GONIOSCOPY

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INTRODUCTION
• Gonioscopy is an essential diagnostic tool and examination technique
used to visualize the structures of the anterior chamber angle

• Unfortunately, this procedure is often underutilized in clinical practice,

potentially leading to incorrect diagnosis and management.

• Gonioscopy is required in order to visualize the angle because, under

normal conditions, light reflected from the angle structures undergoes
total internal reflection at the tear–air interface.
• Gonioscopy lenses eliminate the tear–air interface by placing a plastic or glass
surface adjacent to the front surface of the eye. The small space between the lens
and cornea is filled by the patient’s tears, saline solution, or a clear viscous
substance. Depending on the type of lens employed, the angle can be examined
with a direct (eg. Koeepe) system.
GONIOSCOPIC VIEW OF ANGLE STRUCTURES
 METHODS OF GONIOSCOPY

 1. DIRECT GONIOSCOPY

 2. INDIRECT GONIOSCOPY
- WITHOUT INDENTATION
- WITH INDENTATION
• Direct gonioscopy is performed with a binocular microscope, a ber-optic
illuminator or slit-pen light, and a direct goniolens, such as the Koeppe, Barkan,
Wurst, Swan-Jacob, or Richardson lens. The lens is placed on the eye, and saline
solution is used to ll the space between the cornea and the lens. The saline acts
as an optical coupler between the 2 surfaces.
• The lens provides direct visualization of the anterior chamber angle (ie, light
reflected directly from the angle is visualized). With direct gonioscopy lenses,
the clinician has an erect view of the angle structures, which is essential when
goniotomies are performed. Direct gonioscopy is most easily performed with
the patient in a supine position, and it is commonly used in the operating
room for examining the eyes of infants under anesthesia.
PEMERIKSAAN DIREK
• Indirect gonioscopy is more frequently used in the clinician’s office. Indirect
gonioscopy also eliminates the total internal reflection at the surface of the cornea.
Light reflected from the angle passes into the indirect gonioscopy lens and is reflected
by a mirror within the lens. Indirect gonioscopy may be used with the patient in an
upright position, with illumination and magnification provided by a slit lamp. A
goniolens, which contains 1 or more mirrors, yields an inverted and slightly
foreshortened image of the opposite angle. Although the image is inverted with an
indirect goniolens, the right–left orientation of a horizontal mirror and the up–down
orientation of a vertical mirror remain unchanged. The foreshortening, combined with
the upright position of the patient, makes the angle appear a little shallower than it does
with direct gonioscopy systems.
• The Goldmann-type goniolens requires a viscous
fluid such as methylcellulose for optical coupling
with the cornea. When the goniolens has only 1
mirror, the lens must be rotated to view the entire
angle. Posterior pressure on the lens, especially if it
is tilted, indents the sclera and may falsely narrow
the angle. These lenses provide the clearest
visualization of the anterior chamber angle
structures, and they may be modified with
antireflective coatings for use during laser
procedures.
• The Posner, Sussman, and Zeiss 4-mirror goniolenses allow all 4 quadrants of
the anterior chamber angle to be visualized without rotation of the lens during
examination. Since the Goldmann-type lens has approximately the same
radius of curvature as the cornea, they are optically coupled by the patient’s
tears. However, pressure on the cornea may distort the angle. The examiner
can detect this pressure by noting the induced Descemet membrane folds.
Although pressure may falsely open the angle, the technique of dynamic
gonioscopy is sometimes essential for distinguishing iridocorneal apposition
from synechial closure. Many clinicians prefer these lenses because of their
ease of use and employment in performing dynamic gonioscopy.
 Zeiss-Style Lenses

