Chapter

INTRODUCTION 306
Aqueous production 306
Glaucoma
Combined preparations 333
Systemic carbonic anhydrase
10
PSEUDOEXFOLIATION 366

inhibitors 333 PIGMENT DISPERSION 368

Aqueous outflow 306
Osmotic agents 333 Acute bilateral iris pigment loss with
Intraocular pressure 307
raised IOP 371
Overview of glaucoma 307 LASER TREATMENT OF
GLAUCOMA 334 NEOVASCULAR GLAUCOMA 371
TONOMETRY 307
Goldmann tonometry 307 Laser trabeculoplasty 334 INFLAMMATORY GLAUCOMA 374
Other forms of tonometry 309 Laser iridotomy 335 Introduction 374
Diode laser cycloablation 337 Angle-closure glaucoma with pupillary
GONIOSCOPY 309 Laser iridoplasty 337 block 374
Introduction 309
TRABECULECTOMY 338 Angle-closure glaucoma without pupillary
Indirect gonioscopy 310
Technique 338 block 374
Direct gonioscopy 312
Antimetabolites in filtration surgery 339 Open-angle glaucoma 376
Identification of angle structures 313
Shallow anterior chamber 340 Treatment 376
Grading of angle width 315
Failure of filtration 341 Posner–Schlossman syndrome (PSS) 377
Pathological findings 316
Late bleb leakage 342 LENS-RELATED GLAUCOMA 377
EVALUATION OF THE OPTIC NERVE Bleb-associated bacterial infection and Phacolytic glaucoma 377
HEAD 316 endophthalmitis 343 Phacomorphic glaucoma 377
Normal optic nerve head 316
NON-PENETRATING GLAUCOMA Pupillary block from disruption of lens
Changes in glaucoma 316 position 378
SURGERY 345
IMAGING IN GLAUCOMA 320 TRAUMATIC GLAUCOMA 379
Pachymetry 320 DRAINAGE SHUNTS 346
Shunts using episcleral explants 346 Hyphaema 379
Stereo disc photography 320 Angle-recession glaucoma 380
Optical coherence tomography 320 Mini-shunts 347
Confocal scanning laser OCULAR HYPERTENSION 348 IRIDOCORNEAL ENDOTHELIAL
ophthalmoscopy 321 SYNDROME 381
Scanning laser polarimetry 322 PRIMARY OPEN-ANGLE
GLAUCOMA 349 GLAUCOMA ASSOCIATED WITH
Anterior chamber depth
measurement 322 Introduction 349
INTRAOCULAR TUMOURS 383
Screening 350 GLAUCOMA SECONDARY TO
PERIMETRY 323
Diagnosis 351 EPITHELIAL INGROWTH 384
Definitions 323
Visual field defects 351
Testing algorithms 325 IRIDOSCHISIS 384
Management 351
Testing patterns 326
Analysis 326 NORMAL-TENSION GLAUCOMA 358 PRIMARY CONGENITAL
High-sensitivity field modalities 329 GLAUCOMA 384
PRIMARY ANGLE-CLOSURE Differential diagnosis 387
Sources of error 329
GLAUCOMA 360
MEDICAL TREATMENT OF Introduction 360 IRIDOCORNEAL DYSGENESIS 388
GLAUCOMA 330 Diagnosis 362 Posterior embryotoxon 388
Introduction 330 Treatment 365 Axenfeld–Rieger syndrome 388
Prostaglandin derivatives 330 Peters anomaly 390
CLASSIFICATION OF SECONDARY Aniridia 390
Beta-blockers 331
GLAUCOMA 366
Alpha-2 agonists 332 GLAUCOMA IN PHACOMATOSES 394
Topical carbonic anhydrase inhibitors 332 Open-angle 366
Angle-closure 366 Sturge–Weber syndrome 394
Miotics 333 Neurofibromatosis type 1 394
306 Introduction
INTRODUCTION
Aqueous production
Aqueous humour is produced from plasma by the ciliary epithe-
lium of the ciliary body pars plicata, using a combination of active
and passive secretion. A high-protein filtrate passes out of fenes-
trated capillaries (ultrafiltration) into the stroma of the ciliary
processes, from which active transport of solutes occurs across the
dual-layered ciliary epithelium. The osmotic gradient thereby
established facilitates the passive flow of water into the posterior
chamber. Secretion is subject to the influence of the sympathetic
nervous system, with opposing actions mediated by beta-2 recep-
tors (increased secretion) and alpha-2 receptors (decreased secre-
tion). Enzymatic action is also critical – carbonic anhydrase is
among those playing a key role.
Aqueous outflow
Anatomy
• The trabecular meshwork (trabeculum) is a sieve-like
structure (Fig. 10.1) at the angle of the anterior chamber
(AC) through which 90% of aqueous humour leaves the eye.
It has three components (Fig. 10.2).
○ The uveal meshwork is the innermost portion, consisting
of cord-like endothelial cell-covered strands arising from
the iris and ciliary body stroma. The intertrabecular
spaces are relatively large and offer little resistance to the
passage of aqueous.
○ The corneoscleral meshwork lies external to the uveal
meshwork to form the thickest portion of the
trabeculum. It is composed of layers of connective tissue
strands with overlying endothelial-like cells. The
intertrabecular spaces are smaller than those of the uveal
meshwork, conferring greater resistance to flow.
Fig. 10.1 Scanning electron micrograph of the trabecular
meshwork
E
C
D
B
A
G
F
Fig. 10.2 Anatomy of outflow channels: A, Uveal meshwork;
B, corneoscleral meshwork; C, Schwalbe line; D, Schlemm
canal; E, connector channels; F, longitudinal muscle of the
ciliary body; G, scleral spur
○ The juxtacanalicular (cribriform) meshwork is the outer
part of the trabeculum, and links the corneoscleral
meshwork with the endothelium of the inner wall of the
canal of Schlemm. It consists of cells embedded in a
dense extracellular matrix with narrow intercellular
spaces, and offers the major proportion of normal
resistance to aqueous outflow.
• The Schlemm canal is a circumferential channel within the
perilimbal sclera. The inner wall is lined by irregular
spindle-shaped endothelial cells containing infoldings (giant
vacuoles) that are thought to convey aqueous via the
formation of transcellular pores. The outer wall is lined by
smooth flat cells and contains the openings of collector
channels, which leave the canal at oblique angles and
connect directly or indirectly with episcleral veins. Septa
commonly divide the lumen into 2–4 channels.
Physiology
Aqueous flows from the posterior chamber via the pupil into the
AC, from where it exits the eye via three routes (Fig. 10.3).
• Trabecular outflow (90%): aqueous flows through the
trabeculum into the Schlemm canal and then the episcleral
veins. This is a bulk flow pressure-sensitive route so that
increasing IOP will increase outflow.
• Uveoscleral drainage (10%): aqueous passes across the face
of the ciliary body into the suprachoroidal space, and is
drained by the venous circulation in the ciliary body,
choroid and sclera.
• Iris: some aqueous also drains via the iris.

