Direct and indirect image gonioscopy. A method for inspection of the chamber angle for clinical and surgical use with special reference to early postoperative gonioscopy.
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A proposed simple method for measurement in the anterior chamber angle: biometric gonioscopy.
OBJECTIVE: To design a system of gonioscopy that will allow greater interobserver reliability and more clearly defined screening cutoffs for angle closure than current systems while being simple to teach and technologically appropriate for use in rural Asia, where the prevalence of angle-closure glaucoma is highest. DESIGN: Clinic-based validation and interobserver reliability trial. PARTICIPANTS: Study 1: 21 patients 18 years of age and older recruited from a university-based specialty glaucoma clinic; study 2: 32 patients 18 years of age and older recruited from the same clinic. INTERVENTION: In study 1, all participants underwent conventional gonioscopy by an experienced observer (GLS) using the Spaeth system and in the same eye also underwent Scheimpflug photography, ultrasonographic measurement of anterior chamber depth and axial length, automatic refraction, and biometric gonioscopy with measurement of the distance from iris insertion to Schwalbe's line using a reticule based in the slit-lamp ocular. In study 2, all participants underwent both conventional gonioscopy and biometric gonioscopy by an experienced gonioscopist (NGC) and a medical student with no previous training in gonioscopy (JK). MAIN OUTCOME MEASURES: Study 1: The association between biometric gonioscopy and conventional gonioscopy, Scheimpflug photography, and other factors known to correlate with the configuration of the angle. Study 2: Interobserver agreement using biometric gonioscopy compared to that obtained with conventional gonioscopy. RESULTS: In study 1, there was an independent, monotonic, statistically significant relationship between biometric gonioscopy and both Spaeth angle (P = 0.001, t test) and Spaeth insertion (P = 0.008, t test) grades. Biometric gonioscopy correctly identified six of six patients with occludable angles according to Spaeth criteria. Biometric gonioscopic grade was also significantly associated with the anterior chamber angle as measured by Scheimpflug photography (P = 0.005, t test). In study 2, the intraclass correlation coefficient between graders for biometric gonioscopy (0.97) was higher than for Spaeth angle grade (0.72) or Spaeth insertion grade (0.84). CONCLUSION: Biometric gonioscopy correlates well with other measures of the anterior chamber angle, shows a higher degree of interobserver reliability than conventional gonioscopy, and can readily be learned by an inexperienced observer.
Adult↗
Evaluation of the anterior chamber angle in Asian Indian eyes by ultrasound biomicroscopy and gonioscopy.
PURPOSE: To compare the ultrasound biomicroscopic measurement of the anterior chamber angle in Asian Indian eyes, with the angle width estimated by gonioscopy. MATERIALS AND METHODS PARTICIPANTS: Patients with open and closed angles attending a glaucoma clinic were recruited for the study. OBSERVATION PROCEDURES: Temporal quadrants of the angles of patients were categorized by gonioscopy as Grade 0 to Grade 4, using Shaffer's classification. These angles were quantified by ultrasound biomicroscopy (UBM) using the following biometric characteristics: Angle opening distance at 250 micro (AOD 250) and 500 micro (AOD 500) from the scleral spur and trabecular meshwork-ciliary process distance (TCPD). The angles were further segregated as "narrow angles" (Schaffer's Grade 2 or less) and "open angles" (Schaffer's Grade 3 and 4). MAIN OUTCOME MEASURES: The UBM measurements were computed in each case and analyzed in relation to the gonioscopic angle evaluation. RESULTS: One hundred and sixty three eyes of 163 patients were analyzed. One hundred and six eyes had "narrow angles" and 57 eyes had "open angles" on gonioscopy. There was a significant difference among the mean UBM measurements of each angle grade estimated by gonioscopy (P < 0.001). The Pearson correlation coefficient between all UBM parameters and gonioscopy grades was significant at the 0.01 level. The mean AOD 250, AOD 500 and TCPD in narrow angles were 58+/-49 micro, 102+/-84 micro and 653+/-124 respectively, while it was 176+/-47 micro, 291+/-62 micro and 883+/-94 micro in eyes with open angles (P < 0.001) respectively. CONCLUSIONS: The angle width estimated by gonioscopy correlated significantly with the angle dimensions measured by UBM. Gonioscopy, though a subjective test, is a reliable method for estimation of the angle width.
