Regional V Integrated Eye Workshop and

Symposium (REVIEWS) 2020 

GONIOSCOPY
Mirella Afifudin
 I HAVE NO
FINANCIAL
DISCLOSUR
E
 GONIOSCOPY
Gonioscopy is a clinical technique
Trantas first drawing of iridocorneal angle to examine structure of the anterior
chamber/iridocorneal angle

q Essential diagnostic tool in everyday

ophthalmic practice to detect angle abnormalities that
could have diagnostic and therapeutics implications

Dellaporta A., History Of Gonioscopy. Surv. Ophthalmol.1975; 20:137-149.

Paiting by Salzmann, incomplete peripheral synechiae, pigmentation of

 HISTORY OF GONIOSCOPY
• 1899-1907: Alexio Trantas   examination angle with direct
ophthalmoscope first reported examination of the angle

• 1914: Maximilian Salzmann view the angle through a contact lens

• 1919: Koeppe use Zeiss slit lamp

• 1925: Manuel Uribe Troncosco self- illuminating
monocular gonioscope

• 1936: Otto Barkan combined koeppie lens and Zeiss binocular

microscope.

• 1938:Goldmann mirror contact lens (Indirect Gonioscope)

• 1945: Allen- thorpe Gonioprism
Dellaporta A., History Of Gonioscopy. Surv. Ophthalmol.1975; 20:137-149.
Alward WLM.,  A History Of Gonioscopy. Optom Vis Sci.2011;88:29-35.
Alexio Trantas (1867-1961)
PRINCIPLE
S OF
GONIOSCO Total internal reflection occurs when the light from the iridocorneal
angle strikes the tear-air interface at a shallow enough angle that all
PY the light is reflected back into the eye.

Not possible to view the anterior

chamber of a normal eye directly

Alward WLM.,  A History Of Gonioscopy. Optom Vis Sci.2011;88:29-35.​

PRINCIPLES OF
GONIOSCOPY
Direct lens, this lens change
the approach of the light
from the iridocorneal angle
so that it is more
perpendicular, thus
overcoming total internal
reflection.

Alward WLM.,  A History Of Gonioscopy. Optom Vis Sci.2011;88:29-35.​​

 The Koeppe Lens

TYPES OF LENS
1. Direct Gonioscopy Lenses
Performed with a steeply convex lens, Hoskins-Barkans Surgical
permits light from the angle to exit the eye contact lens
closer to the perpendicular at the interface
between lens and the air

Swan-Jacobs surgical contact lens

Alward WLM. 1994. Color Atlas Of Gonioscopy. San Fransisco: The Foundation Of The American Academy Of Ophthalmology
 TYPES OF LENS Goldmann three-mirror
lens
2. Indirect Gonioscopy lenses
The lens used in indirect gonioscopy use
mirrors to overcome total internal reflection.
The mirror redirects light from the angle so
that it exits the eye perpendicularly to the Ritch trabeculoplasty
lens-air interface laser lens

The Sussman
four-mirror lens Allen-Thorpe
Gonioprism

Alward WLM. 1994. Color Atlas Of Gonioscopy. San Fransisco: The

Foundation Of The American Academy Of Ophthalmology
Possner four
mirror lens
 COMPARISON OF DIRECT AND
INDIRECT GONIOSCOPY
Direct gonioscopy Indirect Gonioscopy

 Procedur done in supine positon   Procedur done in sitting position

 Less magnification  More magnification
 Stright-on view of the angle  Mirror image
 Binocular comparisson is possible  Create corneal wedge  (slit beam) and
indentation gonioscopy
 Used for surgical procedur
  use in laser and day practice

Alward WLM. 1994. Color Atlas Of Gonioscopy. San Fransisco: The Foundation Of The American Academy Of Ophthalmology
Friedman DS and He M. Anterior Angle Chamber Assessment Techniques. Surv Ophthalmol. 2008;53:250-273. 
 TECHNIQUES OF SLIT LAMP
GONIOSCOPY
  Anesthetized the patient eye 

 Seat the patient comfortably at the slit lamp, align the lateral

canthus of the patient aye with canthal marker of the slit lamp

 The magnification of the slit lamp should be set at x10-25.

 A fairly short and narrow beam of light is preferred (2-3 mm)

Alward WLM. 1994. Color Atlas Of Gonioscopy. San Fransisco: The Foundation Of The American Academy Of
Ophthalmology
 TECHNIQUES OF SLIT LAMP
GONIOSCOPY
§ Hold the lens with thumb and forefinger, the
remaining three finger braced against the
patient's face.