C optic neuropathy that is associated with visual field loss as damage
A
B
Fig. 10.3 Routes of aqueous outflow: A, trabecular; B,
uveoscleral; C, iris
Intraocular pressure
Intraocular pressure (IOP) is determined by the balance between
the rate of aqueous production and its outflow, the latter in turn
related to factors that include the resistance encountered in the
trabeculum and the level of episcleral venous pressure.
Concept of normal intraocular pressure
The average IOP in the general population is around 16 mmHg on
applanation tonometry, and a range of about 11–21 mmHg – two
standard deviations either side of the average – has conventionally
been accepted as normal, at least for a Caucasian population.
However, some patients develop glaucomatous damage with IOP
less than 21 mm Hg whilst others remain unscathed with IOP well
above this level. Whilst reduction of IOP is a key modifiable
element in essentially all types of glaucoma, additional incom-
pletely understood factors are critical in determining whether a
particular individual or eye develops glaucomatous damage. These
include features influencing the IOP reading, such as corneal rigid-
ity, and probably factors affecting the susceptibility of the optic
nerve to damage, such as the integrity of its blood supply and struc-
tural vulnerability to mechanical stress at the optic nerve head.
Fluctuation
Normal IOP varies with time of day (diurnal variation), heartbeat,
blood pressure and respiration. The diurnal pattern varies, with a
tendency to be higher in the morning and lower in the afternoon
and evening. This is at least partially due to a diurnal pattern in
aqueous production, which is lower at night. Glaucomatous eyes
exhibit greater than normal fluctuation, the extent of which is
directly proportional to the likelihood of progressive visual field
damage, and a single reading may therefore be misleading. It is
good practice always to note the time of day in conjunction with
a recorded IOP.
10
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Glaucoma 307
Overview of glaucoma
Definition
It is difficult to define glaucoma precisely, partly because the
term encompasses a diverse group of disorders. All forms of the
disease have in common a characteristic potentially progressive
progresses, and in which IOP is a key modifiable factor.
Classification
Glaucoma may be congenital (developmental) or acquired.
Open-angle and angle-closure types are distinguished based on
the mechanism by which aqueous outflow is impaired with
respect to the AC angle configuration. Distinction is also made
between primary and secondary glaucoma; in the latter a recog-
nizable ocular or non-ocular disorder contributes to elevation
of IOP.
Epidemiology
Glaucoma affects 2–3% of people over the age of 40 years; 50%
may be undiagnosed. Primary open-angle glaucoma (POAG) is
the most common form in white, Hispanic/Latino and black indi-
viduals; the prevalence is especially high in the latter. On a world-
wide basis, primary angle closure (PAC) constitutes up to half of
cases, and has a particularly high prevalence in individuals of
Asian descent, although with improved assessment such as the
routine performance of gonioscopy in a darkened rather than a
bright environment, PAC is known to be more prevalent in Cau-
casian individuals than previously realized.
TONOMETRY
Goldmann tonometry
Principles
Goldmann applanation tonometry (GAT) is based on the
Imbert–Fick principle, which states that for a dry thin-walled
sphere, the pressure (P) inside the sphere equals the force
(F) necessary to flatten its surface divided by the area (A) of
flattening (i.e. P = F/A). Theoretically, average corneal rigidity
(taken as 520 μm for GAT) and the capillary attraction of the
tear meniscus cancel each other out when the flattened area has
the 3.06 mm diameter contact surface of the Goldmann prism,
which is applied to the cornea using the Goldmann tonometer
with a measurable amount of force from which the IOP is
deduced (Fig. 10.4). The tonometer prism should be disinfected
between patients and replaced regularly in accordance with the
manufacturer’s instructions. Disposable tonometer prisms and
caps have been introduced to address concerns of infection from
reusable prisms.
308 Tonometry

