle
Disadvantages :
Requires supine position of the patient
Requires operating microscopes
Gives poor detailed anatomy
Common use of direct gonioscopes nowadays

1) for angle evaluation during EUA in children.

2)for surgical procedures like Goniotomy

(Swan-Jacobs lens)
Indirect gonioscope
Advantages
Slitlamp magnification ,illumination, stereopsis,
and convenience
Allows localization of angle structures.
More convenient for patients and examiner
Disadvantages

„ Reflected image is seen.

„ Image is inverted and of opposite angles

„ Small aperture lens may cause distortion of the

angle (following indentation).
 Goldmann 3 Mirror Lens

• Dimensions – 12mm diameter, 3 mm flange width.

• Mirror – View 180 degrees away from mirror (inverted reversed)

¾ Trapezoid - 73 degrees, from posterior pole to equator,

¾ Rectangular- 67 degrees, equator to beginning of ora,
¾ Thumbnail- 59 degrees,
¾ Anterior chamber angle (10 - 12 mm height, 9 mm wide, 7 mm from
the center.
• Radius of curvature – 7.4mm
59 degrees, anterior chamber, ora serrata
Thumbnail
At 55*

73 degrees, from posterior pole to equator

Trapezoid
At 73*

67 degrees, equator to beginning of ora

Rectangular
At 63*
 Indications of gonioscopy
Diagnostic :
• To visualize the anterior chamber angle

• Forms basis for classification of glaucoma

• To note extent of iris neovascularization

• History or evidence of Trauma

• Assess Angle Recession

• Evidence of neoplastic activity in the Anterior Chamber

• To assess Peripheral Anterior Syncheiae (PAS)

Therapeutic indication:
• ALT

• Laser goniotomy

• Reopening of trabeculectomy os
Contraindication of gonioscopy
„ Post-traumatic patients

„ Post-surgical patients
 Technique
• Explain the procedure

• Anesthetize with paracaine

• Position patient at slit lamp

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

„ Indentation gonioscopy

„ Manipulation gonioscopy
Indentation gonioscopy
 Indentation gonioscopy
„ Synechial Vs
appositional closure
„ Difficult >40mm Hg
„ Sliding the lens towards
the angle reduces folds
and improves view
 Manipulation gonioscopy
„ Mirror height and distance
from centre of cornea
(zeiss/Posner advantageous)
„ Tilting or sliding lens
towards angle or having pt
look into the mirror
„ Avoid indentation (Zeiss) or
compression (Goldmann)
„ Tilt astigmatism
shortened TM
Manipulation to see angle
Angle view when pt. looks up
Clearing of edematous cornea
„ Clearing of edematous cornea done with
1) topical glycerin: painful procedure so cornea
should be anesthetized before the procedure.
2)ethanol (70%) –can be used during surgery to
scrape the edematous epithelium.
 Guidelines for disinfection of
gonioscopes
9 70% ethyl alcohol sponge for 10 seconds.
9 1:10 household bleach (sodium hypochlorite)
for 5 mins.
9 3% hydrogen peroxide.
9 1% formaldehyde
9 Operating gonioscopes -ethylene oxide
(sterilisation of tonometers and gonioscopes---
Indian j. Ophthalmol.1998;46:113-16 )
Normal angle structures
Schwalbe's line (SL):
• Is the termination of the descemet's
membrane.
• Schwalbe's line is identified easily with help of
parallelepiped made of slit(2mm wide and of
max. length )
• In most it is a smooth transition zone
between trabecular and corneal endothelium.
Corneal wedge to localize the Schwalbe's line

Schwalbe's line
PIGMENTATION ANTERIOR TO SCHWALBE LINE

PIGMENTATION
„ Trabecular meshwork (TM):
¾ lies between Schwalbe's line and scleral spur.

¾ non-pigmented (anteriorly and nonfiltering )

¾ pigmented part (posteriorly placed and filtering)

*In cases of heavy pigmentation of angle
structures corneal wedge is helpful in its
identification.
Totally open angle –showing TM

TM
Heavily pigmented angle in nevus of ota
Scleral spur (SS) :
¾ Continuation of the sclera into the AC.

¾ Attached anteriorly to the TM and posteriorly to

the sclera

¾ Scleral spur is seen as thin band of white or

light grey color .
Angle showing scleral spur

scleral spur
„ Cilliary body band (CBB):
¾ Light brown to dark brown in appearance
visible anterior to the iris.

¾ Look for asymmetry of CCB width and depth

in both eyes –sign of angle recession,
cyclodialysis or unilateral high myopia .
Iris process:
¾ uveal extention from the iris to the
trabecular meshwork .

¾ Extend into the inferior portion of

the trabecular meshwork. Iris process

¾ Usually follow the concavity of the

angle recess.

¾ Do not inhibit posterior movement

of iris on indentation also not to
the movement of aqueous.

.
Blood vessels in the angle :

¾ Radially oriented or looping branch from the major arterial

circle.

¾ Short segment of major arterial circle may also be visible.

¾ Abnormal vessels are fine, irregularly oriented ,cross the scleral

spur.
Normal blood vessels in the angle

blood vessels
 Scheie system
„ Grade 0 CBB no angle closure
(wide open)
„ Grade I CBB narrow no angle closure

„ Grade II CBB not seen, SS rarely closure possible

„ Grade III Post TM not seen closure likely

„ Grade IV goinioscopically closed

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

„ Grade 0 (0°) no corneal wedge Indentation gonioscopy

 Grading systems for angle
width
1)Shaffer system
Grade Angle width Description Risk of
number closure
4 45*-35* Wide open Impossible
3 35*-20* Wide open Impossible
2 20* Narrow Possible
1 <10* Extremely Possible
narrow
slit slit Narrow to Probable
slit
0 0* Closed Closed
 Spaeth system
„ Iris configuration –
q -- concave peripheral
iris
r -- regularly straight iris
s --steeply convex iris
„ Angular width --
10°, 20°, 30°, 40°
 Spaeth system contd..
„ Level of iris insertion –
A (Anterior to schwalbe’s line)
B ( just behind schwalbe’s line)
C (at the Scleral spur)
d (deep angle CBB seen)
e (extremely deep angle)
„ Iris processes
U along angle recess
V upto TM
W upto schwalbe’s line
 RPC System
Grade 0 -- Closed
Grade 1 -- Schwalbe’s line
Grade 2 -- Anterior (non pigmented) TM
Grade 3 -- Posterior pigmented TM
Grade 4 -- Scleral spur
Grade 5 -- Ciliary body band
Grade 6 -- Root of iris
Steep iris
Regular
Queer
Common findings
Peripheral anterior synechia

PAS
Typical appearance of PAS

PAS
Neovascular glaucoma

new vessels
Neovascular iris

new vessels
NVG (showing ectropion uveae
+PAS+ cilliary processes

cilliary processes
cilliary processes
Angle recession- broadening of the cilliary body
band

Angle recession-
 Angle recession- broadening of the
cilliary body band

Angle recession-
 Silicon oil in angle

Silicon oil
 Pigment dispersal syndrome

Heavily pigmented TM
Closed angle
Iris cyst
Heavy pigmentation of angle in –nevus of ota
 Angle in a failed trabeculectomy patient

closed opening
Glaucoma implant visible in the angle
Gonioscopy showing patent internal opening –
post trab.

internal opening
Melanoma
Foreign bodies
 Posterior embryotoxon

Posterior embryotoxon
„ Axenfield anomaly
Posterior
embryotoxon( )
„ Bridging iris strands
Thank you