GONIOSCOPY presentation dhir hospital bhiwani.pptx

1. GONIOSCOPY
Presenter : Dr Nikhil Agrawal (1st year resident)
Moderator : Dr Ekta Gupta
DHIR HOSPITAL AND POSTGRADUATE INSTITUTE OF OPHTHALMOLOGY

2. Definition
• Method of assessment of anterior chamber angle
• Greek word : Gonia –Angle , Skopein : To observe
• Purpose is to differentiate closed angle and abnormalities of angle .
• Higher risk of blindness in angle closure .
• Asian population has higher incidence of angle closure glaucoma .

3. Historical Background
• Trantas ,1907: First to visualise
angle , by indenting a eye with
keratoglobus .
• Salzmann, 1914 : Goniolens
• Goldmann, 1938 : Gonioprism
Keratoconus
On Indentation of Angle
Alexios Trantas Maximilian salzmann
Goldmann

4. Principle
• Critical angle for cornea –air interface is approximately 46 degree .
Goniolens : Refract the light
Gonioprism : Reflect the light
Critical Angle

5. Indications
• Diagnostic
Visualisation of angle in patients at risk of glaucoma
AC depth appears shallow with Van Herricks’s .
Classification of glaucoma
Degenerative or congenital anomaly of angle
Neovascularization in CRVO/BRVO , proliferative DR
Traumatic angle damage : Angle recession , cyclodialysis , FB
Evidence of inflammation at angle
Neoplastic lesions
Assess trabecular meshwork
• Therapeutic
Laser trabeculoplasty
Iridoplasty
Goniotomy
Microinvasive Glaucoma Surgery

6. Contraindications
• Acute trauma
• Ocular surface infection
• Epithelial defect
• Perforated globe
• Hypema

7. Types of Gonioscopy

8. Direct Gonioscopy
Goniolens Discription
Koeppe Prototype diagnostic
Richardson-Shaffer Small koeppe lens for infants
Thorpe Surgical and diagnostic
Swan Jacob Surgical Goniolens
Hoskins-Barkan Surgical Goniolens
Koeppe Lens : Available
in different diameters
Gonioscope / Hand
held Slit Lamp / IDO
Thorpe Hoskin-Barkan

9. Indirect Gonioscopy
• Gonioprism +Slit Lamp
• Angle is seen indirectly through a mirror .
Gonioprism Description
Goldmann (Single mirror ) 62 degree inclination
Goldmann( three mirror ) One mirror for gonio , two for retina
Zeiss four mirror 64 degree inclination , holder :Unger
Posner four mirror Modified zeiss four mirror with attached
holder
Sussman four mirror Hand held zeiss type
Volk G-6 Six mirrors inclined at 63 degree
7.38 Radius of
Curvature
Zeiss Four Mirror Posner Sussman Goldmann
Volk G-6
The contact surface is
flatter than cornea ,
does not require
coupling agent

10. Goldmann Three Mirror

11. Intraoperative Gonioscopy
• Indirect gonioscopy : Modified Swan Jacob lens , Khaw , Ritch , Hill ,
Vold and Ahmed (1.5 times magnification )
• Endoscopic probes or Eyecams
EyeCam : Clarity-Medical

12. Angle Grading Systems
• Slit lamp grading –Van Heriks
• Gonioscopic
Scheie
Shaffer
Spaeth
RPC
Van Heriks Grading

13. Shaffer’s Grading System

14. Spaeth Grading System

15. Recording Gonioscopy Findings
• Most Posterior Structure seen
• TM pigmentation (1-4)
• Iris Contour
• Presence of PAS
• Any other abnormality
https://entokey.com/clinical-
interpretation-of-gonioscopic-findings/

16. Structures Seen
• Root of iris
• Ciliary Body Band
• Scleral Spur
• TM
• Schwalbe’s line Root
of Iris

18. Root of Iris
1. Site of Insertion
2. Angulation
3. Contour : Flat , steep ,
bow posterior

19. Ciliary Body Band
• Part of ciliary body anterior to iris insertion
• Light gray to dark brown
• Wider in Myopes
• Cholinergic agents, such as pilocarpine, contracts
the fibers in the ciliary body and decrease
uveoscleral outflow. Anticholinergic drugs, such
as atropine : increase .