Anterior Chamber↗
[Clinical evaluation of indentation gonioscopy].
The chamber angles of 31 cases (44 eyes) of angle closure glaucoma were studied by Iwata indentation gonioscopy and Goldman gonioscopy. (1) In 39 (89%) of the 44 eyes, the extent of open filtering angle under the indentation gonioscopy was larger than the that under Goldmann gonioscopy. (2) Peripheral iridectomy was indicated in only 68% of the cases when examined by Goldmann gonioscopy, while all cases were performed peripheral iridectomies successfully as indicated by indentation gonioscopy. Therefore, indentation gonioscopy is very useful in the differentiation of functional apposition of the chamber angle from the pathological peripheral synechiae.
Adult↗
Use of gonioscopy in medicare beneficiaries before glaucoma surgery.
PURPOSE: The American Academy of Ophthalmology Preferred Practice Patterns for angle closure and open-angle glaucoma (OAG) patients recommends performing bilateral gonioscopy upon initial presentation to evaluate the possibility of narrow angle or angle-closure glaucoma (ACG) and then repeating the examination at least every 5 years. This study aims to assess how commonly eye care providers perform gonioscopy before planned glaucoma surgery in OAG, anatomic narrow angle, and ACG in the Medicare population. METHODS: Data obtained from a 5% random sample of Medicare beneficiaries undergoing glaucoma surgery in the United States in 1999 were retrospectively reviewed. The proportion of patients with evidence of at least one gonioscopic examination before glaucoma surgery was determined for the period of 1995 to 1999. Demographic and clinical factors potentially influencing the decision to perform gonioscopy were also examined. RESULTS: Overall, gonioscopy is apparently performed in 49% of Medicare beneficiaries during the 4 to 5 years preceding glaucoma surgery. This rate was significantly lower (P < 0.001) in patients with OAG (46%), as compared with anatomic narrow angle (58%) and ACG (57%) patients. Hispanics, elderly (aged 70 to 84), patients undergoing laser iridotomy, and patients receiving care in the New York/New Jersey area all had significantly higher apparent preoperative gonioscopy rates (P < 0.05). CONCLUSIONS: Gonioscopy examination before glaucoma surgery in Medicare beneficiaries is underused, undercoded, and/or miscoded, given current recommendations. Underuse is of particular concern in patients undergoing laser iridotomy as it is the diagnostic test of choice in ACG.
Aged↗
[Postoperative ultrasound biomicroscopic evaluation of the tangible position of black diaphragm posterior chamber lenses in congenital and traumatic aniridia in comparison with gonioscopy].
BACKGROUND: Ultrasound biomicroscopy (UBM) allows to determine the haptic position of posterior chamber lenses (PCL) in relation to adjacent structures. In transsclerally sutured PCLs, the comparison between intraoperatively endoscopically and postoperatively localized haptic positions via UBM showed a correspondence of only 81%. The different localisation of 19% of the examined haptic positions was explained with postoperative dislocation without any proof for this assumption. The purpose of this study therefore was the correlation of UBM results with simultaneously determined haptic positions via gonioscopy in aniridia after black diaphragm PCL implantation. PATIENTS AND METHODS: The haptic positions of black diaphragm PCL implants in 20 patients with congenital and 13 patients with traumatic aniridia were determined via UBM (50-MHz-probe) and gonioscopy 44.4 (6-75) months postoperatively. RESULTS: 39/66 haptic positions could be localized in gonioscopy as well as in UBM. 38 haptics (97.4%) showed the same position in both examination techniques. Determination of the haptic position through one of the two examination techniques was impossible in 27/66 haptics (11 haptics in gonioscopy, 16 haptics in UBM). Reasons for this were primarily haptic position behind iris remnants and corneal opacities in gonioscopy and scarring of the ciliary body in UBM. CONCLUSIONS: The validity of UBM in localization of PCLs was confirmed gonioscopically, which also confirms our prior assumption of postoperative displacement of IOL-haptics after transscleral suturing in about 20% of cases. Scarring of the ciliary body was the most important obstacle in the determination of PCL haptic positions in relation to adjacent structures.
Adult↗
The effect of Gonioscopy on keratometry and corneal surface topography.