A B

Fig. 10.4 Goldmann tonometry. (A) Physical principles; (B) tonometer

(Courtesy of J Salmon – fig. B)

Technique
• Topical anaesthetic (commonly proxymetacaine 0.5%) and a
small amount of fluorescein are instilled into the
conjunctival sac.
• The patient is positioned at the slit lamp with his or her
forehead firmly against the headrest and instructed to look
straight ahead (often at the examiner’s opposite ear) and to
breathe normally.
• With the cobalt blue filter in place and illumination of
maximal intensity directed obliquely (approximately 60°) at
the prism, the prism is centred in front of the apex of the A
cornea.
• The dial is preset at 1 (i.e. 10 mmHg).
• The prism is advanced until it just touches the apex of the
cornea (Fig. 10.5A).
• Viewing is switched to the ocular of the slit lamp.
• A pattern of two green semicircular mires will be seen, one
above and one below the horizontal midline, which
represent the fluorescein-stained tear film touching the
B
upper and lower outer halves of the prism. Mire thickness
should be around 10% of the diameter of its total arc (Fig.
Fig. 10.5 Applanation tonometry. (A) Contact between the
10.5B). Care should be taken to horizontally and vertically tonometer prism and the cornea; (B) fluorescein-stained
centre the mires so that as far as practically possible two semicircular mires – the diagram at right shows the
centralized semicircles are observed. correct end-point using mires of appropriate thickness
 10
CHAPTER
Glaucoma 309