20. Scleral Spur
• White band just anterior to ciliary body band
• Longitudinal muscle of ciliary body attaches to it Posteriorly (Increase TM outflow)
• Corneoscleral trabecular sheets attaches to it anteriorly
• Iris processes can be seen here

21. Trabecular Meshwork
• Anterior : Whitish , no
functional element , adjacent
to Schwalbe’s line
• Posterior : Pigmented ,
functional part , adjacent to
scleral spur
Pigmentation increases
with age , may appear
greyish-white in young .

22. Schwalbe’s Line
• Most anterior
• Condensed collagen fibres at the
termination of descemet’s membrane
• Difficult to identify in non pigmented
TM
• Corneal wedge is used to identify it

23. Corneal Wedge
• Thin slit is made to incline at an
angle
• Two separate corneal reflections
are perceived
• These reflections intersect at
Schwalbe’s line

24. Sampaolesi’s Line
• At Schwalbe’s line corneal curvature changes to scleral curvature , this provides a
lodging space for pigment granules .
• This pigmentation on and around the Schwalbe’s line is sampaolesi’s line .

25. How to do Gonioscopy
• Semi dark room
• Put anesthetic drops
• Coupling fluid if needed
• Inform the patient
• With pt looking up, one edge of of lens is positioned in the
lower fornix.
• The upper lid is elevated & the pt is instructed to look
straight.
• Lens is rotated into position against the eye.
• Small slit (1-2mm length ), should not cross pupil
• Increase the magnification to visualize the angles clearly
• Rotate the lens for 360 degree view .
• When checking the lateral and medial angles , the slit beam
should be horizontal and for superior & inferior angles , slit
beam should be vertical.

26. Indentation /Dynamic Gonioscopy
• Posner and Sussmann four mirror lens
• Contact surface is flatter than the corneal curvature , do not require a coupling
agent .

27. • Occludable angle : If Posterior TM is not visible in at least 2 quadrants
in primary position
Over the Hill: Either
tilting the mirror
towards the angle or
asking the patient to
see towards the
mirror
Manipulation : By
increasing
illumination of room
or slit lamp causing
pupillary constriction

28. Cleaning of Goinioprism
• Soap and water
• 2% Glutaraldehyde
• 1:10 Sodium Hypochlorite
• Ethylene oxide
• 70% isopropyl alcohol ??

29. PACS
• Absence of PTM in at least 2 quadrants
without manipulation
• Normal IOP and optic disc
• No PAS

30. PAS
Closed Angle
Open Angle
Patchy Pigmentation

31. Double Hump Sign :
Plateau Iris
Pigment Dispersion Syndrome with
Concave Iris Confriguation

32. Hyperpigmentation of Angle
• Pigment dispersion syndrome
• Pseudoexfoliation syndrome
• Blunt ocular trauma
• Anterior uveitis
• Pseudophakic pigment dispersion
• Following acute angle closure attack

33. Pseudoexfoliation
• White flaky material in angle
• Increased pigmentation of TM
• Sampaolesi’s Line
• Usually open angle but can have angle
closure secondary to angle closure

34. Neovascularization of Angles

35. Iris Cyst
Anterior Iris Insertion : Flat iris confriguation , Covers
scleral spur

36. Angle Recession : Widening of
ciliary body band

37. Iridodialysis. Ciliary processes are visible Cyclodialysis Cleft : Sclera is visible

38. Glass FB in Angle Aniridia

43. Highly Pigmented TM

44. Angle recession ?

45. Open angle ?

47. Non Pigmented TM

51. Nidek GS-1

52. Goniopen

53. References
• Shields
• https://www.aao.org/disease-review/gonioscopic-grading-systems
• https://www.aao.org/disease-review/techniques-of-slit-lamp-gonioscopy
• http://www.gonioscopy.org/examples.htm

54. Ultrasound Biomicroscopy