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 CONTENTS

Preface vi

Acknowledgements vii

Abbreviations viii

1 Examination of the Eye 1

2 Eyelids 15

3 Lacrimal Drainage System 49

4 Orbit 59

5 Dry Eye 81

6 Conjunctiva 87

7 Cornea 109

8 Corneal and Refractive Surgery 147

9 Episclera and Sclera 153

10 Lens 161

11 Glaucoma 175

12 Uveitis 209

13 Retinal Vascular Disease 243

14 Acquired Macular Disorders 269

15 Hereditary Fundus Dystrophies 289

16 Retinal Detachment 305

17 Vitreous Opacities 317

18 Strabismus 321

19 Neuro-Ophthalmology 339

20 Ocular Tumours 377

21 Ocular Side Effects of Systemic Medication 401

22 Trauma 407

Index 421

v
PREFACE

This fourth edition of Kanski’s Synopsis of Clinical Ophthalmology is intended to be used principally
as a companion to the ninth edition of Kanski’s Clinical Ophthalmology. It provides a summary of
the larger book and is filled with beautiful illustrations. Synopsis can be used as a portable, rapidly
searchable reference source that is suitable for use in a busy clinic. Alternatively, the contents and
images are available in an online electronic format. The book is ideal as a basis for revision and is
presented as a series of easily absorbed topic summaries. General practitioners, medical students,
optometrists and specialist nurses requiring a shorter, but comprehensive review of ophthalmol-
ogy, may find Synopsis a more appropriate text than the lengthier consideration of Kanski’s Clinical
Ophthalmology.
Jack Kanski’s unique approach of presenting core knowledge in a systematic and succinct form
has been maintained. Brad Bowling had a significant influence on the previous edition and his
accuracy and meticulous attention to detail has been extremely helpful. I have started this edi-
tion with a new chapter on examination techniques and a short overview of the most important
ophthalmic special investigations. Each chapter has been updated and the latest evidence-based
diagnostic and therapeutic advances have been included.
All the illustrations have been reformatted and many new images have been added. I am grate-
ful to colleagues past and present, whose images are included in this edition. I have once again
had the good fortune of working with Jon Brett, a world-class photographer and artist, whose
expertise has been invaluable.
I am indebted to Elsevier for entrusting me with this work and, in particular, I wish to thank
Julie Taylor, Kayla Wolfe and Deborah Poulson for their editorial contribution. I hope you, the
reader, obtain as much enjoyment from the book as I have obtained from preparing it!

J.F. Salmon
Oxford 2021

vi
 ACKNOWLEDGEMENTS

Ambresin A. 1.12A-B, 14.5C-D, 14.7C-D, 14.8A-B, Barry C. 2.23A, 4.7D, 6.3, 7.21D, 8.3D,
12.14, 12.30A, C-D, 13.8B, 13.10A, 13.14B-D, 15.3B, 15.6B, 16.1C, 16.12B, 17.1A, 20.12A,
20.20B, 20.22A, 22.4A, Bates R. 5.2C, 7.19B, 8.3A, 9.4A, 12.28B, 13.7A-B, 20.9A, 22.6B,
Carmichael T. 7.1B, 7.5A, 7.17B, 7.21B, 7.24B, 7.28B, 20.7B, Chen S. 4.7A, 4.16B, 7.32A,
12.26A, 13.8A, 13.9A, 13.10C, 13.14A, 13.19A-B, 14.2A-B, 14.3A, 14.16D, 15.8C, 16.3D,
16.5B, 16.8B, 22.9D, Damato B. 16.11A, 20.8D, 20.13A, 20.17B, Dart J. 6.13B, 7.33B, Farley S,
Cole T, Rimmer L. 19.4B, Gili P. 19.1C, 19.9A, Harry J. 11.17A, Herbort C. 12.15A, 12.23B,
Hildebrand D. 3.5B, 4.10A-B, 18.14A-B, 18.15A-B, 19.9C, Issa P. 12.29A-B, 12.30B, 13.20B,
15.5D, 15.7C-D, Kerr-Muir M. 7.18A, Krachmer J, Mannis M, Holland E. Cornea, Mosby
2005. 8.3C, Leyland M. 8.5D, Lisch W. 7.21A, 7.25C, 7.26C, Malhotra R. 2.27A, Meyer D.
2.27B, Milewski S. 20.13B, Moorfields Eye Hospital 12.23A, Murray ADN. 12.22A, 18.3A-B,
18.4A-B, 18.10A-B, 18.11A-B, 19.11B. 19.19A-B, Nischal K.K. 3.2A, 3.6A, 4.13A, 11.19B,
Norris J. 2.23C, 4.8D, Papadopoulos M. 11.19A, Parulekar M. 2.27C, 18.9A-B, Patel CK.
13.18C-D, Pavesio C. 12.2C, 12.3D, 12.18B, Pearson A. 2.3C, 3.6B, 4.11A-B, 4.12A, 4.15A,
Pennesi M. 15.13D, Ratnarajan G. 11.28A, Ridgway A. 7.25D, Saine P. 6.1A, 15.1A, Scanlon
P. 14.14D, 14.16B, Singh AD, Damato BE, Pe’er J, Murphree AL, Perry JD. Clinical Ophthalmic
Oncology, Saunders 2007, 2.8B, Smit D. 2.44B, Snead M. 15.11A-B, Terry P. 16.10B, Tuft S.
2.14D, 3.9B, 5.2B and D, 6.7D, 6.8B-D, 6.11C, 6.14B, 7.1D, 7.2A, 7.9D, 7.11B, 7.16A, 7.19A,
7. 33A, 8.2C-D, 8.5C, Yangüela J. 19.30B-C, Yusuf I. 21.3A-B, Zitelli B, Davis H. Atlas of
Pediatric Physical Diagnosis. Mosby 2002, 4.17A.