• The dial on the tonometer is rotated to vary the applied sufficiently flatten the cornea relates directly to the level of
force; the inner margins of the semicircles align when a IOP. Contact is not made with the eye and topical
circular area of diameter precisely 3.06 mm is flattened. anaesthesia is not required, so it is particularly useful for
• The reading on the dial, multiplied by 10, gives the IOP; a screening in the community. The sudden jet of air can startle
version is available that shows IOP on a digital display. the patient. Accuracy is improved if an average of at least
three readings is taken.
Sources of error • Portable applanation tonometry (Perkins) uses a Goldmann
prism in conjunction with a portable light source (Fig.
• Inappropriate fluorescein pattern. Excessive fluorescein will
10.6B). It is hand-held, and can therefore be used in
result in the mires being too thick, with consequent
bed-bound or anaesthetized patients.
overestimation of IOP; insufficient will make the semicircles
too thin, with consequent underestimation (see Fig. 10.5B, • Dynamic contour tonometry (DCT) (e.g. PASCAL®) uses a
solid state sensor and a corneal contour-matching surface,
left and centre).
with the aim of measuring IOP relatively independently of
• Pressure on the globe from the examiner’s fingers, eyelid
corneal mechanical factors such as rigidity. It is mounted on
squeezing or restricted extraocular muscles (e.g. thyroid
a slit lamp in similar fashion to the Goldmann tonometer,
myopathy) may give an anomalously high reading.
and IOP is shown on a digital display. Studies comparing
• Central corneal thickness (CCT). Calculations of IOP by
DCT and GAT IOP readings with manometric intracameral
GAT assume that central corneal thickness is 520 μm, with
IOP seem to confirm DCT as providing a more physiological
minimal normal variation. If the cornea is thinner, an
measurement.
underestimation of IOP is likely to result, and if thicker, an
overestimation. Corneas tend to be thicker than average in • Ocular response analyser (e.g. Reichert®) is a form of
pneumotonometer that measures IOP whilst attempting to
individuals with ocular hypertension, and thinner in
compensate for corneal biomechanical properties by using
normal-tension glaucoma (NTG); following refractive
two sequential measurements to assess corneal hysteresis, a
surgery procedures the cornea is both thinner and
function of viscous damping.
structurally altered such that IOP is likely to be
underestimated. Some methods of IOP measurement (e.g. • Electronic indentation/applanation tonometry (e.g.
Tono-Pen® – Fig. 10.6C) is a hand-held electronic contact
DCT – see below) may reduce the effect of structural
tonometer (a modified version of the older Mackay–Marg
confounding variables. Other corneal mechanical factors
tonometer). The probe tip contains a transducer that
may also be important but are less well defined.
measures applied force. Besides portability, its main
• Corneal oedema may result in artificial lowering of IOP,
advantage is the facility to measure IOP reasonably
hypothesized to be due to a boggy softening; the associated
accurately in eyes with distorted or oedematous corneas, and
increased CCT seems to be more than offset.
through a soft contact lens.
• Astigmatism, if significant, may give distorted mires as well
as leading to mechanically induced errors. If over 3 dioptres, • Rebound tonometry (e.g. iCare® – Fig. 10.6D) involves a
1.8 mm plastic ball attached to a wire; deceleration of the
the average reading of two can be taken with the prism
probe upon contact with the cornea is proportional to IOP.
rotated 90° for the second, or optimally the prism is rotated
Anaesthesia is not required. The instrument can be used for
so that the red line on the tonometer housing is aligned with
self-monitoring – a tailored personal version is available
the prescription of the minus axis.
– and for screening in the community.
• Incorrect calibration of the tonometer can result in a false
reading, and calibration should optimally be checked before • Indentation (impression) tonometry (e.g. Schiotz) is a
portable device that measures the extent of corneal
each clinical session using the manufacturer’s calibration
indentation by a plunger of known weight; it is now seldom
arm.
used.
• Wide pulse pressure. It is normal for there to be a small
oscillation of IOP in concert with the rhythm of ocular • Implantable tonometers are under development and if a
clinically workable device is realized should facilitate
perfusion. If this ‘pulse pressure’ is substantial, either the
accurate lifelong 24-hour IOP measurement.
midpoint or the highest level observed may be taken.
• Repeated readings over a short period will often be
associated with a slight fall in IOP due to a massaging effect GONIOSCOPY
on the eye.
• Other factors include a tight collar and breath-holding, both
of which obstruct venous return and can raise IOP. Introduction
Other forms of tonometry Overview
• Pneumotonometry (Fig. 10.6A) is based on the principle of • Gonioscopy is a method of evaluating the AC angle, and can
applanation, but the central part of the cornea is flattened by be used therapeutically for procedures such as laser
a jet of air rather than a prism. The time required to trabeculoplasty and goniotomy.
310 Gonioscopy

