Anterior Chamber Angle Assessment Techniques
Anterior Chamber Angle Assessment Techniques
Anterior Chamber Angle Assessment Techniques
Abstract. Angle-closure glaucoma is a leading cause of irreversible blindness. Diagnosis and treatment
are intricately related to angle assessment techniques. This article reviews the literature on angle assessment and provides recommendations about optimal techniques based on the published evidence. Specically, we review gonioscopy, ultrasound biomicroscopy, and anterior segment optical coherence tomography, all of which can be used to assess the anterior chamber angle directly. In addition, we discuss surrogate approaches to measuring the angle conguration, including Limbal anterior chamber depth measurement, scanning peripheral anterior chamber depth measurement, and Scheimpug photography.
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Instruments Used for Anterior Chamber Angle Examination:1. Torch Light 2. Slit Lamp 3. Gonio Lenses 4. Ultrasound Biomicroscopy 5. Optical Coherence Tomography 6. Pentacam
Gonioscopy
Angle structures are not visible using direct observation of the anterior segment of the eye due to the lower refractive index of air compared with the tear film. According to Snells law, this interface leads to total internal reflection of light because light going from a more to a less dense medium is refracted away from the normal. When a critical angle is reached (in the eye this is approximately 50 ), the light is reflected internally, and the object is not visible without the use of techniques to overcome the bending of light at the tear air interface (such as using indentation or a lens). Overcoming total internal reflection of light emanating from the angle can be done with lenses that allow for direct viewing of the angle structures (e.g., Koeppe and Barkan lenses) or with mirrored lenses that give an indirect view.
Advantages and Disadvantages of Direct and Indirect Gonioscopy Direct Gonioscopy Advantages Patient comfort Possibly better view Disadvantages Second microscope and illumination Space needed Nose can block temporal angle Indirect Gonioscopy Advantages Uses the slit lamp Variable magnication No astigmatic aberrations Disadvantages Bubbles can block the view Plastic can scratch Need rotating head on slit lamp to get slit view nasally and temporally
Astigmatic distortion
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GRADING SCHEMES
Gonioscopy is performed for several reasons:1) To determine the mechanism of glaucoma (i.e., open or closed angle, pigment dispersion, plateau iris, etc.) 2) To identify persons at risk of developing angle closure glaucoma and 3) To monitor changes in the ACA over time as part of clinical care or research.
A recent consensus document published by the Association for International Glaucoma Societies proposed that the ACA should be viewed in a dark room using a 1-mm beam with adequate illumination to visualize angle structures clearly with the patient looking straight ahead. This approach allows one to see the corneal wedge, it minimizes the angle-opening effect of illumination, and it avoids artifactitiously widening the angle by manipulating the lens.
SCHEIE SYSTEM
This system, published in 1957, attempted to categorize risk of angle closure based on gonioscopy although no prospective studies were performed for validation purposes. The system labels the degree of angle closure such that a Scheie grade zero is a wide open angle. Grade 1 is slightly narrow, grade 2 means that the ciliary body root is not visible, and grade 3 means that the posterior (pigmented) Trabecular meshwork is not visible. Grade 4 is closed, meaning that no structures are visible. Scheie believed that persons with grade 3 and grade 4 angles were at greatest risk of angleclosure glaucoma. In addition to grading the structures seen, Scheie also recommended recording the degree of pigmentation and was one of the rst to divide the Trabecular meshwork into pigmented and non-pigmented regions.
SHAFFER SYSTEM
The Shaffer system uses the opposite approach of the Scheie system, grading from closed (grade 0) to wide open (grade 4). The angle width is based on two lines, one drawn from the angle depth to Schwalbes line, and the second drawn through the iris starting from the base of the angle. Angles between 35 and 45 are grade 4, those 20 - 35 are grade 3, those 10 - 20 are grade 2, and those < 10 are grade 1, with a closed angle (zero degrees) is grade 0.
SPAETH SYSTEM
The Spaeth system was designed to give a more comprehensive and readily communicated approach to angle assessment The emphasis is on describing what is seen in the angle, which is divided into three ndings: 1) the angle of insertion (described by estimating a tangent to the endothelial surface of the cornea, but the exact location along the curve or the cornea is not stated) and a tangent to the anterior surface of the iris, measured at the point of Schwalbes line; 2) the conguration of the iris; Page 3 of 7
VARIATION,
SEX
Studies show that superior angle is the narrowest angle. Population-based studies have frequently documented higher rates of occludable angles among women and older persons.