vii
A B B R E V I AT I O N S

AAION: arteritic anterior ischaemic optic neuropathy

AAU: acute anterior uveitis
AC/A ratio: accommodative convergence/accommodation ratio
AD: autosomal dominant
AHP: abnormal head posture
AI: accommodative insufficiency
AIDS: acquired immune deficiency syndrome
AION: anterior ischaemic optic neuropathy
AKC: atopic keratoconjunctivitis
ALT: argon laser trabeculoplasty
AMD: age-related macular degeneration
ANA: antinuclear antibody
APD: afferent pupillary defect
APMPPE: acute posterior multifocal placoid pigment epitheliopathy
AR: autosomal recessive
AREDS: Age-Related Eye Disease Study
ARN: acute retinal necrosis
BCC: basal cell carcinoma
BP: blood pressure
BRAO: branch retinal artery occlusion
BRVO: branch retinal vein occlusion
BSV: binocular single vision
BUT: breakup time
CAI: carbonic anhydrase inhibitor
CAU: chronic anterior uveitis
CCT: central corneal thickness
CDCR: canaliculodacryocystorhinostomy
CHED: congenital hereditary endothelial dystrophy
CHRPE: congenital hypertrophy of the retinal pigment epithelium
CI: convergence insufficiency
CMO: cystoid macular oedema
CNS: central nervous system
CNV: choroidal neovascularization
CPEO: chronic progressive external ophthalmoplegia
CRAO: central retinal artery occlusion
CRP: C-reactive protein
CRVO: central retinal vein occlusion
CSMO: clinically significant macular oedema
CSS: central suppression scotoma
CT: computed tomography
DALK: deep anterior lamellar keratoplasty
CDR: dacryocystorhinostomy
DR: diabetic retinopathy
DSEK: Descemet stripping endothelial keratoplasty
DVD: dissociated vertical deviation
ECG: electrocardiogram
viii
Abbreviations ix

EDTA: ethylenediaminetetraacetic acid

EKC: epidemic keratoconjunctivitis
EOG: electro-oculogram
ERG: electroretinogram
ESR: erythrocyte sedimentation rate
FA: fluorescein angiography
FAP: familial adenomatous polyposis
FAZ: foveal avascular zone
FBC: full blood count
FFM: fundus flavimaculatus
GCA: giant cell arteritis
GPC: giant papillary conjunctivitis
HAART: highly active antiretroviral therapy
HIV: human immunodeficiency virus
HRT: Heidelberg retinal tomograph
HSV-1: herpes simplex virus type 1
HSV-2: herpes simplex virus type 2
HZO: herpes zoster ophthalmicus
ICGA: indocyanine green angiography
Ig: immunoglobulin
IK: interstitial keratitis
ILM: internal limiting membrane
INO: internuclear ophthalmoplegia
IOFB: intraocular foreign body
IOID: idiopathic orbital inflammatory disease
IOL: intraocular lens
IOP: intraocular pressure
IRMA: intraretinal microvascular abnormality
ITC: iridotrabecular contact
IU: intermediate uveitis
JIA: juvenile idiopathic arthritis
KCS: keratoconjunctivitis sicca
KP: keratic precipitate
LA: local anaesthesia
LASEK: laser epithelial keratomileusis
LASIK: laser in situ keratomileusis
LN: latent nystagmus
MLF: medial longitudinal fasciculus
MR: magnetic resonance imaging
MS: multiple sclerosis
MU: mega units
NF1: neurofibromatosis 1
NF2: neurofibromatosis 2
NRR: neuroretinal rim
NSAID: nonsteroidal anti-inflammatory drug
NSR: neurosensory retina
NVD: new vessels at the disc
NVE: new vessels elsewhere
OCT: optical coherence tomography
OHT: ocular hypertension
OKN: optokinetic nystagmus
x ABBREVIATIONS