BACKGROUND: Biometric procedures such as keratometry performed shortly after contact procedures like gonioscopy and applanation tonometry could affect the validity of the measurement. This study was conducted to understand the short-term effect of gonioscopy on corneal curvature measurements and surface topography based Simulated Keratometry and whether this would alter the power of an intraocular lens implant calculated using post-gonioscopy measurements. We further compared the effect of the 2-mirror (Goldmann) and the 4-mirror (Sussman) Gonioscopes. METHODS: A prospective clinic-based self-controlled comparative study. 198 eyes of 99 patients, above 50 years of age, were studied. Exclusion criteria included documented dry eye, history of ocular surgery or trauma, diabetes mellitus and connective tissue disorders. Auto-Keratometry and corneal topography measurements were obtained at baseline and at three follow-up times - within the first 5 minutes, between the 10th-15th minute and between the 20th-25th minute after intervention. One eye was randomized for intervention with the 2-mirror gonioscope and the other underwent the 4-mirror after baseline measurements. t-tests were used to examine differences between interventions and between the measurement methods. The sample size was calculated using an estimate of clinically significant lens implant power changes based on the SRK-II formula. RESULTS: Clinically and statistically significant steepening was observed in the first 5 minutes and in the 10-15 minute interval using topography-based Sim K. These changes were not present with the Auto-Keratometer measurements. Although changes from baseline were noted between 20 and 25 minutes topographically, these were not clinically or statistically significant. There was no significant difference between the two types of gonioscopes. There was greater variability in the changes from baseline using the topography-based Sim K readings. CONCLUSION: Reversible steepening of the central corneal surface is produced by the act of gonioscopy as measured by Sim K, whereas no significant differences were present with Auto-K measurements. The type of Gonioscope used does not appear to influence these results. If topographically derived Sim K is used to calculate the power of the intraocular lens implant, we recommend waiting a minimum of 20 minutes before measuring the corneal curvature after gonioscopy with either Goldmann or Sussman contact lenses.
Aged↗
Anterior chamber angle assessment using gonioscopy and ultrasound biomicroscopy.
PURPOSE: Comparison of anterior chamber angle measurements using ultrasound biomicroscopy (UBM) and gonioscopy. METHODS: Five hundred subjects were evaluated for grading of angle width by the Shaffer method. UBM was done in the same group to document angle width, angle opening distance (AOD 500), and anterior chamber depth. Biometric parameters were documented in all subjects. UBM and gonioscopic findings were compared. RESULTS: A study was conducted in 282 men and 218 women with a mean age of 57.32 +/- 12.48 years. Gonioscopic grading was used to segregate occludable (slit-like, grades 1 and 2) from nonoccludable (grades 3 and 4) angles. Subjective assessment by gonioscopy resulted in an overestimation of angle width within the occludable group when compared with values obtained by UBM. This did not affect the segregation of occludable versus nonoccludable angles by gonioscopy. Biometric parameters in eyes with occludable angles were significantly lower in comparison with eyes with nonoccludable angles, except for lens thickness. AOD 500 correlated well with angle width. CONCLUSIONS: We concluded that clinical segregation into occludable and nonoccludable angles by an experienced observer using gonioscopy is fairly accurate. However, UBM is required for objective quantification of angles, and AOD 500 can be a reliable and standard parameter to grade angle width.
Adult↗
Evaluation and comparison of indentation ultrasound biomicroscopy gonioscopy in relative pupillary block, peripheral anterior synechia, and plateau iris configuration.
PURPOSE: To evaluate and compare the findings and changes of the anterior chamber angle configuration with indentation ultrasound biomicroscopy (UBM) gonioscopy in relative pupillary block (RPB), peripheral anterior synechia (PAS), and plateau iris configuration (PIC). METHODS: This study included 73 eyes of 52 patients with RPB (n = 26), PAS (n = 21), or PIC (n = 26). First, a conventional UBM scan was performed using a normal size standard eye cup before indentation. Then, for indentation UBM gonioscopy, scans were performed using a new eye cup that we designed. For evaluation of the angle, angle opening distance 500 and angle recess area were recorded and evaluated with regard to the effect of expansion on the anterior chamber angle. RESULTS: Indentation UBM gonioscopy showed the characteristic images in each of the eyes. The angle of all examined eyes was significantly widened with indentation (P < 0.01). The angle changes in eyes with RPB were significantly greater than in eyes with PAS or PIC (P < 0.01). CONCLUSION: Indentation UBM gonioscopy is a very useful method for observing the angle and diagnosis of RPB, PAS, and PIC.
