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Assessment of Anterior Chamber Angle

Assessment of anterior chamber angle

1 of 42
Sujay Chauhan
ASSESSMENT OF
ANTERIOR CHAMBER ANGLE
INDICATIONS FOR ASSESSMENT OF
ANTERIOR CHAMBER ANGLE
All patients on the first visit
• Glaucoma suspects
• Open angle glaucoma
• Ocular hypertension
• Angle closure post-iridotomy
• Retinal vein occlusion
• Blunt trauma
Indications
METHODS FOR ASSESSMENT OF
ANTERIOR CHAMBER ANGLE
SUBJECTIVE ASSESSMENT
• Oblique flashlight test
• Van Herrick’s technique
• Gonioscopy
OBLIQUE FLASHLIGHT TEST
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Assessment of Anterior Chamber Angle

  • 2. INDICATIONS FOR ASSESSMENT OF ANTERIOR CHAMBER ANGLE All patients on the first visit
  • 3. • Glaucoma suspects • Open angle glaucoma • Ocular hypertension • Angle closure post-iridotomy • Retinal vein occlusion • Blunt trauma Indications
  • 4. METHODS FOR ASSESSMENT OF ANTERIOR CHAMBER ANGLE
  • 5. SUBJECTIVE ASSESSMENT • Oblique flashlight test • Van Herrick’s technique • Gonioscopy
  • 7. GRADE I GRADE II GRADE III GRADE IV < 1/3 illuminated 1/3-2/3 illuminated >2/3 illuminated Fully illuminated Oblique flashlight test
  • 8. • Good inter-observer agreement (p = 0.04) • Good reproducibility (weighted kappa value = 0.74) • Sensitivity: 75-97% • Specificity: 67-99.4% • Gracitelli et al. Ability of non-ophthalmologist doctors to detect eyes with occludable angles using the flashlight test. Int Ophthalmol. 2014 Jun;34(3):557-561 • Congdon NG et al. Screening techniques for angle-closure glaucoma in rural Taiwan. Acta Ophthalmol Scand 1996;74:113–119 • He M et al. Angle-closure glaucoma in East Asian and European people. Different diseases? Eye 2006;20:3–12 • Thomas R et al. The flashlight test and van Herick’s test are poor predictors for occludable angles. Aust N Z J Ophthalmol 1996;24:251–256 • Vargas E, Drance SM Anterior chamber depth in angle-closure glaucoma. Clinical methods of depth determination in people with and without the disease. Arch Ophthalmol 1973;90:438–439 Oblique flashlight test
  • 9. • Simple • No sophisticated equipment required Advantages Oblique flashlight test
  • 10. • Lack of standardization • Arbitrary cut-offs Limitations Oblique flashlight test
  • 11. LIMBALANTERIOR CHAMBER DEPTH AND VAN HERRICK’S TECHNIQUE
  • 12. 5% 15% 25% 40% 75% >100% Limbal Chamber Depth as a Fraction of Corneal Thickness LCD & VH
  • 13. All Occludable Angles PAC PACG LCD VH Sensitivity Specificity Sensitivity Specificity Sensitivity Specificity 0% NA 17.8% 99.6% 29.3% 99.2% 52.2% 98.9% ≥5% NA 60.5% 96.1% 70.7% 93.7% 91.3% 92.6% ≥15% 1 83.7% 85.7% 84.5% 82.4% 91.3% 81.1% ≥25% 2 99.2% 65.5% 100% 62.4% 100% 61.1% ≥40% 3 100% 40.3% 100% 38.3% 100% 37.5% Performance Indices of Limbal Chamber Depth Estimation in Detection of Gonioscopically Occludable Angles, PAC and PACG Foster PJ et al. Detection of gonioscopically occludable angles and primary angle closure glaucoma by estimation of limbal chamber depth in Asians: modified grading scheme. Br J Ophthalmol. 2000;84:186-192. LCD & VH
  • 14. • Good interobserver agreement (weighted kappa value = 0.73-0.76) • High intraobserver repeatability • Sensitivity = 99% • Thomas R et al. The flashlight test and van Herick’s test are poor predictors for occludable angles. Aust N Z J Ophthalmol 1996;24:251–256 • Foster PJ et al. Detection of gonioscopically occludable angles and primary angle closure glaucoma by estimation of limbal chamber depth in Asians: modified grading scheme. Br J Ophthalmol 2000;84:186–192 • Cockburn DM. Slitlamp estimate of anterior chamber depth as a predictor of the gonioscopic visibility of angle structures. Am J Optom Physiol Opt 1982;59:904–908 LCD & VH
  • 15. Advantages • Quick • Non-invasive • No auxiliary equipment LCD & VH
  • 16. • Subjective • Overestimation of angle depth (if slit beam moved too far on to the cornea, nasal limbus) • Little or no information regarding angle morphology • Affected by corneal degenerations such as arcus senilis • Horizontal quadrants only Limitations LCD & VH
