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REVIEW
1
University of Tennessee Health Science Center, Memphis, TN, USA and 2Mayo Clinic, Jacksonville,
Florida, USA
ABSTRACT
Anterior segment imaging allows objective assessment of the anterior segment of the eye, particularly the
anterior chamber angle. Both qualitative and quantitative analyses are possible and aid in detecting and
managing closed-angle and open-angle mechanisms in various forms of glaucoma. This review focuses
primarily on anterior segment optical coherence tomography and ultrasound biomicroscopy, with emphasis on
principles of technology, commercially available devices, and clinical applications in glaucoma with potential
advantages and disadvantages of each technology.
Keywords: Anterior segment optical coherence tomography, glaucoma, gonioscopy, imaging, scheimpflug
photography, ultrasound biomicroscopy
Received 26 January 2013; accepted 15 February 2013; published online 22 May 2013
Correspondence: Sarwat Salim, MD, FACS, Associate Professor of Ophthalmology, Director, Glaucoma Service, Hamilton Eye Institute/
University of Tennessee, 930 Madison Avenue, Suite 470, Memphis, TN, USA 38163. Tel: 901-448-5883. Fax: 901-448-1260. Cell: 901-351-0777.
E-mail: ssalim@uthsc.edu
113
114 S. Salim and S. Dorairaj
low-coherence light beam (typically a superlumines- chamber angle imaging have been recently described
cent diode emitting in the near-infrared region) to but are not yet commercially available in the United
compare the delay of tissue reflections against a States.14,15
reference reflection.5 The final image is produced by
scanning a light beam laterally, creating a series of
axial scans, and then combining these scans into a AS-OCT versus Gonioscopy and UBM
composite image.
OCT technology was initially used to image the The noncontact feature of AS-OCT eliminates the
posterior segment of the eye by using a wavelength of problem of inadvertent pressure on the cornea
820 nm.6–8 Izatt et al.9 used the same wavelength for seen with gonioscopy by an inexperienced user that
anterior segment imaging but found suboptimal may lead to a misdiagnosis of an open angle when, in
imaging because of limited penetration through fact, the angle is narrow or closed. In addition,
tissues. The wavelength was later altered to improve gonioscopy requires slit lamp light that may also
penetration through light-retaining tissues such as produce the illusion of an open angle by constricting
the sclera to improve visualization of the anterior the pupil in an eye with either a narrow or closed
segment.10,11 angle. AS-OCT can be performed with room lights on
The two AS-OCT devices commercially available and off and aids in objective assessment of angle
are Visante-OCT (Carl Zeiss Meditec; CA, USA) and anatomy. An advantage of gonioscopy over both
slit-lamp OCT (SL-OCT; Heidelberg Engineering AS-OCT and UBM is indentation, which allows
GmbH, Heidelberg, Germany). Only the Vistante- differentiating between appositional and synechial
OCT is available in the United States and will be the angle closure.
focus of discussion in this review. Briefly, compared Advantages of AS-OCT over UBM include a higher
with the Visante-OCT, the SL-OCT has lower axial and axial resolution, faster sampling rate, ability to image
transverse resolution and slower image acquisition the entire cross-section of the eye, and noncontact
and requires manual rotation of the scanning beam. scanning in a seated, upright position. Unlike UBM,
High interobserver reproducibility has been demon- AS-OCT is limited in its ability to visualize structures
strated with each device with poor agreement posterior to the iris because of blockage of wavelength
between the two.12 Both devices have been shown to by pigment. Therefore, several mechanisms of angle
detect more closed angles when compared with closure, including plateau iris, ciliary body cyst or
conventional gonioscopy with better agreement tumor, ciliary effusion, or lens subluxation, are better
noted between SL-OCT and gonioscopy, presumably elucidated with UBM. Both AS-OCT and UBM devices
because of the use of visible light during both are expensive and image only a single cross-section of
procedures.13 With the advent of Fourier domain the angle with the potential to miss pathology at other
OCT technology with higher resolution, imaging of locations. For quantitative analyses, both require
the cornea and conjunctiva is possible, but imaging identification of scleral spur as a reference point,
of the anterior chamber angle remains limited because which may be difficult in about one-quarter of cases.16
of the use of shorter wavelength. Fourier domain OCT The properties of AS-OCT and UBM are listed in
devices with a longer wavelength suited for anterior Table 1.
