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A Picture Atlas and Teaching Aid for Gonioscopy

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A Picture Atlas and Teaching Aid for Gonioscopy Pacific University CommonKnowledge College of Optometry Theses, Dissertations and Capstone Projects 5-1990 A picture atlas and teaching aid for gonioscopy Trisha L. Fjestad Pacific University Terri L. Horst Pacific University Recommended Citation Fjestad, Trisha L. and Horst, Terri L., "A picture atlas and teaching aid for gonioscopy" (1990). College of Optometry. 950. https://commons.pacificu.edu/opt/950 This Thesis is brought to you for free and open access by the Theses, Dissertations and Capstone Projects at CommonKnowledge. It has been accepted for inclusion in College of Optometry by an authorized administrator of CommonKnowledge. For more information, please contact [email protected]. A picture atlas and teaching aid for gonioscopy Abstract Gonioscopy is the only procedure available for viewing the anterior chamber angle structures. As optometry is expanding its scope and playing a more active role in the diagnosis and management of ocular disease, gonioscopy is becoming a procedure with which optometrists must be proficient. This paper is composed of pictures and slides of normal and anomalous anterior chamber angles. Included are interpretations of the pictures, explanations of the procedure, and indications for its use. Degree Type Thesis Degree Name Master of Science in Vision Science Committee Chair Nada Lingel Subject Categories Optometry This thesis is available at CommonKnowledge: https://commons.pacificu.edu/opt/950 Copyright and terms of use If you have downloaded this document directly from the web or from CommonKnowledge, see the “Rights” section on the previous page for the terms of use. If you have received this document through an interlibrary loan/document delivery service, the following terms of use apply: Copyright in this work is held by the author(s). You may download or print any portion of this document for personal use only, or for any use that is allowed by fair use (Title 17, §107 U.S.C.). Except for personal or fair use, you or your borrowing library may not reproduce, remix, republish, post, transmit, or distribute this document, or any portion thereof, without the permission of the copyright owner. [Note: If this document is licensed under a Creative Commons license (see “Rights” on the previous page) which allows broader usage rights, your use is governed by the terms of that license.] Inquiries regarding further use of these materials should be addressed to: CommonKnowledge Rights, Pacific University Library, 2043 College Way, Forest Grove, OR 97116, (503) 352-7209. Email inquiries may be directed to:[email protected] A PICTURE ATLAS AND TEACHING AID FOR GONIOSCOPY By TRISHA L. FJESTAD TERRIL. HORST A thesis submitted to the faculty of the College of Optometry Pacific University Forest Grove, Oregon for the degree of Doctor of Optometry May, 1990 Advisor: Nada Lingel, O.D., M.S. A PICTURE ATLAS AND TEACHING AID FOR GONIOSCOPY Authors: d~~ c-JJ:~W Trisha L. Ffe~ Terri L. Horst Advisor: Dr. Nada Li'rigel BIOGRAPHIES Trisha L. Fjestad, originally from Fergus Falls, Minnesota, received her Bachelor of Arts degree in biology and French from Luther College in Decorah, Iowa. Following graduation from Pacific University College of Optometry in May 1990, she plans to return to the Midwest to practice. Terri L. Horst, a native Oregonian from Scappoose, received her Bachelor of Science degree in biology from Lewis and Clark College. Following graduation from Pacific University College of Optometry in May 1990, she plans to practice in the Pacific Northwest. ABSTRACT Gonioscopy is the only procedure available for viewing the anterior chamber angle structures. As optometry is expanding its scope and playing a more active role in the diagnosis and management of ocular disease, gonioscopy is becoming a procedure with which optometrists must be proficient. This paper is composed of pictures and slides of normal and anomalous anterior chamber angles. Included are interpretations of the pictures, explanations of the procedure, and indications for its use. ACKNOWLEDGEMEN1S We would like to thank our advisor, Dr. N ada Lin gel, for her guidance and support. We would also like to thank Alcon Laboratories for their permission in using the angle drawing by Terry Terrant. TABLE OF CONTENTS PAGE INTRODUCTION History 1 Direct vs. Indirect 2 SIMPLE ANATOMY 4 GRADING SYSTEMS 6 PROCEDURES Van Herick Procedure 8 Gonioscopy Procedure 10 Zeiss or Posner 4-mirror lens 16 PICTURES AND INTERPRETATIONS 17 Common errors 19 Normal angle variations 20 Plateau iris 22 Peripheral anterior synechiae 23 CONDITIONS INDICATING GONIOSCOPY co\ln~ .. ,..,..,o Pl·,..m.ont-:.ry::::Ji h,., """" dic"orci"ni~,._;\:i VI" ..._,]I''""' Vt t tV 24 Pseudoexfoliation syndrome 26 Angle closure with pupillary block 27 Rubeosis iridis 29 Traumatic angle recession 30 Glaucomatocyclic crisis (Posner-Schlossman) 31 Anterior chamber cleavage syndromes (Goniodysgenesis) 32 CONCLUSION 33 REFERENCES 35 INTRODUCTION Now that all 50 states have passed diagnostic pharmaceutical agent (DPA) legislation and 25 states have passed therapeutic pharmaceutical agent (TPA) legislation, optometrists have gained the right and the responsibility to diagnose ocular disease. Gonios.copy is the only procedure available to assess the configuration and structures of the anterior chamber and to evaluate disease involving the anterior chamber of the eye. It is necessary to perform gonioscopy on all glaucoma suspects and on patients in whom you suspect other anterior chamber anomalies such as pigmentary dispersion syndrome, pseudoexfoliation syndrome, angle recession, plateau iris, iris bombe, rubeosis iridis, and anterior cleavage syndromes. 