GONIOSCOPY

DEFINITION OF GONIOSCOPY

Gonioscopy allows us to examine the angle of anterior chamber and forms part of complete
ophthalmic examination and it is mandatory for the diagnosis and management of
glaucoma. Gonioscopy permits the identification of eyes at risk for closure and detects angle
abnormalities that could have diagnostic and therapeutic implications.
Gonioscopy refers to the techniques used for viewing the anterior chamber angle of the eye
for evaluation, management and classification of normal and abnormal angle structures.

CLINICAL USES OF GONIOSCOPE

Ophthalmologist will perform a gonioscopy if certain conditions are found during your eye
exam. Most commonly, gonioscopy is done to check for signs of glaucoma. The exam can
show if your drainage angle is too narrow for fluid to drain properly, or if it is blocked by part
of the iris. In other cases, gonioscopy may be done when there are signs of uveitis, eye
trauma, tumors or other eye conditions.
Diagnostic Uses
● For visualization of anterior chamber angle.
● Evidence of angle closure or narrow peripheral anterior chamber (Van Herricks).
● Classification of glaucoma.
● To look for any abnormality in angle-neovascularization angle recession,
inflammation, tumor, degenerative ordevelo mental abnormality.
Therapeutic Uses
● Develop mental abnormality. Argon laser trabeculoplasty, selective laser
trabeculoplasty.
● Goniotomy and trabeculotomy
● Laser iridoplasty
● Laser sclerostomy
PRINCIPLES OF GONIOSCOPE
When light passes from a medium with a greater index of refraction to a medium with lower
index of refraction, the angle of refraction (r) becomes greater than the angle of incidence
(i). I reaches a “critical angle” when r is equal to 90°.

Only when the light originating from the angle structures strikes the cornea at an angle
steeper than the critical angle of 46 degrees can light exit the eye and angle structures be
visualized. Goniolens make this possible and neutralize the refractive power of the cornea
thereby helping us visualize the anterior chamber angle.

DIFFERENCE BETWEEN DIRECT AND INDIRECT GONIOSCOPY

INDIRECT GONIOSCOPY
● The procedure is done in sitting position.
● Provides more magnification of the two procedures
● Lesser patient comfort.
● Binocular comparison is not possible.
 ● Indirect gonioscopy can’t be used for surgical procedure..
● Segmental view
● Examples of indirect gonioscopy lenses include the Posner, Sussman, Zeiss, and
Goldmann lenses.

DIRECT GONIOSCOPY
● The procedure is done in supine position.
● Patient is more comfortable during procedure.
● Provides less magnification as compared to indirect gonioscopy.
● Binocular comparison is possible in direct gonioscopy.
● The procedure can be used for goniotomy and goniosynechialysis.
● Panoramic view of iridocorneal angle with ability to adjust view by examiner.
● Examples of direct goniolenses include Koeppe, Barkan, Wurst, Swan-Jacob, or
Richardson lenses.

DIRECT GONIOSCOPY is performed with gonioscopic lenses used with portable slit- lamp or
an operating microscope. It is done in supine position after instilling topical anaesthesia,
though it can be done under general anaesthesia too. Goniolens is positioned on cornea
using a bridge of balanced salt solution and viscous preparation. Examiner holds goniolens in
one hand and light source in another during the procedure. It provides panoramic view of
the entire circumference and is very useful to compare the angles of two eyes by looking at
them simultaneously. It can also be used for goniotomy and goniosynechialysis

INDIRECT GONIOSCOPY uses mirrors or prisms to overcome the problem of total internal
reflection. Patient is positioned on slit lamp and topical anaesthesia is instilled. Gonioprismis
placed against cornea with or without use of fluid as bridging agent and rotated to see
angles slit-lamp illumination and magnification.

ADVANTAGES AND DISADVANTAGES OF GONIOSCOPY

INDIRECT GONIOSCOPY
ADVANTAGES
● Convenient
● Easier to learn
● Faster to perform
● Patient need not lie flat
● Slit lamp examination provides details compared to direct gonioscopy techniques
● Requires less instrumentation
● Less time-consuming
● Dynamic gonioscopy is possible.
DISADVANTAGES
● Mirror image is produced
● Inadvertent pressure can open or close the angle
● Depth of narrow angle cannot be seen
DIRECT GONIOSCOPY
ADVANTAGES
● Provides straight-on view. The angle of visualization can be changed by altering the
height of the observer which may enable evaluation over the curvature of iris e.g. iris
bombe or narrow angles.
● Less distortion of the anterior chamber is produced by goniolenses.
● The view is more panoramic
● Lenses in both eyes simultaneously can make comparison easier
● Fundus examination through a small pupil is also possible
● Direct view for surgery e.g. Goniotomy.
● Can be used in sedated patient and also in infants
DISADVANTAGES
● Inconvenient procedure, with the patient having to lie supine.
● Time consuming
● Benefits of slit-lamp (like variable light and better clarity) are not available