Seminars in Ophthalmology
Imaging in Glaucoma 115
TABLE 2. Biometric parameters which can be measured with the UBM are listed below.
Angle-opening distance AODn mm Distance from cornea to iris at n mm from the scleral spur (n typically
500 or 750)
Trabecular–iris contact length TICL mm Linear distance of contact between iris and cornea/sclera beginning at
scleral spur
Angle-recess area ARAn mm2 Area of triangle between angle recess and iris and cornea n mm from
scleral spur (n typically 500 or 750)
Trabecular–iris space TISA mm2 Area of trapezoid between iris and cornea from sclera to n mm (n
typically 500 or 750)
Trabecular–iris angle TIA Degrees Angle formed from angle recess to points 500 mm from scleral spur on
trabecular meshwork and perpendicular on surface of iris
Trabecular–ciliary process distance TCPD mm Measured from point on endothelium 500 mm from scleral spur
through iris to ciliary process
Iris–zonular distance IZD mm Distance from posterior iris surface to first visible zonule at point
closest to ciliary body
Iris thickness IT mm Measured from perpendicular 500 mm from scleral spur, and possibly
other points
Scleral spur–iris insertion distance SS-IR mm Linear distance from scleral spur to iris insertion
Iris radius of curvature IRC mm Radius of posterior iris surface using an arc transecting three points:
iris root, pupil margin and point of maximal iris displacement
Iris convexity IC mm Maximum distance from the posterior surface of the iris to the line
from posterior iris at pupillary margin to the iris root
Iris–lens contact distance ILCD mm Length of contact between surfaces of lens and iris
Anterior–posterior chamber depth ACD/PCD Ratio of anterior chamber to posterior chamber depth measured 1 mm
from the scleral spur
location is reported to be successful in approximately eyes, including both normal subjects and subjects
72% of images obtained with AS-OCT.18 The difficulty with narrow angles, with AS-OCT and UBM and
in visualizing the scleral spur was mostly seen in demonstrated similar values for angle opening dis-
areas where images were superior or inferior to the tance, angle recess area, trabecular-iris space area, and
nasal and temporal quadrants. AS-OCT and UBM trabecular-iris contact length with both devices.
have been reported to produce similar quantitative The same investigators also showed high specificity
measurements of angle anatomy by using the afore- and sensitivity in detecting narrow angles with these
mentioned biometric parameters.11 two devices when compared with gonioscopy. Nolan
et al.17 reported higher sensitivity in detecting angle
closure with AS-OCT than with gonioscopy. Widening
Narrow Angles and Angle Closure of the angles after laser iridotomy and quantitative
assessment in eyes with narrow angles has been
Anatomically narrow angles can be diagnosed with demonstrated with AS-OCT.19
AS-OCT both qualitatively and quantitatively
(Figures 2 and 3). Radhakrishnan et al.11 imaged 31
Open-Angle Glaucoma
FIGURE 3. AS-OCT, Raw Image Mode Showing Deep Anterior Chamber and Iris Concavity in an Eye with Pigment Dispersion
Syndrome.
Seminars in Ophthalmology
Imaging in Glaucoma 117
FIGURE 5. UBM, Raw Image Mode: UBM image of occludable angles depicting the importance of evaluating anterior chamber angles
in total darkness. C:Cornea, AC; Anterior chamber, S: Scleral spur, PC: Posterior capsule, I: Iris,CB: Ciliary Body, L: Lens.