Zeiss Four-mirror Lens

Posner Four-mirror Lens

Sussman Four-mirror Lens

• Because the posterior diameter of these goniolenses is smaller than the corneal diameter,
posterior pressure can be used to force open a narrowed angle. With dynamic gonioscopy
(compression or indentation gonioscopy), gentle pressure is placed on the cornea, and
aqueous humor is forced into the angle (see Fig 3-3). In inexperienced hands, dynamic
gonioscopy may be misleading, as undue pressure on the anterior surface of the cornea
may distort the angle or may give the observer the false impression of an open angle.
• With all indirect gonioscopy techniques, the observer may manipulate the
anterior chamber angle by repositioning the patient’s eye (having the
patient look toward the mirror) or by applying pressure with the posterior
surface of the lens to provide more complete evaluation of the angle.
However, caution must be used to avoid inducing artificial opening or
closing of the angle with these techniques.
Gonioscopic Assessment & Documentation

• In performing both direct and indirect gonioscopy, the clinician must recognize
the landmarks of the anterior chamber angle. It is important to perform
gonioscopy with dim room light and a thin, short light beam in order to
minimize the amount of light entering the pupil. An excessive amount of light
could result in increased pupillary constriction and a change in the peripheral
angle appearance that could falsely open the angle, thereby preventing the
correct identification of a narrow or occluded angle.
• The scleral spur and the
Schwalbe line, 2 important angle
landmarks, are most consistently
identified. A convenient
gonioscopic technique to
determine the exact position of
the Schwalbe line is the
parallelepiped technique.
• The parallelepiped, or corneal light wedge, technique allows the observer to
determine the exact junction of the cornea and the trabecular meshwork. Using
a narrow slit beam and sharp focus, the examiner sees 2 linear reflections, one
from the external surface of the cornea and its junction with the sclera and the
other from the internal surface of the cornea.
Corneal Wedge

External beam Schwalbe

Line

Internal beam
• The 2 reflections meet at the Schwalbe line (see Fig 3-1). The scleral spur is a thin,
pale stripe between the ciliary face and the pigmented zone of the trabecular
meshwork. The inferior portion of the angle is generally wider and is the easiest
place in which to locate the landmarks. After verifying the landmarks, the clinician
should examine the entire angle in an orderly manner (see Table 3-1).
• Proper management of glaucoma requires that the clinician determine not only
whether the angle is open or closed, but also whether other pathologic findings,
such as angle recession or peripheral anterior synechiae (PAS), are present. In
angle closure, the peripheral iris obstructs the trabecular meshwork—that is, the
meshwork is not visible on gonioscopy. The width of the angle is determined by
the site of insertion of the iris on the ciliary face, the convexity of the iris, and
the prominence of the peripheral iris roll. In many cases, the angle appears to be
open but very narrow. It is often difficult to distinguish a narrow but open angle
from an angle with partial closure; dynamic gonioscopy is useful in this
situation (see Figs 3-2 and 3-3).
• The best method for describing the angle is to use a standardized grading system or
draw the iris contour, the location of the iris insertion, and the angle between the iris
and the trabecular meshwork. A variety of gonioscopic grading systems have been
developed, all of which facilitate standardized description of angle structures and
abbreviate that description. Keep in mind that, with abbreviated descriptions, some
details of the angle structure will be eliminated. The most commonly used gonioscopic
grading systems are the Shaffer and Spaeth systems. A quadrant-by-quadrant narrative
description of the chamber angle noting localized findings such as neovascular tufts,
angle recession, or PAS may also be used to document serial gonioscopic findings. If a
grading system is used, the clinician should specify which system is being used.
The Shaffer system describes the angle between the trabecular meshwork and the iris as
follows:
• Grade 4: The angle between the iris and the surface of the trabecular meshwork is 45°.
• Grade 3: The angle between the iris and the surface of the trabecular meshwork is greater
than 20° but less than 45°.
• Grade 2: The angle between the iris and the surface of the trabecular meshwork is 20°. Angle
closure is possible.