INDICATIONS AND CONTRAINDICATIONS OF GONIOSCOPY

CONTRAINDICATIONS
● Globe rupture
● Fresh/Recent hyphema
● Ocular surface infections like herpes simplex; epidemic keratoconjunctivitis .
● Epithelial basement membrane dystrophy
● Painful inflamed eye
● Acute glaucoma with edematous cornea
● Patients with known recurrent corneal erosion.
● Patients with corneal abrasions
● Patients with keratopathy (ie., bullous, band, punctate, etc.)
● Perforating eye injuries
● Acute trauma to the globe.
INDICATIONS
● Narrowness of angle as observed by Van Herick's technique
● History of angle closure attack
● History/ evidence of blunt trauma or penetrating ocular foreign body
● Active or past inflammation in chamber
● Evidence of neoplastic activity in chamber
● Possibility of neovascularization
● High intraocular pressure (IOP)
● Pigment dispersion syndrome
● Pseudoexfoliation syndrome
● Retinal vascular occlusion
● History of any type of glaucoma, field loss, or disc damage
● History of ocular tumor
● Unexplained hypotony to look for a cyclodialysis cleft
 ● Ischemic disease
● Anterior segment developmental anomalies (establish predisposition for aqueous
drainage complications).
DEFINITION OF GONIOSCOPY
It is a painless exam your ophthalmologist uses to check a part of your eye called the
drainage angle. This area is at the front of your eye between the iris and the cornea. It is
where fluid called aqueous humor naturally drains out of your eye. It is using a goniolens
(also known as a gonioscope) together with a slit lamp or operating microscope to view the
iridocorneal angle, or the anatomical angle formed between the eye's cornea and iris. Its use
is important in diagnosing and monitoring various eye conditions associated with glaucoma.
HISTORY OF GONIOSCOPY .
ALEXIOS TRANTAS - first used the word "gonioscopy", from the Greek origins on gonia
meaning "angle" and skopein to "observe". He described the anterior chamber angle using a
direct ophthalmoscope and simultaneous digital pressure on the limbal region.
MAXIMILIAN SALZMANN - years later would be the first to use a contact lens and indirect
gonioscopy for examination of the angle. Both are regarded as the "fathers of gonioscopy".
HOW TO PERFORM GONIOSCOPY
Gonioscopy is usually performed at the slit lamp. It can also be used during examination
under anesthesia in children and also in glaucoma surgery. . With the increasing emphasis on
Micro-invasive Glaucoma Surgery (MIGS), intraoperative gonioscopy has become even more
frequent. Gonioscopy should be performed in a relatively dark room. A brightly lit room will
constrict the pupil, opening the angle, and possibly missing ITC and apposition. Likewise, a
shorter and less bright slit beam should also be used.

PROCEDURES
INDIRECT GONIOSCOPY
⮚ As with any procedure, the patient and the examiner must be positioned in a
comfortable fashion.
⮚ A drop of topical anesthetic is then applied to the conjunctiva of both eyes.
⮚ If using the Goldmann lens, contact gel is placed in the concave part of the lens.
⮚ If using a Posner or similar type lens, a drop of artificial tears can be placed on the
concave surface.
⮚ The patient is then asked to open both eyes and look upwards.
⮚ The examiner can then pull down slightly on the lower lid and places the lens on the
surface of the eye.
⮚ The patient is then asked to look straight ahead.
⮚ Most examiners choose to start with the inferior angle as it is usually a bit more
open, and the pigmentation of the trabecular meshwork is slightly more prominent,
allowing for easier identification of the angle structures.
⮚ Continue identifying all angle structures in all 4 quadrants, and then repeat with the
other eye.
DYNAMIC GONIOSCOPY
 ⮚ In eyes with a closed angle, one must distinguish between an anatomically closed
angle with iridotrabecular contact (ITC, apposition) and peripheral anterior synechiae
(PAS).
⮚ To perform dynamic or compression gonioscopy, you will need to be using either the
Posner, Sussman, or Zeiss style lens.
⮚ The patient is positioned as noted above. Gentle pressure is placed on the cornea,
and aqueous humor is forced into the chamber angle.
⮚ If there is ITC or apposition, the angle will open and the structures should become
more visible.
⮚ If PAS is present, the angle will stay the same in the affected areas. Examine all areas
of the angle and repeat on the other eye.
DIRECT GONIOSCOPY
⮚ Direct gonioscopy is most easily performed with the patient in a supine position and
is commonly used in the operating room for examination of the eyes of infants under
anesthesia.
⮚ It can be performed using a direct goniolens and either a binocular microscope or a
slit-pen light.
⮚ Examples of direct goniolenses include Koeppe, Barkan, Wurst, Swan-Jacob, or
Richardson lenses.
⮚ The lens is positioned after saline or viscoelastic is placed on the eye, which can act
as a coupling device.
⮚ The lens provides direct visualization of the chamber angle (ie, light reflected directly
from the chamber angle is visualized) in an erect position.
⮚ This is essential for performing goniotomies or other angle-based surgeries, including
MIGS.