PAC: primary angle-closure

PACG: primary angle-closure glaucoma
PACS: primary angle-closure suspect
PAM: primary acquired melanosis
PAS: peripheral anterior synechiae
PCF: pharyngoconjunctival fever
PCO: posterior capsular opacification
PCR: polymerase chain reaction
PCV: polypoidal choroidal vasculopathy
PDR: proliferative diabetic retinopathy
PDS: pigment dispersion syndrome
PDT: photodynamic therapy
PED: pigment epithelial detachment
PIOL: primary intraocular lymphoma
PION: posterior ischaemic optic neuropathy
PKP: penetrating keratoplasty
POAG: primary open-angle glaucoma
POHS: presumed ocular histoplasmosis syndrome
PPCD: posterior polymorphous corneal dystrophy
PPRF: paramedian pontine reticular formation
PPV: pars plana vitrectomy
PRK: photorefractive keratectomy
PRP: panretinal photocoagulation
PVD: posterior vitreous detachment
PVR: proliferative vitreoretinopathy
PXF: pseudoexfoliation
RAPD: relative afferent pupillary defect
RD: retinal detachment
ROP: retinopathy of prematurity
RP: retinitis pigmentosa
RPE: retinal pigment epithelium
RRD: rhegmatogenous retinal detachment
SCC: squamous cell carcinoma
SF: short-term fluctuation
SJS: Stevens–Johnson syndrome
SLK: superior limbic keratoconjunctivitis
SLT: selective laser trabeculoplasty
SRF: subretinal fluid
TAL: total axial length
TB: tuberculosis
TEN: toxic epidermal necrolysis
TGF: transforming growth factor
TIA: transient ischaemic attack
TTT: transpupillary thermotherapy
UBM: ultrasonic biomicroscopy
US: ultrasonography
VA: visual acuity
VEGF: vascular endothelial growth factor
VHL: von Hippel–Lindau syndrome
VKC: vernal keratoconjunctivitis
VKH: Vogt–Koyanagi–Harada syndrome
VZV: varicella zoster virus
X-L: X-linked
To Susie
 C H A P T E R 1
Examination of the Eye

C HAPTE R OUTLI NE

Ophthalmic history 1 External examination 4

Common ocular symptoms 1 Slit lamp biomicroscopy of the anterior
segment 6
Visual acuity 2
Direct ophthalmoscopy 7
Snellen visual acuity 2
Indirect ophthalmoscopy 7
LogMAR visual acuity 2
Tonometry 7
Contrast sensitivity 2
Central corneal thickness 9
Amsler grid 3
Gonioscopy 9
Colour vision 3
Ishihara 3 Optical coherence tomography (OCT) 10
Farnsworth–Munsell 100-hue test 3 OCT angiography 10
Visual field 3 Fundus angiography 11
Analysis of visual fields 4 Fluorescein angiography (FA) 11
Microperimetry 4 Indocyanine green angiography (ICG) 13

Ophthalmic history
Before examining the eye, a thorough ophthalmic history should be taken. The history can be
divided into the following basic categories of questioning:
◾ Main complaint: (a) rapidity of onset, (b) circumstances surrounding the onset, (c) severity,
(d) duration of symptoms, (e) frequency of symptoms.
◾ Past ocular history: e.g. previous surgery, inflammation, trauma.
◾ Past medical history: e.g. diabetes and hypertension.
◾ Systemic medication: e.g. corticosteroids, tamsulosin.
◾ Allergies: e.g. antibiotics, topical glaucoma medications.
◾ Family history: e.g. glaucoma, macular degeneration, inherited retinal disease.
◾ Occupation and hobbies

Common ocular symptoms

◾ Abnormality in vision: (a) visual loss and blurring (central or peripheral), (b) change in
colour vision, (c) visual aberration (scotoma, distortion, flashing lights, floaters), (d) diplopia
(monocular, binocular, neurological symptoms).
◾ Pain and discomfort: (a) ocular, (b) periocular (lids, sinus, temporal artery), (c) retrobulbar
(orbital inflammation), (d) nonspecific (eyestrain, dryness, scratching).
◾ Change in appearance: (a) redness, (b) swelling of the eyelids, (c) displacement of the
eyeball, (d) changes to the lids and periocular tissues, (e) discharge and watering.