which the transducer is mounted. These sound waves Principle of Ultrasound Biomicroscopy
travel at different speeds through the eye as they
encounter tissues of varying acoustic impedance and A-scan represents the reflectivity along one line of
are reflected at differing time intervals. UBM probe sight. In UBM, a B-scan is formed from an A-scan by
provides a scan rate of 8 Hz, giving real-time imaging, rotating the transducer around a fixed axis and
with scans consisting of 256 lines of sight (vectors) writing new lines of sight in correct registration.47–48
over a 5 5-mm field. UBM has lateral and axial The final video image presents a two-dimensional
resolutions of 50 mm and 25 mm, respectively.35–36 cross-section through the eye (Figure 6). The essential
These resolutions allow imaging of anatomic areas components of UBM are identical to those of a
of interest in the anterior segment but not the whole conventional B-mode imaging system except with a
anterior segment in a single scan. A computer system higher frequency. A standard speed of 1530 m/s is
collates and magnifies these reflected sound waves used by the instrument to determine distance meas-
and provides a high-resolution B scan image. (Table 1) urements for most internal ocular tissue. The UBM
Pavlin and coworkers carried out the first clinical contains internal calipers for distance measurements.
UBM studies of the anterior segment in glaucoma in The technique of ultrasound biomicroscopy is
the early 1990s.37,38 They demonstrated the utility of similar to that of B-scan ultrasound. The probe is
UBM in characterizing several forms of glaucoma, placed opposite the area of interest in a water bath,
including plateau iris syndrome39 and pupillary and the image is observed on the screen. Sterile
block40, which together constitute the most common methylcellulose is generally used as a coupling fluid,
forms of primary angle-closure glaucoma.41 In add- as its viscosity prevents fluid from running out of the
ition, UBM’s ability to visualize posteriorly located bottom of the cup. Although subjective gonioscopic
structures such as the ciliary body, lens zonules, and assessment occasionally resulted in an overestimation
anterior choroid puts it at an advantage over other of the angle width as compared with the UBM values
modalities, especially for investigating the mechan- in eyes with occludable angles,49angle dimensions
isms behind angle closure. Mechanisms include anter- measured by UBM correlated significantly with
ior rotation of the ciliary body in plateau iris, gonioscopy in general.46
iridociliary masses causing secondary angle closure, In 1992, Pavlin described UBM biometric criteria
and choroidal effusions.35,42 Additionally, UBM may that could be used for reproducible measurement of
also play a role in evaluating certain types of secondary various anterior segment structures.37 Tello et al.
glaucoma, such as pigment dispersion43 (posteriorly reported on the reproducibility of these measures in
bowed, causing iris pigment shaffing) and assessing 1994.52 These criteria are important in defining repro-
for a tilted or subluxed lens in exfoliation syndrome.44 ducible criteria for characterizing different glaucoma
Studies comparing UBM to gonioscopy have found types and for documenting change over time or with
a high agreement between the two modalities when treatment. Marchini, for instance, used UBM to
both are performed in a completely dark room biometrically compare different forms of angle closure
(Figure 5y).45 UBM is sufficiently sensitive such that glaucoma,53 and Sihota et al. applied these criteria to
significant differences among the mean UBM meas- compare subtypes of primary angle-closure glau-
urements (angle-opening distances at 250 mm and coma.54 Ramani used UBM to compare anterior-
500 mm from the scleral spur and trabecular mesh- segment biometry between primary angle-closure
work-ciliary process distance) of each angle grade suspects and age-matched controls, including param-
estimated by gonioscopy can be detected (Figure 1).46 eters such as trabecular-ciliary process distance and
Seminars in Ophthalmology
Imaging in Glaucoma 119
FIGURE 6. UBM, Raw Image Mode: UBM image of open angles depicting normal structues. C:Cornea, AC; Anterior chamber,
S: Scleral spur, PC: Posterior capsule, CB: Ciliary Body, L: Lens.
FIGURE 8. UBM, Raw Image Mode: UBM image depicting plateau iris configuration with anteriorly positoned ciliary body, placing
the peripheral iris in apposition to the trabecular meshwork. C: Cornea, AC; Anterior chamber, S: Scleral spur, PC: Posterior capsule,
CB: Ciliary Body, L: Lens.