9,1 0,23,25,31 ,40,45,47 Additionally, gonioscopy should be performed prior to dilation on all patients who appear to have narrow anterior chamber angles. The purpose of this paper is to provide practicing O.D.'s and students with a comprehensive teaching guide to aid in the· acquistion of the skill of gonioscopy. This aid will contain the procedures and "pearls" that we have learned in performing this technique along with photographs and explanations of the configurations and appearance of various anterior chambers. History Gonioscopy (derived from the Greek root gonia-angle and scopia-to view) actually began in 1907 when Trantas, an ophthalmologist, indented the limbus on a keratoglobus patient, bringing the anterior chamber into view. 5 Salzmann, in 1914, became the first to utilize a dome goniolens to 1 directly view the anterior chamber angle.s Koeppe, Troncoso, and Barkan further developed and modified the dome goniolens.s Present day gonioscopy began in 1938 when Goldmann used a gonioprism mirror and a biomicroscope to indirectly view the anterior chamber angle.s The biomicroscope allowed improved viewing due to variable illumination and magnification of the angle. Direct vs. Indirect Normal observation of the anterior segment of the eye does not allow a view of the anterior chamber angle, because the light rays from the anterior chamber are reflected back into the anterior chamber when they reach the corneal-air interface. The goniolens acts to eliminate the refractive interface between the cornea and the air allowing the light rays to pass through the cornea and the angle structures to be viewed. Direct gonioscopy is performed when a dome goniolens such as a Koeppe or Balkan lens is placed directly on the cornea. An illumination system and gonioscope are then used to obtain a direct, 3600 view of the anterior chamber angle. This direct system does provide excellent stereopsis in all 4 quadrants, but a distorted image of the angle is created by the aberration of the dome lens. Indirect gonioscopy, unlike direct, uses a mirror to view the angle. It is the most common procedure and requires only a biomicroscope and a mirrored goniolens, e.g., Goldmann 3-mirror or Zeiss 4-mirror. 2 bullet-shaped mirror --....... eHiting light n:tys AC angle being uiewed iris Fig. 1. Indirect gonioscopy Like direct gonioscopy, a lens is placed directly in contact with the cornea, but the image created is inverted. The observed angle is actually 180 degrees from the position of the mirror. For example, when looking through the superior mirror, it is actually the inferior angle that is viewed. With this method, the patient can remain seated behind the slit­ lamp, the magnification can be varied, and angle details can easily be seen. However, in order to see all quadrants of the angle, the goniolens must be rotated on the cornea. 3 SIMPLE ANATOMY l l ! ! e Fig. 2. Anterior chamber angle structures (courtesy of Alcon Laboratories) Before it is possible to assess an anomalous anterior chamber, it is necessary to learn the anatomy of a normal anterior chamber angle. From posterior to anterior, the wall of the anterior chamber angle is composed of the ciliary body, scleral spur, trabecular meshwork, and Schwalbe's line. The iris forms the other side of the anterior chamber angle. The peripheral part of the iris, the iris root, inserts into the ciliary body. The angle at which the iris approaches the ciliary body determines which structures of the anterior chamber wall will be visible. The ciliary body is the most posterior structure in the anterior chamber angle. It extends from the ora serrata into the anterior chamber 4 and appears dark grey to tan. The ciliary body inserts into the more anteriorly positioned scleral spur. The scleral spur is a white band composed of collagen and elastin that anchors the ciliary body. Slight adjustments in the position of the goniolens may cause light to be reflected off the scleral spur making it appear brighter and more visible. The trabecular meshwork is adjacent to the scleral spur. It is composed of porous plates and acts as a sieve channeling the aqueous out of the anterior chamber. The trabecular meshwork is darker than the scleral spur and often has a ground glass or beige appearance. Pigment is commonly seen in the posterior portion of the trabecular meshwork.
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