A B

C D

Fig. 10.6 Portable tonometers. (A) Keeler pneumotonometer; (B) Perkins applanation tonometer; (C) Tono-Pen®; (D) iCare®
(Courtesy of Mainline Instruments Ltd – fig. D)

• Other means of angle assessment such as anterior segment
optical coherence tomography (OCT) and high-frequency
ultrasound biomicroscopy (UBM) offer advantages in some
aspects of angle analysis, but current clinical opinion
suggests they should supplement rather than replace visual
gonioscopic analysis.
it ensures that light is retained within the core of a cable. Because
the refractive index of a goniolens is similar to that of the cornea,
it eliminates total internal reflection by replacing the tear film–air
interface with a tear film–goniolens interface (Fig. 10.7, bottom).
Light rays can then be viewed as they exit the contact lens, directly
or indirectly (see below).

Optical principles Disinfection

Lenses must be cleaned between patients to remove any particulate
The angle of the AC cannot be visualized directly through the
matter and then sterilized; a suggested regimen is soaking in 2%
intact cornea because light from angle structures undergoes ‘total
hypochlorite solution (this has activity against transmissible
internal reflection’ at the anterior surface of the precorneal tear
spongiform encephalopathies) for at least 5 minutes followed by
film (Fig. 10.7, top). When light travels from a medium of higher
thorough rinsing in sterile saline, then air-drying.
to one of lower refractive index (such as cornea to air) it will be
reflected at the interface between the two unless the angle of inci-
dence is less than a certain ‘critical angle’ dependent on their
Indirect gonioscopy
refractive index difference (46° for the tear film–air interface). The Indirect goniolenses use a mirror to reflect rays from the angle
phenomenon is utilized in optical fibre signal transmission, where such that they exit the goniolens at much less than the critical
 10
CHAPTER
Glaucoma 311

○ The size and intensity of the slit beam should be reduced

to the absolute minimum compatible with an adequate
view, in particular avoiding any of the beam being
directed through the pupil.
○ The patient is seated at the slit lamp and advised that the
lens will touch the eye but will not usually cause
discomfort; the forehead must be kept against the
headband and both eyes should remain open.
i ○ A drop of local anaesthetic is instilled.
○ A drop or two of coupling fluid (e.g. hypromellose 0.3%)
is placed on the contact surface of the lens.

n=1.50

n=1.37

A
Fig. 10.7 Optical principles of gonioscopy; n = refractive
index; i = angle of incidence

angle. They provide a mirror image of the opposite angle and can
be used only in conjunction with a slit lamp.

