Download - Gonioscopy
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GONIOSCOPYMADE BY : SWATI PANARA
FROM : BHARTIMAIYA COLLEGE OF OPTOMETRY
2nd YEAR 4th SEMESTER
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INTROUCTION
• THE TERM GONIOSCOPY WAS COINED BY TRANTAS IN 1907.
• IT IS A CLINICAL TECHNIQUE THAT IS USED TO EXAMINE STRUCTURE IN THE ANTERIOR CHAMBER ANGLE.
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PURPOSE OF GONIOSCOPY
• WHY DO I NEED PERFORM GONIOSCOPY ?? - fundamental part of comprehensive exam. - done initially for all glaucoma patient and
suspects. - repeated periodically for patients with angle
closure glaucoma.
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• WHAT CAN I ACHIEVE WITH GONIOSCOPY ?? - Visualization of anterior chamber angle - view of the peripheral iris - differentiation between angle closure ,
occludable and secondary glaucoma.
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• WHAT SHOULD I LOOK FOR IN GONIOSCOPY ? - level of iris insertion - shape and profile of peripheral iris - estimated width of the angle approach - degree of trabecular pigmentation - areas of iridotrabecular apposition
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PRINCIPLE• The total internal reflection at the cornea occurs
because the angle of incidence of the rays from the anterior chamber angle structure is greater than the critical angle of the cornea – air interface , which is approximately 46°
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TYPES
DIRECT GONIOSCOPE
INDIRECT
GONIOSCOPE
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DIRECT GONIOSCOPY
• It is performed with a steep convex lens which permits light from the angle to exit the eye closer to the perpendicular at the lens – air interface.
• These lenses are used with a operating microscope.
• Direct gonioscopy is useful but fairly impractical for routine use.
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TYPES
Koeppe goniolens
Huskins barkan’s lens
Swan Jacob's lens
Richardson- Shaffer's lens
Sieback goniolens
Worth goniolens
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KOEEPE LENS
• It is the most commonly used for diagnostic direct gonioscopy.
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HUSKINS BARKAN’S LENS• It is a prototype surgical goniolens used for
goniotomy.
SWAN JACOB’S LENS• It is also used for surgical purpose..
SIEBACK GONIOLENS• It is a tiny goniolens which floats on the cornea.
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RICHARDSON – SHAFFER’S LENS
• It is basically a small Koeppe lens used for infants.
WORTH GONIOLENS• It anchors to cornea by partial vacuum.•
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TECHNIQUE
• Cornea is first anaesthetized with 4% xylocaine instilled topically.
• Ideal position – patient lying supine with the examiner sitting on the side of the eye.
• Patient looking up , lower lip of the goniolens is inserted below the lower lid.
• Patient is asked to look down and upper lip is placed beneath upper lid.
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• Now the patient’s head turned towards the examiner , the nasal lip of goniolens is slightly raised and normal saline drops are used for irrigation
• Now gonioscopy is performed with the patient looking to the ceiling.
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ADVANTAGE
• Greater flexibility• Used in goniotomy surgery• Used in anaesthetized patients as in infants• Causes lesser distortion of anterior chamber• angle becomes deep in supine position so it is
easy to see the angle.• Panoramic view is obtained so one part of
angle could be compared with the other.
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• Using two lenses , both eyes can be examined simultaneously.
• Provide a straight view rather than inverted view.
• Detailed examination of minor structure is possible.
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DISADVANTAGE
• Inconvenient• Annoying light reflex from cornea• Time – consuming• Benefits of slit lamp are not available
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INDIRECT GONIOSCOPY
• Indirect gonioscopy uses mirrors or prism to over come the problem of total internal reflection.
• Moreover , it uses the slit lamp’s illumination and magnification system to its advantage.
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TYPES
GONIOPRISM
REQUIRING COUPLING
AGENT
GONIOPRISM NOT
REQUIRING COUPLING
AGENT
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GONIOPRISM REQUIRING COUPLING AGENT
GOLDMANN THREE MIRROR GONIOPRISM
GOLDMANN TWO MIRROR GONIOPRISM
GOLDMANN SINGLE MIRROR
GONIOPRISM
ALLEN – THROPE GONIOPRISM
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GOLDMANN THREE MIRROR GONIOPRISM
• The mirror having inclination of 59° and domed upper border is used for gonioscopy.
• (1) the mirror inclined at 67° is used to examine pars plana area of ciliary body.
• (2) the mirror having inclination of 73° is used to examine ora serrata area of peripheral fundus.
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GOLDMANN TWO MIRROR GONIOPRISM
• Both the mirrors are inclined at 62°• It need to be rotated once to examine the
whole angle.• Laser trabeculoplasty
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GOLDMANN SINGLE MIRROR GONIOPRISM
• The mirror is inclined at 62°• It is prototype diagnostic gonioprism.• It is to be rotated three times to examine the
whole angle.
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ADVANTAGE OF GOLDMANN GONIOPRISM
• Easy to use• Excellent view• Stabilizes the globe and there for can be used
in argon laser trabeculoplasty.• Peripheral retina can be seen• Goldman two mirror gives best In – situ view
of the angle.
