4/13/17
Navigating the Angle: Gonioscopy
Justin Schweitzer, OD, FAAO Cataract, Cornea, Refractive and Glaucoma Surgery Specialist Vance Thompson Vision Sioux Falls, South Dakota
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Allergan Glaukos Bausch and Lomb Bio-Tissue Alcon BioTissue Reichert
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How do we view the angle?
Direct Lens – use a contact lens with specific anterior curvature that will overcome critical angle
Indirect – use a mirror to overcome the critical angle
Direct Gonioscopy
Koeppe Lens
Indirect Gonioscopy
Goldmann Three Mirror
Zeiss four-mirror lens
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Gonioscopy
The gold standard for assessing the drainage apparatus of the eye
CPT code 92020
Gonioscopy
Important in distinguishing between different types of glaucoma
Open vs Closed angle glaucoma
Types of Goniolenses
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6 mirror lens?!?!
5 4/13/17
SlitS -Lamp Setup
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Set-up Tips
Position mirror at 12:00
Keep gonio lens oriented straight, not tilted
Put light on mirror before you go to the oculars
Consider resting hand on the patient’s head and using elbow rest if needed
Start with Low Mag and Observe Iris Conformation
Optical Corneal Wedge
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How Do We Do It?
Angle Anatomy
Angle Anatomy
Posterior Iris Insertion Ciliary Body (Band)
Scleral Spur
Trabecular Meshwork
Anterior Schwalbe’s Line
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Ciliary Body (Band)
Visibility - Wide
Pigmentation
Scleral Spur
Tr ab ec u l ar Mesh w o r k
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Schwalbe’s Line
Review – Identifying Angle Structures – Two Basic Techniques
Posterior Anterior
Anterior (Optical Wedge) to Posterior
Angle Presentations
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What Are You Seeing?
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What Are You Seeing?
What Are You Seeing?
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Recording Your Findings
St. Andrew’s Cross
Most Posterior Anatomical SS Angle Seen 1+ pig CB CB 1+ pig Rating of Angle “Openness 1+ pig SS Other Significant Findings 2+ pig Iris flat 360 degrees
Shaffer Classification
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Spaeth’s Classification
Insertion of iris root – Spaeth Classification
Width of angle recess – Spaeth Classification
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Peripheral Iris – Spaeth Classification
Pigmentation – Spaeth Classification
Spaeth Grading
B15b 2+ ptm Schwlbe’s line visible (B) 15 degree angle Describes open but somewhat narrow Angle with mild pigmentation and a Anterior bowing of iris (b) Bowed iris 2+ pigment in tm (2+ptm)
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Scheie’s Grading of Angle Classification
Wide Open – all structures visible
Grade I – hard to see over iris root into recess
Grade II – Ciliary body band obscured
Grade III – posterior trabeculum obscured
Grade IV – Only Schwalbe’s line visible
Angle Presentations
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What Are You Seeing?
Plateau Iris Syndrome
Development of residual angle closure after patent Laser Peripheral Iridotomy (LPI) Flat iris plane Deep anterior chamber Narrow angle due to anterior insertion of iris root
17 4/13/17
What Are You Seeing?
Angle Recession
#1 Risk Factor is Trauma
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What Are You Seeing?
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Thank You
gonioscopy.org
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