Aged↗
Evaluation of eyes with relative pupillary block by indentation ultrasound biomicroscopy gonioscopy.
PURPOSE: To investigate changes in anterior chamber angle configuration with indentation ultrasound biomicroscopy gonioscopy of relative pupillary block (RPB). DESIGN: Cross-sectional study. METHODS: This study included 26 eyes of 26 patients with RPB. We determined angle opening distance 500 and angle recess area using indentation ultrasound biomicroscopy gonioscopy and compared a small-sized standard eye cup with a new eye cup with an area for inducing pressure. RESULTS: Indentation ultrasound biomicroscopy images documented concavity of the iris in eyes with RPB. Both the new and the small standard eye cups widened the anterior chamber angle significantly (P <.0001) without causing corneal damage. Angle changes were significantly greater for the new eye cup design. CONCLUSIONS: Indentation ultrasound biomicroscopy gonioscopy is a useful technique for observation and diagnosis of RPB. Using a small standard or the newly designed eye cup, the procedure can be performed easily and without causing corneal damage.
Aged↗
Gonioscopy: uses old and new. The inheritance of occludable angles.
The goniolens has become increasingly important in the practice of ophthalmology, For example, the treatment of angle closure and neovascular glaucoma is most effective in the earliest stages of the diseases, even prior to the onset of symptoms. Routine gonioscopy is essential if patients are to be provided optimum care. The critical nature of pressure gonioscopy is reviewed. The use of the goniolens to examine the corneal endothelium is described and recommended. Characterization of the configuration of the angle recess demands description of at least three aspects: (1) the angular approach to the recess, (2) the peripheral curvature of the iris, and (3) the point of insertion of the iris onto the ciliary body or endothelial surface. The nature of these three considerations is reviewed, as is their frequency in a normal population, in a group of ten people with definite 1 degree angle-closure glaucoma, and in 95 relatives of the subjects with angle-closure glaucoma. Marked anterior convexity of the peripheral iris appears to be highly correlated with the development of 1 degree angle closure. The three aspects of the angle configuration appear to be independently inherited. Gonioscopy of relatives of cases with 1 degree angle-closure glaucoma is highly recommended.
Anterior Chamber↗
Gonioscopy.
Gonioscopy forms part of a complete ophthalmic examination and is mandatory for the diagnosis and management of glaucoma. Gonioscopy permits identification of eyes at risk for closure and detects angle abnormalities that could have diagnostic and therapeutic implications. The technique of gonioscopy, its value in management, and guidelines for routine use are discussed in this paper.
Cornea↗
Comparison of gonioscopy and ultrasound biomicroscopy for evaluating the iridocorneal angle in dogs.
OBJECTIVE: To compare iridocorneal angle grading systems on the basis of gonioscopy and ultrasound biomicroscopy (UBM). DESIGN: Original cross-sectional observational study. ANIMALS: 22 dogs. PROCEDURE: Gonioscopy, goniophotography, and UBM were performed on 38 eyes from dogs without clinical evidence of glaucoma in the eyes examined. RESULTS: Predominant gonioscopic grades derived from goniophotographs were considered normal (n = 26) and mild (12). Ultrasound biomicroscopy angle measurements ranged from 16 to 38 degrees (mean +/- SD, 26.2 +/- 4.5 degrees). Ciliary clefts depicted on UBM images were graded as open (n = 4), compact/narrow (23), and closed (11). Significant differences were not found between UBM-derived ciliary cleft grades and goniophotography-derived dysgenesis grades, nor between UBM-derived ciliary cleft grades and subjective gonioscopic grades. CLINICAL IMPLICATIONS: Because gonioscopy allows evaluation of the anterior face of the ciliary cleft, whereas UBM provides cross-sectional information of the iridocorneal filtration angle, UBM may yield more information regarding pathogenesis and prognosis of, and preferred management approaches to, glaucoma. Ultrasound biomicroscopy may also be useful as a predictor of glaucoma or to diagnose early stages of glaucoma.
Animals↗
The detection of post-traumatic angle recession by gonioscopy in a population-based glaucoma survey.