GRADING SYSTEMS
Gonioscopy grading systems were established to provide a standardized description of the
anatomy of the anterior chamber angle. There are many grading systems used today.
Scheie system
It is based upon visibility of the anatomical structures of the angle. They are graded Wide
through IV, with Wide being the most open.
Shaffer system
It is based on angularity. It also uses a number system, but is in reverse of the Scheie system.
For example, a Grade 4 angle in the Shaffer system is wide open, while a Grade IV in the
Scheie system is anatomically closed with no structures visible.
Spaeth system
It is much more complex and describes each detail of the anatomic angle. This system
describes the iris insertion, angularity, configuration, and pigmentation of the posterior
trabecular meshwork.
Becker system
The Becker classification focuses on the amount of trabecular meshwork present and the
distance between the seleral spur and the insertion of the iris. Numbers (0- 3) are used to
describe how much trabecular meshwork is present, Letters (A-C) are used to describe the
level of iris insertion.
Shaffer-Kanski system
This system is based on the width of the angle as previously described in the Shaffer system
and the risk of angle closure.
Van Herick system
This is a non-gonioscopic grading system. It uses an estimation of the peripheral anterior
chamber depth. It is done at the slit lamp and is most helpful before dilation. A thin slit
beam is angled approximately 60 degrees and aimed at the cornea peripherally near the
limbus. The corneal thickness is compared to the anterior chamber depth. The ratio is then
used to provide some information on the width of the chamber angle. Because it is done
without gonioscopy, no angel structures can be identified and it does not replace
gonioscopy.

TYPES OF GONIOLENS
KOEPPE DIRECT GONIOLENS this transparent device is placed directly on the cornea along
with lubricating fluid, to avoid damaging its surface. The steeper curvature of this goniolens'
exterior surface optically eliminates the total internal reflection problem and allows a view
of the iridocomeal angle. Unfortunately, it requires the patient to be lying down, and so it
cannot be so easily used with an ordinary slit lamp in an optometric environment. In an
ophthalmological setting, an operating microscope is one available option.
GOLDMANN INDIRECT GONIOLENS this truncated-cone like device utilizes mirrors to reflect
the light from the iridocomeal angle into the direction of the observer (as shown by the
schematic diagram). In practice the image comes out roughly orthogonal to the back surface
(nearer the practitioner), making observation and magnification with a slit lamp easy and
reliable. The small, curved front surface does not rest on the cornea, but instead vaults over
it, with lubricating fluid filling the gap. The border of the front surface rests on the sclera.
While the view obtained is smaller than that of the Koeppe goniolens, it can be used with
the patient sitting upright, and other mirrors within the device can be used to obtain views
of other parts of the eye, such as the retina and the ora serrata.
ZEISS INDIRECT GONIOLENS this instrument uses a similar method to the Goldmann, but
employs prisms in the place of mirrors. Its four symmetrical prisms allow visualisation of the
iridocorneal angle in four quadrants of the eye simultaneously, and works well with a slit
lamp. Most importantly, the size and shape of the instrument - a smaller front surface that
rests on the cornea without requiring lubricating fluid, only the patient's tear film allows for
indentation gonioscopy, which can be used for further diagnosis.

PROCESS OF GONIOSCOPY
● Briefly explaining the procedure to the patient
● Cleaning and sterilizing the front (curved) surface of the goniolens
● Applying lubricating fluid to the front surface if appropriate
● Anaesthetizing the patient's cornea with topical anaesthetic
● Preparing the slit lamp for viewing through the goniolens
● Gently moving the patient's eyelids away from the cornea
● Slowly applying the goniolens to the ocular surface, forming suction
● Fine-tuning the slit lamp to optimize the view
● Interpreting the gonioscopic image
● Swiveling the goniolens to view each section of the iridocorneal angle
● When satisfied, very carefully breaking suction via the eyelids cleaning the
instruments and irrigating the patient's eyes with [saline] if desired.