§ The lens should be applied lightly, just until

the air disappear from the cornel surface 

§ The appearance of folds in

Descemet's membrane is an
indication too much pressure being applied

Alward WLM. 1994. Color Atlas Of Gonioscopy. San Fransisco: The Foundation Of The American Academy Of Ophthalmology
  Slit lamp gonioscopy is performed through mirror

GONIOSC  The part of the angle that is viewed is 180o away from

the  mirror that is being used

OPIC  The image is mirror image (not an inverted)

VIEW  The angle seen in superior part of the temporal mirror

is the superior part of the nasal angle

Alward WLM. 1994. Color Atlas Of Gonioscopy. San Fransisco: The Foundation Of The American Academy Of Ophthalmology
 ANATOMY OF THE ANGLE

Alward WLM. 1994. Color Atlas Of Gonioscopy. San Fransisco: The Foundation Of The American Academy Of Ophthalmology
Dada T et al. 2013. Gonioscopy A Text and Atlas. New Delhi: JaypeeBrother Medical Publishers
 SCHWALBE'S LINE
Anterior border of the

trabecular meshwork
Termination of Descemet's

membrane
A faint white line, corneal

wedge help identified

Fahinger C and Hommer A. 201. Gonioscopy.London: Springer

Alward WLM. 1994. Color Atlas Of Gonioscopy. San Fransisco: The Foundation Of The American Academy Of Ophthalmology
 TRABECULAR MESHWORK
Between Scwalbe's line and Scleral
spur
Posterior trabecular meshwork
(between white arrow) more
pigmented
Anterior trabecular meshwork
(between black arrow)
Pigment in the angle usually heaviest
in the inferior

Fahinger C and Hommer A. 201. Gonioscopy.London: Springer

Alward WLM. 1994. Color Atlas Of Gonioscopy. San Fransisco: The Foundation Of The American Academy Of Ophthalmology
 SCHLEMM'S CANAL
1. Not visible, lies deep within posterior
trabecular meshwork. Anterior to
trabecular meshwork

2. Visible  when filled with blood

(hypotoni, sturge weber syndrome)

Fahinger C and Hommer A. 201. Gonioscopy.London: Springer

Alward WLM. 1994. Color Atlas Of Gonioscopy. San Fransisco: The Foundation Of The American Academy Of Ophthalmology
 SCLERAL SPUR
q A ridge of scleral tissue, anterior to the
ciliary body band, posterior to the
trabecular meshwork
q Important landmark

Fahinger C and Hommer A. 201. Gonioscopy.London: Springer

Alward WLM. 1994. Color Atlas Of Gonioscopy. San Fransisco: The Foundation Of The American Academy Of Ophthalmology
 CILIARY BODY BAND
Longitudinal fibers of the ciliary

muscle

Anterior to the iris and posterior to

Scleral spur

Wide in myopic and absent in

hyperopic
Fahinger C and Hommer A. 201. Gonioscopy.London: Springer
Alward WLM. 1994. Color Atlas Of Gonioscopy. San Fransisco: The Foundation Of The American Academy Of Ophthalmology
 IRIS PROCESSES
Often found in normal angles

Usually fine and extent into the posterior

portion of the trabecular meshwork

Peripheral anterior synechiae broad and

irregular, attach iris stroma to trabecular

meshwork

Fahinger C and Hommer A. 201. Gonioscopy.London: Springer

Alward WLM. 1994. Color Atlas Of Gonioscopy. San Fransisco: The Foundation Of The American Academy Of Ophthalmology
 CORNEAL WEDGE
Reflection of the inner and

outer aspect of the cornea

The line of the corneal wedge

intersect at Schwalbe's line

Alward WLM. 1994. Color Atlas Of Gonioscopy. San Fransisco: The Foundation Of The American Academy Of Ophthalmology
 ARTIFACTS WHEN
PERFORMING GONIOSCOPY
Pressure on larger base lens lead to compression schwalbe's area

Angle artifactitiously widened when the lens not centred on the cornea

Localized corneal compression cause fluid displacement

Inadvertently compress the cornea leading to image distortion, angle
widening or narrowing

Friedman DS and He M. Anterior Angle Chamber Assessment Techniques. Surv Ophthalmol. 2008;53:250-273.
 DYNAMIC
GONIOSCOPY
Initial approaches to  visualization of the anterior
chamber angle distinguished synechial closure from
appositional closure

Forbes M. Gonioscopy With Corneal Indentation. A Method For Distinguished Between Appositional Closure and Synechial Closure. Arch Ophthalmol. 1966;
488-492.
Friedman DS and He M. Anterior Angle Chamber Assessment Techniques. Surv Ophthalmol. 2008;53:250-273.​
Terminology And Guidelines For Glaucoma. European Glaucoma Society. 4th ed.
DYNAMIC GONIOSCOPY
 Neovascular on the angle
Closed angle
Cyclodialysis cleft

ANGLE PATHOLOGIES
Fahinger C and Hommer A. 201. Gonioscopy.London: Springer
Dada T et al. 2013. Gonioscopy A Text and Atlas. New Delhi: JaypeeBrother Medical Publishers
 Emulsified silicon oil
Post trabeculectomy,  scelrostomy and surgical iridectomy
Glaucoma implant tube on the
angle

POST SURGICAL EVALUATION OF THE

ANGLE
Fahinger C and Hommer A. 201. Gonioscopy.London: Springer
Dada T et al. 2013. Gonioscopy A Text and Atlas. New Delhi: JaypeeBrother Medical Publishers
GRADING OF GONIOSCOPY
Scheie system

Spaeth system

Terminology And Guidelines For Glaucoma. European Glaucoma Society. 4th ed.
Alward WLM. 1994. Color Atlas Of Gonioscopy. San Fransisco: The Foundation Of The American Academy Of Ophthalmology
TAKE HOME MESSAGES
Gonioscopy is standard procedur for assessing iridocorneal angle
stuctures and configuration

 Angle assessment is essential for determining treatment

Understanding and practicing will lead to mastering the technique

of gonioscopy
THANK YOU