1
2 SYNOPSIS OF CLINICAL OPHTHALMOLOGY

Visual acuity
Visual acuity is directly related to the minimum angle of separation between two objects that
allows them to be seen distinctly. Visual acuity should always be determined first, regardless of
whether the patient complains of visual disturbance or not. Each eye is tested separately, with and
without spectacles. A pinhole disc is a simple method of focusing light and temporarily removes
the effect of refractive error.

SNELLEN VISUAL ACUITY

A Snellen chart is used, with the subject reading the chart from a standard distance (Fig. 1.1A).
Normal visual acuity equates to 6/6 (20/20 in non-metric notation). If the patient is unable to see
the chart using either spectacles or a pinhole disc the vision can be determined by counting fingers
(CF), seeing hand movements (HM), or by assessing the ability to see light (PL).

LOGMAR VISUAL ACUITY

LogMAR is an acronym for the base-10 logarithm of the minimum angle of resolution. A Bailey–
Lovie chart is used, which has an equal number of letters on each line and the lines are balanced
for consistency of readability (Fig. 1.1B). LogMAR 0.00 is equivalent to 6/6 and logMAR 1.00
is equivalent to 6/60. Because logMAR acuity addresses many of the deficiencies of the Snellen
chart it is commonly used when research is undertaken.

Contrast sensitivity
Contrast sensitivity is a measure of the ability of the visual system to distinguish an object against
its background. The Pelli–Robson contrast sensitivity letter chart is viewed at 1 m and consists
of rows of letters of equal size, but with decreasing contrast of 0.15 log units for groups of three
letters (Fig. 1.2A).

A B
Fig. 1.1 Visual acuity chart: (A) Snellen, (B) Bailey–Lovie logMAR chart. (From Salmon JF, Kanski’s Clinical
Ophthalmology: A Systematic Approach, 9th edition. Oxford, UK: Elsevier; 2020.)
Chapter 1—Examination of the Eye 3

A B
Fig. 1.2 (A) Pelli–Robson contrast sensitivity letter chart, (B) Amsler grid showing wavy lines indicating
metamorphopsia and a dense scotoma. (From Salmon JF, Kanski’s Clinical Ophthalmology: A Systematic
Approach, 9th edition. Oxford, UK: Elsevier; 2020.)

Amsler grid
The Amsler grid evaluates the central 20° of the visual field centred on fixation (Fig. 1.2B). It is
an easy method of monitoring central visual field and is commonly abnormal in patients with
macular disease.

Colour vision
ISHIHARA
This test is simple to undertake, is widely available, and is frequently used to screen for red-green
colour anomalies. Inherited colour vision deficiency affects 8% of men and 0.5% of women. The
test can also be used to assess optic nerve disease (Fig. 1.3A).

FARNSWORTH–MUNSELL 100-HUE TEST

This test is sensitive but takes longer than the Ishihara to perform. It is used for congenital and
acquired colour defects (Fig. 1.3B).

Visual field
Visual field results should always be used in conjunction with the clinical findings. The test is
particularly important in glaucoma and neurological disease.
◾ The visual field: can be represented as a three-dimensional structure akin to a hill of increas-
ing sensitivity. The outer aspect extends approximately 50° superiorly, 60° nasally, 70° inferi-
orly and 90° temporally.
◾ Static perimetry: is a method of assessing fields in which the stimulus remains fixed, with
intensity increasing until it is seen by the subject or decreasing until it is no longer detected.
Standard automated perimetry (SAP) uses this method (Fig. 1.4).
4 SYNOPSIS OF CLINICAL OPHTHALMOLOGY

A B
Fig. 1.3 Colour vision tests: (A) Ishihara, (B) Farnsworth–Munsell 100-hue test. (From Salmon JF, Kanski’s
Clinical Ophthalmology: A Systematic Approach, 9th edition. Oxford, UK: Elsevier; 2020.)