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DISADVANTAGE OF GOLDMANN GONIOPRISM
• Curvature of lens is more than that of cornea so a coupling material is required. it blurs vision and fundus therefore field charting , direct and indirect ophthalmoscopy cannot be done immediately after its use.
• It cannot be used for indentation gonioscopy.• Only one mirror is there for gonioscopy so it
needs to rotated by 360°
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ALLEN – THROPE GONIOPRISM
• It has got four prisms instead of mirror and allows examination of the whole angle without rotating the prisms.
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GONIOPRISM NOT REQUIRING COUPLING AGENT
ZEISS FOUR MIRROR
GONIOPRISM
POSNER GONIOPRISM
SUSSMAN LENS
TOKEL GONIOPRISM
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ZEISS FOUR MIRROR GONIOPRISM
• Four identical mirrors angled at 64° which allow examination without rotation of the lens.
• ADVANTAGE : coupling material not required• Easy to perform when mastered• Indentation gonioscopy can be performed• DISADVANTAGE : difficult to master• Does not stabilize the globe
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POSNER LENS
• It is similar to zeiss gonioprism but is made of plastic instead of glass and also has fixed rather than detachable handle.
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TOKEL GONIOPRISM
• It is a single mirror gonioprism and has got a wider field of view.
• SUSSMAN LENS• It is also similar to zeiss lens except that it has
no handle.
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TECHNIQUE
• Eye is anaesthetized with the topical anaesthetic anent
• Patient who is sitting on the slit lamp is asked to look down
• The thumb of one hand is used to retract the upper lid.
• The lower edge of the gonioscope is placed on the lower lid.
• Slit lamp beam is focused on the mirror that shows the angle diametrically opposite to it.
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ADVANTAGE
• Easier to learn.• Faster to perform.• Requires less instrumentation and space.• Slit lamp provides better optics and lighting.• Indentation gonioscopy can also be done.• Magnified stereoscopic view of optic disc can
also be obtained.
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DISADVANTAGE
• Comparison is not possible.• Limited positioning of light rays.• Difficult to perform in horizontal meridian.• Mirror image seen , so confusing.• Excessive pressure may open or close the
angle artefactually.
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RECORDING
• Most posterior angle structure observed.• Angular approach at the recess.• Iris contour• Amount of pigment• to what degree the angle opens with
indentation• Surgical alteration such as sclerectomy and
peripheral iridotomy.
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GRADING SYSTEM FOR THE ANGLE OF ANTERIOR CHAMBER
SCHEIE’S GRADING
SHAFFER’S GRADING
RP CENTRE GONIOSCOPIC
GRADING
Speath GONIOSCOPIC
GRADING
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SCHEIE’S GRADING
• Grade 1 narrow = hard to see over iris root into recess
• Grade 2 narrow = ciliary body band obscured• Grade 3 narrow = posterior trabeculum
obscured• Grade 4 narrow = only schwalbe’s line visible.
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SHAFFER’S GRADING SYSTEM
• Grade 0 —PARTIAL OR COMPLETE CLOSURE
• Grade I </= 10° angle of approach
• Grade II -20° angle of approach
• Grade III 20°–35° angle of approach
• Grade IV 35°–45° angle of approach
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RP CENTRE GONIOSCOPIC GRADING• Grade 0 = no dipping of the beam• Grade 1 = dipping of the beam• Grade 2 = schwalbe’s line and anterior one –
third of the trabecular meshwork visualized.• Grade 3 = middle one – third of trabecular
meshwork visualized.• Grade 4 = posterior one – third of trabecular
meshwork• Grade 5 = scleral spur visualized• Grade 6 = ciliary body band visualized
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SPEATH CLASSIFICATION
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GONIOSCOPIC VIEW OF ANGLE STRUCTURE
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SCHWALBE’S LINE
• Termination of descement’s membrane• It is marked only by a slight change in colour
from trabecular meshwork or by a faint white line.
• Important landmark in identifying the gonioscopic anatomy in confusing angle.
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TRABECULAR MESHWORK
• It has an anterior non pigmented trabecular meshwork and posterior pigmented trabecular meshwork.
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CILIARY BODY BAND
• It is light grey or dark brown just posterior to the scleral spur.
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ROOT OF IRIS
• Iris contour is slightly convex or flat.• Colour varies in different individuals.
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GONIOSCOPIC TECHNIQUE
GONIOSCOPIC IN SITU MANIPULATIVE GONIOSCOPY
INDENTATION GONIOSCOPY
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CLINICAL USE OF GONIOSCOPY
• Differentiation between primary open angle glaucoma and primary closure angle glaucoma
• To diagnose and provide a prognosis for the congenital glaucoma.
• To diagnose secondary glaucoma and unusual causes of glaucoma.
• For treatment• To diagnose condition like tumours of anterior
segment , intraocular foreign body.
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LIMITATION
• Cannot be performed in painful inflamed eyes.• Difficult to perform in case of acute glaucoma
where eyes are painful.
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REFERENCE• CLINICAL PROCEDURE IN PRIMARY EYE CARE –
DAVID B. ELLIOTT• OPTIC AND REFRACTION – A K KHURANA• NET• PURAB SIR’S NOTES• COMPREHENSIVE OPHTHALMOLOGY – A K
KHURANA• KANSKI
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THANK YOU