Download - Gonioscopy and angle closure
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Gonioscopy
David M. Cale, OD, FAAO
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Disclaimer
This lecture has been independently developed by the
lecturer.
Dr. Cale has no financial relationship or conflict of
interest with any referenced authors, studies, or business
related to topics discussed in this lecture
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Learning Objectives
At the end of the lecture the attendee will be able to:
List indications for performing gonioscopy
Recognize good gonioscopy technique
Interpret & document observed angles
Recognize normal & abnormal angle architecture &
implications
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Anatomy:Where is the canal of Schlemm?
Schwalbe’s line (SL) Sampaolesi line
TM anterior
posterior
Scleral spur (SS)
Ciliary body (CB) wider in myopes
Iris root
Widest inferior
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When to perform gonioscopy (92020)
Narrow angle (365.02) or suspected obstruction of TM
per Van Herick estimate
Shallow A/C (penlight shadow test)
Evidence of prior angle closure
POAG or secondary glaucoma or suspect
History of ocular contusion (NOT acute injury)
R/O angle recession, iridodialysis, cyclodialysis
Risk of NVA (e.g. ischemic CRVO, BRVO)
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Penlight shadow test
uthsc.edu
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Subsequent
figures
courtesy:
W Alward
Color Atlas of
Gonioscopy
1994
Gonioscopy
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Is your view all the way in?
The iris beam
meets the
anterior wall
beam where the
iris root inserts
OR where there
is apposition
A gap separating
these 2 beams
indicates there is
open space
beyond your view
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Corneal wedge with
light TM pigment
Corneal wedge
reveals that 2
pigmented lines are
not TM.
PAS/inflammation
has resulted in iris
contact with cornea
Corneal wedge/ Focal line
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Gonioscopic
Variations
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Clear
posteriorTM with
pigmented
anteriorTM
Convex, no
CB/SS, ‘banded’
TM, Sampaolesi
line
Narrow CB,
wide SS,
pigmented post
TM
Gonioscopic
Variations
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Gonioscopy Technique – Dark Room
Conditions
Minimize the impact of room light or slit lamp beam on
constricting the pupil
It is estimated (Barkana, et al) that 38% of closed angles may be
misdiagnosed by the light opening an appositionally closed
angle
This is supported by evidence viewed with ultrasound biomicroscopy
examination under dark and light conditions on closed angles
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Angle Variation with Light (UBM)
Lights ON Lights OFF
Friedman, He Survey of Ophthalmology Vol53,No3 2008; reprinted from
Radhakrishnan et al Arch of Ophth
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Missing the diagnosis of angle closure
Not performing gonioscopy
Not performing gonioscopy under “dark “ conditions
Increasing IOP/opening the angle using gonio lens
Misinterpretation of a Sampaolesi line as pigmentedTM
Paul Palmberg, Gonioscopy in the Laser
Age 2003
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How we view the angle
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Positioning the lens for best view
Look “over
the hill”
without
pressing by
tilting lens
toward the
angle being
viewed
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Indentation or compression
Applying pressure to the globe by pushing in
on the lens (usually more toward one side or
edge of lens) can open up the angle and is used
to help differentiate appositional closure from
synechial closure.
This is better accomplished with a 4-mirror
(or small faced lens)
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Narrow angle,
convex iris
Indenting with
gonio lens
opens view to
CB
Indenting with 4-mirror
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Ultrasound Biomicroscopy
Friedman, He Survey of Ophthalmology Vol53,No3 2008
SS
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AS-OCT
Friedman, He Survey of Ophthalmology Vol53,No3 2008; reprinted
from Radhakrishnan et al Arch of Ophth
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Gonioscopy Lenses
Direct (Koeppe)
Indirect
3-mirror
4-mirror
pediatric
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Lens Choice Advantages
Goldmann 3-mirror
Stability
4-mirror
Quick
May not require interface solution
Compression
Adding flange improves stability
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The Procedure
Anesthetic
Interface Solutions
Goniosol (hydroxypropyl methylcellulose)
Refresh Celluvisc (carboxymethylcellulose)
RGP conditioning solution
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Classification
Shaffer (widely used)
Spaeth
Scheie (rarely used)
Van Herick (non-gonio estimate)
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van Herick
van Herick : compare a/c depth (endothelium to iris depth) at limbus to corneal thickness in slit lamp optic section
4 : a/c = cornea
3 : a/c = 1/4 to 1/2 cornea (and ½ to full)
2 : a/c = 1/4 cornea
1 : a/c = < 1/4 cornea
slit
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Angle Grades (Shaffer)
Grade 0 = closed
Slit = (<10deg) partial closure
Grade 1 = (10deg) closure probable
Grade 2 = (20deg) closure possible
Grade 3-4 = (30-40deg) wide open
Correspondance similar to van Herick
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Modified (Shaffer) Diagram
Documentation
Identify most posterior structure seen in each of 4 quadrants
SL, anterior TM, posterior TM, SS, CB
Iris approach into angle
Iris processes or PAS
Pigmentation in TM
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Spaeth grading (e.g. D40r)
site of iris insertion
A: @ SL
B: post to SL (@ TM)
C: @ SS
D: @ CB
E: posterior CB
angle width: 10, 20, 30 40°
configuration: s (steep), r
(regular or flat), q (queer or concave)
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Normal angle
Spaeth grade D40r
Spaeth
Grading
6-2 equiv A-E
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Scheie
Reversed grading system