Malignant Glaucoma
can be used to image the tear into the ciliary body that
occurs with angle recession. This can be helpful if
anterior opacities and blood prevent visualization of
the anterior chamber angle. Ozdal compared UBM
with gonioscopy following such trauma and reported
UBM to be diagnostically useful in imaging angle
recession, cyclodialysis, zonular deficiency, lens dis-
location, and synechiae.70
Postglaucoma Surgery Imaging with UBM FIGURE 12. UBM, Raw Image Mode: UBM image showing
synechial angle closure (small downward directed arrows). C:
Ultrasound biomicroscopy is superior to slit lamp for Cornea, AC; Anterior chamber, S: Scleral spur, PC: Posterior
capsule, I: Iris, CB: Ciliary Body, L: Lens.
evaluating bleb function and failure, allowing a
demonstration of flattened, encapsulated, and cystic
avascular thin-walled blebs. The height, wall thick- supplement to gonioscopy and intraocular
ness, apposition of the scleral flap to sclera, and the microendoscopy.75
patency of the internal ostium can be assessed. Bleb Postpenetrating keratoplasty glaucoma is a major
assessment with UBM can influence clinical decision- cause of graft failure and one of the most common
making regarding laser suture lysis following trabe- causes of irreversible visual loss after keratoplasty.
culectomy.71 Bochmann et al.50 described the use of UBM allows imaging of anterior-segment anatomy in
UBM to identify narrow-diameter (5100 mm) iridot- the presence of corneal opacity. The visualization of
omy sites, which were then retreated based on UBM synechiae and secondary angle closure by UBM in
findings. Ishikawa et al. demonstrated that indenta- such cases can be a valuable tool for planning filtering
tion of the cornea by a small eyecup can result in surgery or implanting drainage devices (Figure 12).76
angle widening.72 Following this work, Matsunaga UBM is able to evaluate glaucoma tube shunts
et al. described the use of a special UBM eyecup that placed beneath the sclera or iris plane. The position of
allowed simultaneous corneal compression with UBM the tube of artificial drainage devices can be ascer-
observation of the angle configuration before and tained using UBM (Figure 11). Rothman et al. demon-
after compression.73 This eyecup allowed a differen- strated that UBM is instrumental in diagnosing the
tiation between appositional angle closure and syne- presence and cause of tube obstruction, as UBM can
chial closure. Carillo demonstrated the usefulness of detect focal obstructions of Baerveldt tubes caused by
UBM to diagnose obstruction of an Ahmed valve by kinking at the scleral entry site after pars plana
the iris (Figure 11).74 UBM may also potentially offer insertion.77 Numerous clinical studies using AS-OCT
intraoperative guidance in the anterior segment as a and/or UBM have used biometric parameters. Using
! 2013 Informa Healthcare USA, Inc.
122 S. Salim and S. Dorairaj
UBM, Dada et al. compared changes in anterior such that the focal, lens, and film planes are not
chamber anatomy in patients with primary angle parallel, thereby shifting the plane of sharp focus to
closure and primary angle-closure glaucoma follow- the intersection point of the film and lens planes and
ing iridotomy, demonstrating widening of the anterior allowing slit images of the anterior segment of the eye
chamber angle and a deepening of the anterior that retain depth to be obtained. Using a rotating
chamber in eyes with primary angle closure but no camera, commercial devices based on the
significant change in eyes with primary angle-closure Scheimpflug principle can obtain multiple images,
glaucoma.78 Dada also described the UBM changes which are then reconstructed into a 3-dimensional
occurring during a Valsalva maneuver: narrowing of image and enabling a rapid assessment of the anterior
the anterior chamber angle recess and thickening of chamber. Semiautomated analysis of angle width
the ciliary body and iris. In eyes anatomically requires the user to determine the iris plane and
predisposed to primary angle closure, the Valsalva plane of corneal curvature by placing up to 10 marks
maneuver may lead to angle closure. Also, studying on the corneal endothelium, from which the angle
the effect of iridotomy on angle-closure suspect eyes, width is measured. Although subjective, this fast and
He et al. found iridotomy to result in a significant noncontact method of anterior chamber angle assess-
increase in angle width but with some iridotrabecular ment has been previously reported to be highly
contact in 59% of eyes with a patent iridotomy.79 Their reproducible, at least in eyes with open angles.81–84
findings were associated with smaller angle dimen- Scheimpflug photographic techniques, however,
sions and a thicker iris, both of which may play a have not been documented to reliably image a variety
causative role in maintaining angle closure after of angle configurations. The anterior chamber angle
iridotomy. Kaushik et al. compared UBM and gonio- details cannot be entirely visualized, and only the
scopy in evaluating changes in angle anatomy fol- angle approach can be photographed as light is
lowing laser iridotomy.80 They reported that the angle unable to penetrate to the angle recess. A major
significantly widened in the quadrant with iridotomy limitation is that the user has to define the iris plane.