  • 17. GONIOSCOPY • Indirect gonioscopy – most common, reference standard • Grading of anterior chamber angle depth • Iris configuration • Insertion of iris root • Peripheral anterior synechiae • Pigment deposition • Neovascularisation • Uveitis (nodules) • Blunt trauma (angle recession, cyclodialysis cleft)
  • 18. High interobserver agreement (kappa value = 0.62-0.82) • Foster PJ et al. Detection of gonioscopically occludable angles and primary angle closure glaucoma by estimation of limbal chamber depth in Asians: modified grading scheme. Br J Ophthalmol 2000;84:186–192 • Jacob JT et al. Evaluation of interobserver agreement in gonioscopy. Kerala J Ophthalmol. 2008;XX:253–255 • Lavanya R et al. Screening for narrow angles in the Singapore population: evaluation of new noncontact screening methods. Ophthalmology 2008:115:1720–1727 • Thomas R et al. The flashlight test and van Herick’s test are poor predictors for occludable angles. Aust N Z J Ophthalmol. 1996;24:251–256 Gonioscopy
  • 19. Advantages • Easily and quickly performed • Not expensive Gonioscopy
  • 20. • Invasive • Subjective, requires skill and experience • Variables – inadvertent pressure on cornea, light exposure onto pupil, patient cooperation, type of lens used, direction of gaze • Does not provide quantitative evaluation of the angle • Can not visualize structures posterior to iris Limitations Gonioscopy
  • 21. OBJECTIVE MEASURES • Ultrasound biomicroscopy (UBM) • Anterior segment optical coherence tomography (AS-OCT) Gonioscopy
  • 23. • Two-dimensional high-resolution gray-scale images of ocular structures anterior to pars plana • Quantitative and qualitative evaluation • Principle similar to that of B-scan (10 MHz) • Frequency – 50 MHz – More frequency – less penetration (5 mm) and more resolution UBM
  • 24. Interpretation of anterior chamber angle configuration is dependent on determining the location of scleral spur (inward protrusion of sclera) UBM
  • 25. Kong X, Foster PJ, Huang Q et al. Appositional Closure Identified by Ultrasound Biomicroscopy in Population-Based Primary Angle-Closure Glaucoma Suspects: The Liwan Eye Study. Glaucoma. 2011;52:7. No ITC High ITC (S type) High ITC (B type) Low ITC UBM
  • 26. • Angle opening distance (AOD500): Length of a perpendicular from TM to iris at a point 500 µm from SS • Trabecular-iris angle (Ø1): Apex in the iris sulcus and arms passing through the point 500 µm from SS and the point perpendicularly opposite on the iris UBM
  • 27. AOD500 : • Sensitivity = 82% • Specificity = 96% Trabecular iris angle: • Sensitivity = 83% • Specificity = 93% Henzan, IM et al. Comparison of Ultrasound Biomicroscopic Configurations Among Primary Angle Closure, Its Suspects, and Nonoccludable Angles: The Kumejima Study. Am J Ophthalmol. 2011;151(6):1065-1073 UBM
  • 28. Advantages • High resolution of 50 µm at a frequency of 50 MHz • Cross-sections of angle can be captured without lighting – changes in iris shape with or without light can be ascertained • Independent of corneal opacity • Dynamic changes can be recorded • Images can be automatically quantified UBM
  • 29. Assessment of areas not possible by gonioscopy: • Ciliary body • Inside the iris • Posterior chamber • Inside filtering blebs • Outflow tract for aqueous humour inside sclera UBM
  • 30. Limitations • Supine position – iris diaphragm falls back – angle opens • Only 1 quadrant can be imaged at a time • Angle region measured is located subjectively as superior, nasal, inferior and temporal • Skilled examiner • Longer image acquisition time • Use of anaesthesia • Contact with the eye using a cup with a coupling medium or a probe – corneal abrasion, infection UBM
  • 31. Can not detect: • Pigmentation in the angle • Inflammatory exudate in the angle • Neovascularization in the angle UBM
  • 32. ANTERIOR SEGMENT OPTICAL COHERENCE TOMOGRAPHY (AS-OCT)