Non-indentation gonioscopy
• Goniolenses
○ The classic Goldmann lens consists of three mirrors (Fig.
10.8A), one of which is specifically for gonioscopy; some
goniolenses have one (Fig. 10.8B), two or four mirrors.
○ Lenses of similar basic structure but with modifications
include the Magna View, Ritch trabeculoplasty and the
Khaw direct view.
○ Because the curvature of the contact surface of the lens is
steeper than that of the cornea, a viscous coupling
substance of refractive index similar to the cornea is
required to bridge the gap between cornea and lens.
• Technique B
○ It is essential that the examination takes place in a room
in which the ambient illumination is very low – Fig. 10.8 Goldmann goniolens. (A) Three mirrors; (B) single
completely dark if possible. mirror
312 Gonioscopy

○ The patient is asked to look upwards and the lens is

inserted rapidly so as to avoid loss of the coupling fluid.
The patient then looks straight ahead.
○ Indirect gonioscopy gives an inverted view of the portion
of the angle opposite the mirror.
○ Once the initial examination has been performed and the
findings noted, increasing the level of illumination may
help in defining the angle structures.
○ When the view of the angle is obscured by a convex iris,
it is possible to see ‘over the hill’ by asking the patient to
look in the direction of the mirror. Only slight movement
is permissible, otherwise the structures will be distorted
and a closed angle may appear open.
○ Excessive pressure with a non-indentation lens narrows
the angle appearance (in contrast to the effect of pressure
during indentation gonioscopy – see below). Excessive
pressure also causes folds in the cornea that compromise A
the clarity of the view.
○ In some eyes, suction on the cornea from the lens may
artificially open the angle; awareness of the need to avoid
retrograde, as well as anterograde, pressure on the lens
will tend to prevent inadvertent distortion.

Indentation (dynamic, compression) gonioscopy

• Goniolenses include the Zeiss (Fig. 10.9), Posner and
Sussman (no handle), all of which are four-mirror
gonioprisms.
○ The contact surface of the lenses has a curvature flatter
than that of the cornea, negating the need for a coupling
substance.
○ The lenses do not stabilize the globe and are relatively
unsuitable for laser trabeculoplasty.
○ A common criticism is that it is easy to inadvertently
open the angle, giving a misleadingly reassuring
impression, especially if inexperienced. B
• Technique
○ The first stages are as set out above for non-indentation Fig. 10.9 (A) Zeiss goniolens; (B) slit lamp view with lens in
gonioscopy. place on the cornea
○ Indentation is performed by gently pressing the lens
posteriorly against the cornea; this forces aqueous into
the angle, pushing the peripheral iris posteriorly.
○ If the angle is closed only by apposition between the iris
rays strike the contact lens/air interface at a steeper than critical
and cornea it will be forced open, allowing visualization
angle so that they will pass through to the observer. This approach
of the angle recess (Fig. 10.10).
is called ‘direct’ because light rays from the angle are viewed
○ If the angle is closed by adhesions between the peripheral
directly, without reflection inside the lens. They do not require a
iris and cornea – peripheral anterior synechiae (PAS) – it
slit lamp and are used with the patient in the supine position,
will remain closed.
typically under general anaesthesia in the evaluation and surgical
○ Dynamic gonioscopy can be invaluable in helping to
treatment of infantile glaucoma.
define the structures in angles that are difficult to assess,
such as in distinguishing an extensive or double highly • Direct goniolenses include the Koeppe (Fig. 10.11A), Medical
Workshop, Barkan and Swan–Jacob (Fig. 10.11B).
pigmented Schwalbe line from the pigmented meshwork.
• Technique
○ Gonioscopy is performed with the patient in the supine
Direct gonioscopy position (note that this may deepen the angle) in
Direct goniolenses work by constructing the viewing surface of the conjunction with an operating or hand-held microscope
lens in a domed or slanted configuration such that exiting light or magnifying loupes.

