What Am I Seeing?: Answers to Gonioscopy

5/12/2015
What Am I Seeing?:
Answers to Gonioscopy
Questions
Dr. Nate Lighthizer, O.D., F.A.A.O.
Assistant Professor, Oklahoma College of
Optometry
Chief of Specialty Care Clinics
Chief of Electrodiagnostics Clinic
Director of Continuing Education
[email protected]
Gonioscopic view
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History of Gonioscopy
How do you see the angle?
 Use


either
Direct lens – use a contact lens with specific
anterior curvature that will overcome critical
angle
Indirect – use a mirror to overcome the critical
angle
Direct Gonioscopy
 Koeppe
lens is the gold standard in direct
gonioscopy
 Usually used for pediatric patients in
association with a hand held slit lamp
(gonioscope + focal illuminator)
 Provides 15X to 20X mag
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Indirect Gonioscopy
 Two
major types

Goldmann Three Mirror lens

Zeiss four-mirror lens
• AKA Posner
• AKA Sussman without
the handle
Gonioscopy
 Is
the gold standard for assessing the
drainage apparatus of the eye
 Gonioscopy
should be performed on all
patients at least once a year?
 CPT
code 92020…MCR reimb = ~$25
Gonioscopy
 Used
to distinguish one type of glaucoma
from the other
 Mainly open from closed angle glaucoma
 Also angle recession and others
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Optics of Gonioscopy
Instructing and Counseling
the Patient
“Why and How”
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Preparing the Lens
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Insertion Techniques
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Types of Goniolenses
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6 mirror lens!
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Slit-Lamp Setup
Tips on Set-up
 Position
mirror at 12:00. (I always view
inferior angle first to get my landmarks.)
 To begin, keep gonio lens oriented straight
(i.e., not tilted)
 Put light on mirror before you go to the
oculars.
 I rest my hand on the patient’s head.
 Elbow rest if needed.
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Appreciating and Anticipating the
Anterior
Chamber Morphology
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Start with the “Big View” First
Low Mag and Iris Conformation
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Illuminating the Angle
Optical “Corneal Wedge”
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Getting the Wedge and Variations
of the Wedge Presentation
Set-up for Wedge
 Illumination
very bright
very narrow and vertical
 Move illumination angle a few degrees to
the right or left. (Not straight ahead)
 May have to move light left or right until
optimal position found.
 Slit
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 Most
clinicians will view the optical
“corneal wedge” once – in the inferior
angle. Using the landmarks found in the
inferior angle, the other three quadrants
can be evaluated.
 If needed, the wedge can also be viewed
in the superior angle. (Cannot be done in
lateral angles)
Angle Anatomy
“Clinical Variations on a Theme”
Angle Anatomy





Iris Insertion
Ciliary Body (Band)
Scleral Spur
Trabecular Meshwork
Schwalbe’s Line
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Ciliary Body (Band)


Visibility – “Width”
Pigmentation
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Scleral Spur
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Trabecular Meshwork
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Schwalbe’s Line
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Identifying Angle Structures –
Two Basic Techniques


Posterior to Anterior
Anterior (Optical Wedge) to Posterior
Quiz Time – 3 presentations
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Recording Your Findings
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St. Andrew’s Cross
Essential Findings to Record



Most Posterior Anatomical Feature of
Angle Seen
Rating of Angle Conformation, i.e., the
Angle “Openness”
Other Significant Findings, ex., pigment
Rating of Angle Conformation
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Spaeth’s angular width of the angle
recess
Spaeth’s configuration of the iris
OR
Steep (s)
Regular (r)
Queer (q)
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Spaeth’s insertion grading
Pigmentation
Spaeth grading
 B15b
2+ptm
meshwork (B)
 15 degree angle
 Anterior bowing of iris (b)
 2+ pigment in tm (2+ptm)
 Describes open but somewhat narrow
angle with moderate pigmentation and a
bowed iris
 Trabecular
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Shaffer classification
Techniques for Removing Lens
Different Angle Presentations
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Plateau Iris Syndrome

Development of residual angle closure after
patent Laser Peripheral Iridotomy (LPI)





Flat iris plane
Deep anterior chamber
Narrow angle due to anterior insertion of iris root
Dilation, being in a dark environment often
promotes bunching of peripheral iris in the angle
Consider the demographics

20-50 year old Caucasian females seem to be the
most prominent demographic
Plateau Iris Syndrome
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Angle Recession
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 Angle
recession
Pigment Dispersion Syndrome
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Pigment dispersion
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Quiz Time – 3 presentations
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Describe this angle
Iris processes
Pigmented Schwalbe’s
line – AKA
Sampaolesi’s line
TM
Gray CB
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Sampaolesi's Line,
pig glaucoma pt.
Iris processes
Gray CB
Gray CB
Open angle with blood in Schlemm's canal
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A hint of CB
Lightly pigmented TM
Lightly pigmented Schwalbe’s line
Normal iris and iris vessels
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