• Grade 1: The angle between the iris and the

surface of the trabecular meshwork is 10°. Angle
closure is probable in time. Slit: The angle
between the iris and the surface of the trabecular
meshwork is less than 10°.
• Angle closure is very likely. 0: The iris is against
the trabecular meshwork. Angle closure is present.
The Spaeth gonioscopic
grading system expands this
system to include a
description of the peripheral
iris contour, the insertion of
the iris root, and the effects of
dynamic gonioscopy on the
angle configuration (Fig 3-4).
Ordinarily, the Schlemm canal is invisible by
gonioscopy. However, blood enters the Schlemm
canal when episcleral venous pressure exceeds
IOP, most commonly because of compression of
the episcleral veins by the lip of the goniolens
(Fig 3-5). Pathologic causes include hypotony
and elevated episcleral venous pressure, as in
carotid-cavernous fistula or Sturge-Weber
syndrome.
Normal blood vessels in the angle include radial iris vessels, portions of the arterial circle of the
ciliary body, and vertical branches of the anterior ciliary arteries. Normal vessels are oriented
either radially along the iris or circumferentially (in a serpentine manner) in the ciliary body face.
Vessels that cross the scleral spur to reach the trabecular meshwork are usually abnormal (Fig 3-
6). The vessels seen in Fuchs heterochromic uveitis are fine, branching, unsheathed, and
meandering. Patients with neovascular glaucoma have trunklike vessels crossing the ciliary body
and scleral spur and arborizing over the trabecular meshwork. Contraction of the myofibroblasts
accompanying these vessels leads to PAS formation.
It is important to distinguish PAS
from iris processes (the uveal
meshwork), which are open and
lacy and follow the normal curve
of the angle. The angle structures
are visible in the open spaces
between the processes. Synechiae
are more solid or sheetlike (Fig 3-
7). They are composed of iris
stroma and obliterate the angle
recess.
• Pigmentation of the trabecular meshwork increases with age and tends to be
more marked in individuals with darkly pigmented iris. Pigmentation can be
segmental and is usually most marked in the inferior angle. The pigmentation
pattern of an individual angle is dynamic over time, especially in conditions
such as pigment dispersion syndrome. Heavy pigmentation of the trabecular
meshwork should suggest pigment dispersion or pseudoexfoliation syndrome.
• Pseudoexfoliation syndrome may appear clinically
similar to pigment dispersion syndrome, with pigment
granules on the anterior surface of the iris, increased
pigment in the anterior chamber angle, and secondary
open-angle glaucoma. In addition, a line of pigment
deposition anterior to the Schwalbe line is often present
in pseudoexfoliation syndrome (Sampaolesi line).

Other conditions that cause increased anterior chamber angle pigmentation include
melanoma, trauma, surgery, inflammation, angle closure, and hyphema.
Posttraumatic angle recession may be associated with monocular open-angle
glaucoma. The gonioscopic criteria for diagnosing angle recession include :

• an abnormally wide ciliary body band (Fig 3-8)

• increased prominence of the scleral spur

• torn iris processes

• marked variation of ciliary face width and angle depth in different quadrants of the
same eye
In evaluating for angle
recession, the clinician
may find it helpful to
compare one part of
the angle to other
areas in the same eye
or to the same area in
the fellow eye.
Figure 3-9 illustrates the variety of
gonioscopic findings caused by blunt
trauma. If the ciliary body separates from
the scleral spur (cyclodialysis), it will
appear gonioscopically as a deep angle
recess with a gap between the scleral spur
and the ciliary body. Detection of a very
small cleft may require ultrasound
biomicroscopy.
Other findings that may be visible by gonioscopy are

• microhyphema or hypopyon

• retained anterior chamber foreign body

• Iridodialysis

• sclerostomy site and tube shunts

• angle precipitates suggestive of glaucomatocyclitic crisis

• pigmentation of the lens equator

• other peripheral lens abnormalities

• intraocular lens haptics

• ciliary body tumors/cyst

Video Four-mirror gonioscopy Technique
Dokumentasi Hasil Gonioskopi

Goniogram By Schaffer
 Gonioscopy Flow Diagram (Indentasi)
Scleral spur Visible ?

Yes No
Grade : Record findings Do Indentation gonioscopy
Any synechiae?
Ope n ang le

Yes No
Grade : Record findings IOP raised?

Primary ang le c lo s ure

(S yne c hiae )

Yes No
Grade : Record findings Grade : Record findings

Primary ang le c lo s ure Primary ang le c lo s ure

(Appo s itio n) s us pe c t
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