B
Fig. 10.10 Indentation gonioscopy in appositional angle
closure. (A) Total angle closure prior to indentation;
(B) during indentation the entire angle becomes visible
(arrow) – the corneal folds seen are typical
(Courtesy of W Alward, from Color Atlas of Gonioscopy, Wolfe 1994)
○ The technique cannot be used with a desktop slit lamp so
clarity, illumination and variable magnification are not
comparable with indirect lenses.
Identification of angle structures
Accurate identification of angle structures (Fig. 10.12) is not always
straightforward, even for highly experienced gonioscopists.
• Schwalbe line. This is the most anterior structure,
appearing whitish to variably pigmented. Anatomically it
demarcates the peripheral termination of Descemet
membrane and the anterior limit of the trabeculum. It may
be barely discernible in younger patients. In contrast, there
may be pigment deposits on or anterior to the Schwalbe
10
CHAPTER
Glaucoma 313
Fig. 10.11 Goniolenses. (A) Koeppe; (B) Swan–Jacob
line – a Sampaolesi line – especially in heavily pigmented
angles (e.g. pseudoexfoliation syndrome). It may have a
double-line configuration, when the posterior component
may be mistaken for the pigmented meshwork.
• The corneal wedge is useful in locating an inconspicuous
Schwalbe line. Using a narrow slit beam, two distinct linear
corneal reflections can be identified, one on the inner and
one on the outer corneal surface; the outer reflection will arc
round across the corneoscleral interface – due to the sclera
being opaque – to meet the inner reflection at the apex of
the corneal wedge that coincides with the Schwalbe line.
• The trabeculum extends from the Schwalbe line to the
scleral spur, with an average width of 600 μm. In younger
people it has a ground-glass translucent appearance. The
anterior non-functional part lies adjacent to the Schwalbe
line and has a whitish colour. The posterior, pigmented
functional part lies adjacent to the scleral spur and has a
greyish-blue translucent appearance in the young.
Trabecular pigmentation is rare prior to puberty, but in
older eyes involves the posterior trabeculum to a variable
extent, most marked inferiorly. Patchy trabecular
pigmentation in a suspiciously narrow angle raises the
possibility of intermittent iris contact.
314 Gonioscopy

Fig. 10.12 Normal angle structures. (A) Schematic

representation – inset painting demonstrates corneal
wedge; (B) goniophotograph – a broad Schwalbe line is
indicated by the white arrow, below which are the non-
pigmented meshwork, the pigmented meshwork, the scleral
spur and the ciliary body (black arrow) – the ciliary body is
B relatively lightly pigmented
(Courtesy of W Alward, from Color Atlas of Gonioscopy, Wolfe 1994 – fig. A)

• The Schlemm canal may be identified in the angle, especially
if non-pigmented, as a slightly darker line deep to the
posterior trabeculum. Blood can sometimes be seen in the
canal (Fig. 10.13), either physiologically (sometimes due to
excessive pressure on the episcleral veins with a goniolens),
or in the presence of low intraocular or raised episcleral
venous pressure.
• The scleral spur is the most anterior projection of the sclera
and the site of attachment of the longitudinal muscle of the
ciliary body. Gonioscopically it is situated immediately
posterior to the trabeculum and appears as a narrow whitish
band that yellows with age.
• The ciliary body stands out just behind the scleral spur as a
pink, dull brown or slate grey band. Its width depends on
the position of iris insertion and it tends to be narrower in
hypermetropic eyes and wider in myopic eyes. The angle
recess represents the posterior dipping of the iris as it inserts
into the ciliary body. It may not be visible in some eyes due
to a physiological anterior iris insertion, though fixed
pathological angle narrowing due to peripheral anterior
synechiae (PAS) – adhesions between the iris and angle
structures – should be excluded.
• Iris processes are small, usually tenuous extensions of the
anterior surface of the iris that insert at the level of the
scleral spur and cover the ciliary body to a varying extent
(see Fig. 10.13). They are present in about one-third of
normal eyes and are most prominent during childhood and
in brown eyes. The processes should not be confused with
PAS, which typically extend more anteriorly and are more
substantial.
• Blood vessels. Radial vessels at the base of the angle recess
are often seen in normal eyes. Pathological blood vessels
run randomly in various directions. As a general principle,
any blood vessel that crosses the scleral spur onto the
trabecular meshwork is abnormal. Larger circumferential
vessels may also be seen.