  • 33. POSTERIOR SEGMENT OCT ANTERIOR SEGMENT OCT 830 nm 1310 nm Unable to penetrate sclera Penetrates sclera and iris More time for image acquisition Reduced time Compromised image quality Reduced motion artefacts – better image quality AS-OCT
  • 34. • Low coherence interferometry to obtain cross-sectional images of the ocular structures • Similar to UBM, interpretation of anterior chamber angle configuration is dependent on determining the location of scleral spur AS-OCT
  • 35. Angle closure in more than one quadrant was detected by: • AS-OCT in 71% of patients • Gonioscopy in 49.5% of patients When performed in dark conditions, AS-OCT identified angle closure in: • 98% of subjects found to have angle closure on gonioscopy • 44.6% of subjects found to have open angles on gonioscopy Specificity of AS-OCT to detect angle closure: 55.4% Nolan et al. Detection of primary angle closure using anterior segment optical coherence tomography in Asian eyes. Ophthalmology. 2007 Jan;114(1):33-39. AS-OCT
  • 36. Intraobserver variability = 9.4% to 12.5% Interobserver variability = 10.7% High reproducibility: 0.875-0.942 Tan AN et al. Reproducibility of anterior chamber angle measurements with anterior segment optical coherence tomography. Invest Ophthalmol Vis Sci, 52(5), 2095-2099 AS-OCT
  • 37. AS-OCT scanning protocol Sensitivity Specificity Nasal-temporal quadrants 47% 88% Inferior quadrant 84% 69% Superior-inferior quadrants 92% 54% Khor WB et al. Evaluation of scanning protocols for imaging the anterior chamber angle with anterior segment-optical coherence tomography. J Glaucoma. 2010 Aug;19(6):365-368. AS-OCT
  • 38. Advantages • Higher resolution than UBM (18 µm vs 25 µm) • Non-contact method • All 4 quadrants are imaged at once • Entire cross-section of anterior segment is imaged into one frame – permits assessment and documentation of iris profile and its relationship to other anatomical parameters of eye • Patient in sitting position – no alteration in anterior chamber depth • Does not require a skilled operator AS-OCT
  • 39. Limitations • Infrared light blocked by iris pigment – precludes assessment of structures located behind iris • Degradation of light by sclera – ciliary body not imaged fully • Can not obtain clear images through opaque media • Obstruction by eyelids – difficulty in imaging superior and inferior angles AS-OCT
  • 40. OCT and UBM had similar • mean values of angle opening distance, angle recess area and trabecular-iris space area • reproducibility, and • sensitivity-specificity profiles in identifying eyes with narrow angles Radhakrishnan S et al. Comparision of optical coherence tomography and ultrasound biomicroscopy for detection of narrow anterior chamber angles. Arch Ophthalmol. 2005 Aug:123(8):1053-1059. AS-OCT
  • 41. CONCLUSION • UBM and AS-OCT provide real-time cross-sectional images of anterior chamber angle – accuracy and reproducibility yet to be proved • Gonioscopy – continues to remain essential for glaucoma evaluation and management

Editor's Notes

  1. As many diagnoses are made only after angle assessment
  2. Comparison of limbal AC depth & periph corneal thickness. Traditionally divided into 4 grades
  3. Modified van Herick grade
  4. Foster et al hv shown dt Sensitivity of limbal chamber depth measurement as a method for detecting occludable angle, PAC and PACG decreases with narrowing of angle. While specificity increases.
  5. Plateau, Queer/concave peripherally, regular/straight, steep/convex. High insertion in dev gl.
  6. B-type (closure starts from bottom of angle recess without aqueous filled space). S-type (closure occurs at level of Schwalbe's line with an aqueous filled space)
  7. UBM compensates for shortcomings of gonioscopy but doesn’t replace it. Combination of the techniques maximizes the usefulness
  8. Visante OCT, 200 Asian subjects (71% clinically diagnosed as PAC). Gonioscopy - Spaeth classification. ACA closed on gonioscopy – PTM not seen. AS-OCT – contact between iris and angle wall anterior to scleral spur