GONIOSCOPY CONCLUSIONS
Gonioscopy is the current reference standard for assessing ACA structures and conguration. It requires a subjective assessment by an observer placing a contact lens on the eye of the patient. Denitions of angle ndings vary across grading schemes, and no single scheme is used, although the Shaffer angle width appears to be commonly reported in research.
Scheimpug Photography
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The Scheimpug principle (named after Theodor Scheimpug, an Austrian army captain), describes the change in the focal plane that occurs when the lens is tilted. Instead of having the focal plane, the lens plane and the lm plane aligned so that they are exactly parallel (as occurs in standard cameras), the lm plane is tilted, which shifts the plane of sharp focus to the intersection point of the lm and lens planes. This approach has been used to allow investigators to obtain slit images of the anterior segment of the eye that retain depth. In addition to studying anterior segment biometry, the Scheimpug cameras have been adapted for measuring cataract density and following cataract progression. In summary, although Scheimpug cameras offer a non-contact approach to angle assessment (which is highly appealing for screening purposes), they dont allow detailed visualization of angle structures and have relatively low correlation with gonioscopy (the current reference standard). Furthermore, while angle width and anterior chamber depth measures have been highly reproducible in persons with open angles, more research is needed to determine the reproducibility in populations with more angle variation (i.e., the populations of greatest interest for using such a device).
Images are then captured on a small charge-coupled device camera and automatically analyzed by computer. The SPAC also calculates the corneal thickness and the radius of corneal curvature in order to derive a more accurate assessment of the anterior chamber depth at various points. The entire scan takes 0.67 seconds to capture, with images captured at 0.4-mm intervals. Studies indicate that the SPAC ndings correlate with angle ndings to some extent, but it is unclear if the degree of correlation is high enough for the device to be used effectively for screening for angle closure. More research will be needed to clarify the role that SPAC will play in angle assessment.
Responses of the ACA to External Stimuli (Light-Dark Changes, Corneal Indentation, and Pilocarpine)
LIGHT-DARK CHANGES Angle appearance can change dramatically depending on the amount of illumination that strikes the eye. When light shines on the eye the iris sphincter contracts and the peripheral iris moves centrally away from the angle. The result is in many cases a more open angle appearance. Pavlin rst described a dark-room provocative test using UBM in eight patients who developed angle closure and appositional closure in response to decreased illumination. Friedman reported that the fellow eyes of persons with unilateral acute attacks have more substantial angle narrowing in the dark than normal controls, indicating that the dynamic response to external stimuli may play a role in the pathologic process. Sugimoto and colleagues in Japan have recently published an example of gonioscopy captured using infrared light. These authors showed substantial angle narrowing compared to standard gonioscopy with brighter illumination. CHANGES WITH CORNEAL INDENTATION There is widening of the Anterior Chamber Angle with corneal indentation according to the study published by Matsunaga and colleagues PILOCARPINE EFFECTS ON ACA CONFIGURATION Hitchings demonstrated that when persons had a shallowing of the central anterior chamber depth in response to 4% pilocarpine, the peripheral anterior chamber also shallowed, whereas if the central ACD did not shallow, the peripheral ACD widened.
Conclusions
Anterior Chamber Angle assessment is challenging, but it is a key clinical activity that alters how patients with glaucoma or suspect glaucoma are treated. Gonioscopy remains the reference standard, but it is suboptimal. Newer technologies may improve our ability to assess and monitor the ACA.
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Glossary
ACA- Anterior Chamber Angle ACD- Anterior Chamber Depth UBM-Ultrasound Biomicroscopy SPAC- Scanning Peripheral Anterior Angle depth analysis system LACD-Limbal Anterior Chamber Depth AS-OCT -Anterior Segment Optical Coherence Tomography
References
1. Alsbirk PH: Primary angle-closure glaucoma. Oculometry, epidemiology, and genetics in a high risk population. Acta Ophthalmol 127(Suppl). 5--3, 1976 2. Arkell SM, Lightman DA, Sommer A, et al: The prevalence of glaucoma among Eskimos of northwest Alaska. Arch Ophthalmol 105:482--5, 1987 3. Aung T, Lim MC, Chan YH, et al: Conguration of the drainage angle, intraocular pressure, and optic disc cupping in subjects with chronic angle-closure glaucoma. Ophthalmology 112:28--32, 2005 4. Baez KA, Orengo S, Gandham S, et al: Intraobserver and interobserver reproducibility of the Nidek EAS-1000 Anterior Eye Segment Analysis System. Ophthalmic Surg 23:426--8, 1992 5. Barkan O: Pigment changes in the anterior segment in primary glaucoma. Trans Am Ophthalmol Soc 55:395--413, 1957
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