and in the quadrant furthest away in patients with Doing so in a straight line leads to inaccuracies in
chronic angle closure and established glaucomatous angle width measurement. Comparing anterior cham-
damage. This change was much better appreciated by ber angle width measurements using Scheimpflug
UBM than by gonioscopy. photography and UBM revealed only moderate cor-
relation, with Scheimpflug images having a much
lower resolution.85 In addition, one study found that
Limitations of UBM angle measurements from Scheimpflug images were
less sensitive to changes in illumination compared
Limitations of UBM include the requirement of a with those obtained using UBM.86 In a recent study,
coupling medium and supine position for scanning, Scheimpflug photography was reported to provide
which might theoretically lead the iris diaphragm to insufficient detail of the angle for assessment of angle
fall back and change the depth of the anterior anatomy, with limited agreement existing between
chamber and the angle opening. Ishikawa et al.72 gonioscopy, Scheimpflug photography, and UBM.87
demonstrated that inadvertent pressure on the eyecup Scheimpflug photography also does not display the
while scanning can influence the angle configuration. retroiridal structures or the ciliary body, which are of
In addition, UBM might be more time consuming and great interest in glaucoma diagnosis.88
require a skilled operator to obtain high-quality,
precision images. Nevertheless, these limitations are
outweighed by the benefit of UBM for visualizing the
ciliary body, zonules, and posterior chamber, thereby CONCLUSION
making it an essential tool in defining the mechanism
of closure in angle-closure glaucomas. UBM remains AS-OCT and UBM are useful technologies for imaging
the gold standard in cases of plateau iris configuration the anterior chamber angle and offer the advantages
and imaging of ciliary processes. Its accuracy and of objective, reproducible, and quantitative analyses
ability to visualize behind a clouded cornea makes it with rapid image acquisition and storage capacity for
very useful in the preoperative assessment of anterior future comparisons. These tools also facilitate anterior
segment pathology, thereby contributing to optimal segment imaging in the presence of corneal opacities,
surgical planning. which may not be possible with gonioscopy. While
none of these new devices, individually, can replace
conventional slit-lamp biomicroscopy and gonio-
Scheimpflug (Pentacam) Photography scopy, these new devices and techniques of anterior
segment and angle imaging can complement existing
The Scheimpflug principle describes the change in methods in clinical practice, particularly when gonio-
focal plane that occurs when the film plane is tilted scopy is difficult or additional information is required
Seminars in Ophthalmology
Imaging in Glaucoma 123
to assess pathology in structures adjacent or posterior 15. Fukuda S, Kawana K, Yasuno Y, et al. Repeatability and
to the iris.89,90 reproducibility of anterior ocular biometric measurements
with 2-D and 3-D optical coherence tomography. J Cataract
Refract Surg 2010;36:1867–73.
16. Sakata LM, Lavanya R, Friedman DS, et al. Assessment of
the scleral spur in anterior segment optical coherence
DECLARATION OF INTEREST tomography images. Arch Ophthalmol 2008;126:181–185.
17. Nolan WP, See JL, Chew PTK, et al. Detection of primary
angle closure using anterior segment optical coherence
The authors report no conflicts of interest. The authors tomography in Asian eyes. Ophthalmology 2007;114:33–39.
alone are responsible for the content and writing of 18. Sakata LM, Lavanya R, Friedman DS, et al. Comparison of
this article. gonioscopy and anterior segment optical coherence tom-
The authors report no financial disclosures related ography in detecting angle closure in different quadrants
to this topic. of the anterior chamber angle. Ophthalmology 2008;115:
769–774.
19. Chalita MR, Li Y, Smith S, et al. High-speed optical
coherence tomography of laser iridotomy. Am J Ophthalmol
2005;140:1133–1136.
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