◾ Kinetic perimetry: is undertaken by moving a stimulus of constant intensity from a

non-seeing area to a seeing area at a constant speed until it is perceived.

ANALYSIS OF VISUAL FIELDS

◾ Reliability indices (Fig. 1.4A): with SITA strategies false positive or false negative responses
over 15% should be considered significant. If the test is found to be unreliable, further evalu-
ation of the printout is pointless.
◾ A numerical display (Fig. 1.4B): gives the threshold in dB at each point tested in the field. A
grey scale (Fig. 1.4C) represents the numerical display in graphical form; decreasing sensi-
tivity is represented in darker tones.
◾ Total deviation (Fig. 1.4D): shows the difference between a test-derived threshold at a given
point and the normal sensitivity at that point for the general population.
◾ Pattern deviation (Fig. 1.4E): is the total deviation adjusted for a generalized decrease in
sensitivity in the whole field (for example, the presence of cataract).
◾ Summary values (Fig. 1.4F): represent distilled statistical information: (a) visual field index
(VFI) is a measure of overall visual field function expressed as a percentage, (b) mean devia-
tion (MD) provides an indication of the overall sensitivity of the field, (c) pattern standard
deviation (PSD) is a measure of focal loss (an increased PSD is an indicator of glaucoma),
(d) the glaucoma hemifield test (GHT) compares corresponding areas in the superior and
inferior hemifields.

Microperimetry
Microperimetry is a subjective visual field test that measures retinal sensitivity and fixation
behaviour in patients with macular disease and glaucoma involving the central 9° of visual field
(Fig. 1.5).

EXTERNAL EXAMINATION
External examination of the eye, periorbital tissues and orbit should be undertaken before mag-
nification is used. Fluorescein dye allows pathology on the surface of the cornea to be visualized
(see Fig. 22.8B) and is used when Goldmann applanation tonometry is undertaken.
Chapter 1—Examination of the Eye 5

Fig. 1.4 Humphrey SITA-Fast printout (A–F; see text). (From Salmon JF, Kanski’s Clinical Ophthalmology: A
Systematic Approach, 9th edition. Oxford, UK: Elsevier; 2020.)
6 SYNOPSIS OF CLINICAL OPHTHALMOLOGY

Fig. 1.5 Microperimetry in a patient with geographic atrophy of the macula. (From Salmon JF, Kanski’s Clinical
Ophthalmology: A Systematic Approach, 9th edition. Oxford, UK: Elsevier; 2020.)

Slit lamp biomicroscopy of the anterior segment

The purpose of slit lamp examination is to determine the position, depth and size of any abnormality
of the cornea and anterior segment. It provides good lighting and a stereoscopic view: (a) direct illu-
mination with a diffuse light is used to detect gross abnormalities, (b) scleral scatter involves decen-
tring the slit beam laterally so that the light is incident on the limbus with the microscope focused
centrally; light is transmitted within the cornea by total internal reflectivity which allows subtle
Chapter 1—Examination of the Eye 7

A B
Fig. 1.6 (A) Direct ophthalmoscopy, (B) indirect slit lamp biomicroscopy. (From Salmon JF, Kanski’s Clinical
Ophthalmology: A Systematic Approach, 9th edition. Oxford, UK: Elsevier; 2020.)

stromal haze to be detected, (c) retroillumination uses reflected light from the iris to illuminate the
cornea, permitting the detection of fine epithelial and endothelial changes, (d) specular reflection
shows abnormalities of the endothelium such as reduced cell density and guttata.

DIRECT OPHTHALMOSCOPY
◾ Ophthalmoscope (Fig. 1.6A). Direct examination of the structures of the fundus using an
ophthalmoscope can reveal disease of the eye itself or may reveal an abnormality indica-
tive of disease elsewhere in the body (for example: diabetes, systemic hypertension, raised
intracranial pressure). The image obtained is magnified (×15), but the disadvantages are that
there is no stereopsis and that the field of view is small.