BACKGROUND: Blunt trauma is responsible for most eye injuries in urban populations. Anterior chamber angle recession has been reported to be the most common sign of previous blunt trauma to the eye. The cumulative lifetime prevalence of post-traumatic angle recession has not been reported previously, and the relation between angle recession and glaucoma in a population-based setting is unknown. METHODS: As part of a population-based glaucoma survey, gonioscopy was performed on 987 (82.7%) of 1194 inhabitants of the village of Mamre, near Cape Town, South Africa, who were 40 years of age or older. RESULTS: Some degree of angle recession was identified in one eye of 60 people and in both eyes of 86 people. Men were affected more than three times as often as women in the fifth, sixth, and seventh decades. The cumulative lifetime prevalence of angle recession in this community was 14.6%. The prevalence of glaucoma in people with angle recession was 5.5% (8/146). Of 87 eyes with 360 degrees of angle recession, only 7 (8.0%) had glaucoma. Excessive alcohol consumption was significantly related to the presence of angle recession in women (P < 0.001). The prevalence of monocular blindness due to trauma was 2.5% (25/987). CONCLUSION: Although the importance of the study may be limited to this community, the findings suggest that future population-based studies of ocular trauma should include gonioscopy on all individuals examined. Secondary glaucomas, especially those related to trauma, should be screened for in developing countries when trying to establish the prevalence of potential visual loss from glaucoma.
Adult↗
The risk of missing angle neovascularization by omitting screening gonioscopy in acute central retinal vein occlusion.
OBJECTIVE: The purpose of the study was to determine whether angle neovascularization can occur without pupillary margin neovascularization in central retinal vein occlusion (CRVO). DESIGN: The study design was a prospective study of the main question and a retrospective study of ancillary issues. PARTICIPANTS: The authors examined 105 eyes of 100 patients with CRVO having clinical evidence of ischemia between July 1, 1986, and March 18, 1996. INTERVENTION: The authors looked for iris and angle neovascularization with both undilated slit-lamp biomicroscopy and Zeiss four-mirror gonioscopy. MAIN OUTCOME MEASURES: The presence of anterior segment neovascularization was measured. RESULTS: Of 34 eyes developing anterior segment neovascularization, 4 (12%) developed angle neovascularization without pupillary margin neovascularization over a mean follow-up of 2.2 +/- 2.4 standard deviation years. CONCLUSIONS: Angle neovascularization can occur without pupillary margin involvement in CRVO, implying the necessity of screening gonioscopy and supporting the Central Vein Occlusion Study conclusion (based on a photographic technique not used clinically).
Acute Disease↗
Gonioscopy: evaluation of the anterior chamber angle. Part II.
Gonioscopy is the standard procedure for examination of the anterior chamber angle, and is an invaluable technique in primary eye care. The clinician must practise the technique and observe many angles, because enormous but often subtle variation can be seen by the experienced observer in both normal and abnormal angles. Gonioscopy is essential to master, not only for the assessment of patients' risk for angle closure following dilation, but also in the diagnosis and subsequent management of the acute and chronic glaucomas and many other anterior segment disorders.
Adult↗
Gonioscopy in no-stitch cataract incisions.
To evaluate the internal appearance of the no-stitch cataract incision, gonioscopy was performed in 68 of 78 consecutive eyes of cataract surgical patients with no-stitch incisions. All incisions were located anterior to Schwalbe's line, and 32 (42%) had smooth linear internal incisions. In another 32 (42%), small tags or curls were located along the internal incision. Four eyes (5%) had discernible Descemet's membrane detachments visible by gonioscopy but not slitlamp biomicroscopy. The Descemet's detachments were less than 2mm long in three patients and more than 2 mm in one patient. The width of the detachments were 1 mm or less. The detachments did not lead to clinically significant sequela such as filtration blebs or persistent corneal edema.
Cataract Extraction↗
New gonioscopy system using only infrared light.
PURPOSE: To describe an infrared gonioscopy system designed to observe the anterior chamber angle under natural mydriasis in a completely darkened room. METHODS: An infrared light filter was used to modify the light source of the slit-lamp microscope. A television monitor connected to a CCD monochrome camera was used to indirectly observe the angle. RESULTS: Use of the infrared system enabled observation of the angle under natural mydriasis in a completely darkened room. CONCLUSION: Infrared gonioscopy is a useful procedure for the observation of the angle under natural mydriasis.
Anterior Chamber↗