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Consultant:
dr. Prima Maya Sari, Sp.M
Ophthalmology Department
Medical Faculty Of Sriwijaya University
Dr. Moh. Hoesin Hospital Palembang
2019
BACKGROUND
01 Anterior Chamber Angle
Important structure Aqueous humor outflow,
diseases, diagnose, and management
It can be examined using van Herick and
gonioscopy
02 Van Herick
Measurement technique to
estimate anterior chamber angle
using slit lamp
03 Gonioscopy
Gold standard for examining the
anterior chamber angle
objective
Van Herick
examination
Objective
Gonioscopy Structures
examination involved
Anatomy and Structures
Anterior Chamber Angle
• Schwalbe’s line
• Trabecular meshwork
• Schlemm’s canal
• Collectors channel
• Scleral spur
Anatomy and Structures
Anterior Chamber Angle
• Schwalbe’s line
• Trabecular meshwork
• Schlemm’s canal
• Collectors channel
• Scleral spur
Schwalbe’s line Scleral spur
Trabecular meshwork
Iris Processes
•Principle
Van Herick •Technique
Examination •Results
Principle
1. Informed consent
2. Patient and examiner sit on slitlamp setting
3. His/her chin and head stay comfortably on chinrest and headrest
4. Slit rays from illumination system make 600 angle to observation system
5. Slit rays hit temporal side of limbus, perpendicular to the cornea
6. Look at corneal thickness
7. Look at blank chamber between the rays on cornea and rays o the iris, it is
the peripheral anterior chamber
8. Compare anterior chamber thickness to corneal thickness.
9. Move to the other eye
10. Record the findings
RESULTS
Grade 4 : AC/CT =
1
Grade 3 : AC/CT =
½-¼
Grade 2 : AC/CT =
¼
Grade 1 : AC/CT =
<¼
Shaffer Principle
Scheie Results
Spaeth
Gonioscopy Types
Examination
Lenses
Technique
Principle
Direct Indirect
Gonioscopy Gonioscopy
• Koeppe lens • Goldmann-single mirror
1. Informed consent
2. Topical anaesthesia
3. Patient and examiner sit on slitlamp setting
4. His/her chin and head stay comfortably on chinrest and headrest
5. Prepare goniolens, use viscous material as needed, avoid air bubbles
6. Pull lower eyelid with left thumb
7. Ask him/her to look up and put goniolens to lower eyelid
8. Put the rest of goniolens contacting cornea, ask patient to look forward
9. Look using observation system of slitlamp, use 10x magnification
10. Learn at upper goniolens (inferior), note the findings
11. Rotate the lens clockwise to learn the other quadrants
12. Note the findings
Technique
Schwalbe’s
Spaeth : based on iris
line
insertion, angular
approach, peripheral B Between b bowed 1+ minimal
iris, and pigmentation Schwalbe’s anteriorl
line and y
of T.M.
scleral spur
s steep
C Scleral 00 p 2+ mild
spur visible to plateau
500 iris
Example :
D Deep with q queer c 3+ moderate
D40f 1ptm, A40f 1ptm,
ciliary body concave
(B)D30p 0ptm visible
E Extremely 4+ intense
deep with >
1 mm of
ciliary body
visible
Van Herick and Gonioscopy Relations
Gonioscopy
Van Herick
• Easier to do • More accurate
• Fast • All quadrants can be
visualized directly
• Non invasive • Harder to master
Sometimes, both examination results can correspond to each other, but its
not always the case.
Conclusion
3. The fast, ease and non invasive examination of Van Herick can
be used as adjuvant before Gonioscopy is undertaken by the
physician.
Thank You
Thank You
Total internal reflection
• Occurs when light strikes a medium boundary at an angle larger than the
critical angle
• If light strikes at angle lower then critical angle, partial light will be refracted
and part will be refrelcted
• Can only occur when light travels from higher refractive index medium to
lower one
Peripheral Anterior Chamber
• Direct visualization
• Using domed gonioscope
• Using Handheld biomicroscope
• Patient in supine position, mostly
pediatric setting
• Most popular : Koeppe lens
• Koeppe lens : 50+D, inner radius 7.5mm,
outer radius 12.5mm
• Other lens : Swan-Jacob
Indirect goniolens