INDIRECT OPHTHALMOSCOPY
This can be undertaken using a slit lamp or a head-mounted ophthalmoscope. A condensing lens
is held at the focal point of the eye and provides an inverted and laterally reversed image.
◾ Slit lamp biomicroscopy (Fig. 1.6B): (a) non-contact lenses: 60D (high magnification); when
estimating optic disc size use a correction factor of ×1.0; for the 90D (wide-field) lens use a
correction factor of 1.3 and for the 78D lens use ×1.1, (b) contact lenses: the Goldman three
mirror lens has a central lens and three mirrors set at different angles. A viscous coupling solu-
tion is required.
◾ Head-mounted binocular indirect ophthalmoscopy (Fig. 1.7A and B): allows retinal visualiza-
tion through a greater degree of media opacification than slit lamp ophthalmoscopy. A 20D
lens magnifies ×3 and a 28D lens (shorter working distance; used in a smaller pupil) magni-
fies ×2.27.

Tonometry
Tonometry is the method of measuring the intraocular pressure (IOP) using calibrated instru-
ments. The normal range for individuals over 40 years of age is 11–21 mm Hg, but 4–7% of normal
individuals have an IOP of more than 21 mm Hg (see Chapter 11).
8 SYNOPSIS OF CLINICAL OPHTHALMOLOGY

A B
Fig 1.7 (A) Head-mounted binocular indirect ophthalmoscopy, (B) showing technique of indentation.
(From Salmon JF, Kanski’s Clinical Ophthalmology: A Systematic Approach, 9th edition. Oxford, UK:
Elsevier; 2020.)

B C
Fig. 1.8 Goldmann applanation tonometry: (A) contact between the tonometer prism and the cornea, (B) cor-
rect end-point using mires of appropriate thickness, (C) tonometer calibration bar in position. (From Salmon
JF, Kanski’s Clinical Ophthalmology: A Systematic Approach, 9th edition. Oxford, UK: Elsevier; 2020.)

◾ Goldmann tonometry: This is an accurate variable-force tonometer consisting of a double

prism which applanates the central cornea (Fig. 1.8A). Fluorescein stain is used to create
semi-circular mires (Fig. 1.8B). Accuracy is lost with constant use and the tonometer should
be checked on a regular basis for calibration error (Fig. 1.8C). Calculations are based on a
central corneal thickness of 520 microns (if the cornea is thinner, an underestimation of
IOP is likely to result and if thicker, an overestimation). Corneal oedema may result in an
artificial reduction in the IOP value. Other sources of error include inappropriate fluores-
cein pattern and pressure on the globe.
◾ Perkins applanation tonometry: as above, but hand-held with portable light source.
Chapter 1—Examination of the Eye 9

◾ Other methods: (a) pneumotonometry (‘air-puff ’) is based on the principle of applanation

using a jet of air rather than a prism, (b) electronic applanation tonometry (tonopen); the
probe tip contains a transducer that measures applied force, (c) dynamic contour tonometry;
a solid-state sensor and a corneal contour-matching surface is used. It has the advantage of
measuring the IOP independent of corneal mechanical factors.
◾ Ocular response analyser and corneal hysteresis
This instrument uses air-puff technology to record two applanation measurements: one while
the cornea is moving inward and one when the cornea returns to its normal position. The aver-
age of these two measurements provides a Goldmann-related IOP measurement. The difference
between the IOP measurements is called corneal hysteresis. The value obtained is accurate in
individuals who have undergone laser refractive surgery. Patients with a low hysteresis value are
at greater risk of glaucoma progression and it may serve as a biomarker to aid glaucoma case
detection.

Central corneal thickness

This can be measured using pachymetry or by imaging with an Orbscan. The average value is
540 microns (range: 510–570 microns). It is an important measurement when determining the
risk of conversion to glaucoma in individuals with raised intraocular pressure.

Gonioscopy
Gonioscopy is a method of evaluating the anterior chamber angle. A contact lens is used, e.g.
Goldmann one-mirror lens (Fig. 1.9A), Zeiss four-mirror lens (Fig. 1.9B). The examination should
take place in a darkened room. Abnormalities that can be detected using gonioscopy include: (a)
angle closure, (b) neovascularization, (c) hyper-pigmentation, (d) angle recession (see Chapter 11).
◾ Indirect gonioscopy provides an inverted view of the portion of the angle opposite the mirror.
Non-indentation requires a coupling fluid. Indentation gonioscopy does not require a cou-
pling fluid and allows a view of the angle when there is apposition between the peripheral
iris and cornea. It allows the degree of synechiae to be determined.

A B
Fig 1.9 (A) Goldmann one-mirror goniolens, (B) Zeiss lens in position. (From Salmon JF, Kanski’s Clinical
Ophthalmology: A Systematic Approach, 9th edition. Oxford, UK: Elsevier; 2020.)