Optical instruments
Gonioscopy
Lecture 8
M.Sc Ali Hadi Alhussaini
Gonioscopy is a very important part of glaucoma evaluation, but is often underrated.
In addition to differentiating between open and closed angle glaucoma, other clues
in the angle also may help in diagnosis. Documenting the gonioscopic photographs
would help in objective assessment. This article covers the latest techniques in
gonioscopic imaging.
Indications
narrowness or closure of the anterior chamber angle
historical evidence of angle closure
history of previous attack of angle closure
evidence suggesting possible anterior chamber neovascularisation
recent or previous central or branch vein occlusion
evidence of neoplastic activity in the chamber
active or past inflammation in the chamber
history or evidence of trauma,
history or signs of penetrating ocular foreign body
degenerative conditions affecting the anterior segment
There are two types of gonioscopy
1- Direct gonioscopy: requires a coupling fluid and a gonioscopy lens, and the
patient most commonly lies in a supine position. This is used mainly in
operating theatres, and is an essential part of goniotomies or Gonioscopy-
Assisted Transluminal Trabeculotomy. It is also used for infants under
anesthesia.
2- Indirect gonioscopy: more commonly used in optometry and in clinical
practice. Patient sits upright, a slit lamp is used, and only topical corneal
anesthesia is required.
contraindications
Corneal or conjunctival inflammation or infection
Corneal abrasions or erosion where the risk of damaging the already
compromised corneal epithelium is unwarranted
Significant epithelial basement membrane dystrophy in which the corneal
epithelial attachment is weakened
Presence or suspicion of lacerated or perforated globes
Recent history of hyphaema or recent ocular contusion which may cause
recurrence of bleeding.
Systemic connective tissue disorders such as Epidermolysis Bullosa 6
Recent intraocular or corneal surgery
In brief (steps taken from gonioscopy(
Assess the eye and cornea for contraindications
Discuss the procedure with the patient, letting them know that the lens will
be very near their eye and their eyelids will have mild discomfort but no pain
Anaesthetise the cornea
Place the clean gonio on the cornea (you may require coupling fluid
depending on lens or style)
Ensure to hold squarely and not in a diamond configuration, and if using a
coupling fluid filling it only half-way reduces dripping down the patient’s
face
Lightly hold the lens on the eye to avoid artificially opening the angle.
Corneal folds alert the practitioner to applied pressure, which should be
avoided unless intentionally performing indentation gonioscopy
Commence in the superior mirror, which provides a view of the inferior irido-
corneal angle, which is the deepest and the most pigmented.
Assess the angles in the four mirrors/four quadrants .
Assess the cornea post gonioscopy
Compression or Indentation Gonioscopy (Dynamic)
1- Dynamic gonioscopy is where gentle pressure is placed on the four mirror lens and
subsequently the cornea, to assess for synechiae versus appositional closure and for
the extent of any peripheral anterior synechiae. The slit lamp beam should
illuminate the meshwork, and the beam size should be small to minimize the pupil
reducing miosis and artificial angle opening.
2-This may give false appearance of an open angle in the circumstance of angle
closure however when the practitioner is inadvertently applying too much pressure.
When this occurs, the pressure can be noted via induced folds in Descemet’s
membrane.
Grading the Angle
There are multiple different classification systems to report the angle but the most
common is Scheie which describes the degree of angle closure, and Shaffer which
describes the degree to which the angle is open
These two classification systems are in opposition of each other, with one discussion
the degree the angle is open, and the other to which the angle is closed which can
lead to
confusion when not clearly documented. Many practitioners choose to simply record
the most posteriorly visible structure in each quadrant, this avoids confusion when
records are reviewed later.
When should Gonioscopy be repeated
Glaucoma suspects
Patients on miotic therapy
Patients with fluctuating IOP
Suspicion of angle closure/anterior chamber shallowing or anterior chamber
abnormalities
Anterior Chamber Imaging
There are a number of technological advances that have been improving the view,
documentation and assessment we have of the anterior chamber angles such as
optical coherence tomography (OCT), Scheimpflug photography and ultrasound
biomicroscopy. These do not, however, replace gonioscopy in providing a full clinical
picture of recession, pigmentation of the angle, peripheral anterior synechiae and
evidence of past angle closure.These also do not allow for manipulation and manual
moving of the angle for assessment. Whilst these are useful additional assessment
tools, they cannot replace traditional gonioscopy.
Limitations
Imaging resolution is limited based on the quality of the camera and the
lighting
Nothing currently compares to the resolution of direct visualization of
gonioscopy
