Clinical Update EXTRA

VIDEO & ADDITIONAL CONTENT AVAILABLE MD Roundtable: Expert Tips for Assessing the Narrow Angle

moderated by sanjay g. asrani, md, with paul j. foster, frcs, paul f. palmberg, md, phd, and robert ritch, md, facs

his article is part of an occa- Light vs. Dark sional series of MD Round- tables, in which a group of 1A 1B experts discuss a topic of interest in their field. This month,T Sanjay G. Asrani, MD, of the Duke Eye Center, leads a roundtable on diagnosing the narrow angle. He is joined by Paul J. Foster, FRCS, of Uni- versity College London, Paul F. Palm- berg, MD, PhD, of Bascom Palmer Eye Institute, and Robert Ritch, MD, FACS, of the New York Eye and Ear In- firmary. Following are edited excerpts Angle is open in the light (1A) but closed in the dark (1B), showing the impor- from their conversation. tance of darkness in assessing a narrow angle. Next month, these experts discuss when to consider laser iridotomy for we had a lot of practical information So now, it’s uncommon for me to narrow angles. on how to do . Unfortu- get referrals from ophthalmologist nately, in the subsequent issues, much colleagues where I think that they’ve An Increase in Narrow Angles? of that practical information on criti- missed angle closure. But, certainly, Dr. Asrani: Do you feel that you are cal features somehow dropped out, and there are a lot of cases that come from diagnosing narrow angles with greater it would be nice to get it back in: for optometry where they have been re- frequency than your colleagues over example, no light through the pupil, ferred for high pressure, and no assess- the past five to 10 years? no fixation target, doing it in a dark ments of the angle were performed. Dr. Palmberg: I take it you’re ask- room, using a Zeiss-type , and us- Second, Even Third, Opinions. Dr. ing if we’re finding a lot of cases of ing the parallelepiped method. Ritch: About 30 years ago, there was angle closure that were referred to us Status in the U.K. Dr. Asrani: Paul so much angle closure that was undi- for poor IOP [intraocular pressure] Foster, what is your take on this? agnosed and misdiagnosed. Patients control by doctors who thought the Dr. Foster: In the United Kingdom, would be referred with chronic open- patients had open-angle glaucoma. Of- the system is probably slightly differ- angle glaucoma or primary open-angle ten, at cocktail parties, glaucoma spe- ent. We tend to get fewer referrals from glaucoma, but they had 90 percent cialists get together and say, “What’s general ophthalmologists. More of the PAS [peripheral anterior synechiae]. wrong with the general ophthalmolo- time, the referral has come from an And either people recognize that bet- gists? They’re missing a lot of angle optometrist direct to a glaucoma spe- ter now, or I’m not getting that many closure.” And I usually say, “Well, cialist. I think that glaucoma special- referrals. what’s wrong with us that we haven’t ists in the U.K. now are fairly sensitive I still see a few patients who have been teaching gonioscopy and related to the idea that everybody should have been misdiagnosed, but mostly I see techniques well?” gonioscopy. And I think the standards people who have already been diag- When the first Preferred Practice of gonioscopy have improved dramati- nosed—they have been told by one

robert ritch, md Pattern for angle closure was written, cally in the last 10 years. doctor that they had narrow angles but

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2A 2B your technique of gonioscopy that Paul Palmberg started to talk about? Darkness Is Essential. Dr. Ritch: Yes. I agree with everything that Paul said. It’s really important, number one, to do gonioscopy in a completely darkened room. I tell this to my fellows and go over it over and over again. And after they’ve done six months of a fel- WHAT LINE IS THIS? (2A) Is this somewhat discontinuous pigmented line (arrow) lowship, I’ll walk in on them and they the pigmented band of the ? The angle appears to be fairly tell me it’s a grade 2 angle; but when I open, grade 3. (2B) With indentation gonioscopy, the angle opens, and the same turn the lights out and do gonioscopy, line is clearly shown to be a Sampaolesi line, with a splotchy, “salt-and-pepper” the angle closes up. And I say, “Did appearance; below it is the true trabecular meshwork line, a continuous line with you do it in the dark,” and they say a “fine powdered brown sugar” appearance. yes. Then I say, “Real dark? I mean the lights completely out; the computer didn’t need an iridotomy, and the next a second opinion because of poor IOP screen off?” And they say, “Oh, uh, no, one told them they had narrow angles control, and they are being treated just mildly dark.” but needed an iridotomy, and another by other glaucoma specialists when I There should be no light through would tell them they didn’t have nar- diagnose that they actually have inter- the pupil. So the main thing is to use a row angles, not to worry about it. mittent angle closure or narrow angles. small slit beam—a little square slit— And I’ll give them the definitive And they are surprised that the other and look first in the inferior mirror. decision. You know, I had one patient glaucoma specialists did not pick it up. The superior angle is the narrowest come in, and her husband was taking So Paul Palmberg, I agree entirely with 98 percent of the time. If the superior all these notes. I said, “Look, you’ll get your ability to show the patient’s fam- angle is more open than the inferior a copy of the consultation letter. Your ily members the condition. angle, I consider that a potential sign husband doesn’t need to take all these With Teaching Scope. Dr. Asrani: of exfoliation syndrome. notes.” She said, “That’s not my hus- Also, sometimes I use the teaching Dr. Palmberg: And don’t use a band—that’s my lawyer.” scope that I have on all the slit lamps. I fixation target because that alters the encourage the family members to look pupil. Demonstrating Angle Closure through it when I examine patients Be Sure to Wait. Dr. Asrani: I re- With Video. Dr. Palmberg: For patients who are skeptical or doubtful of this ally encourage my fellows to wait 10 like that, I have found it helpful to have diagnosis. I show this to them on an- seconds after the gonio lens has been a video camera on my slit lamp. I show terior segment OCT by turning on the placed on the eye, so as to let the them the angle, and then I make sure lights and then turning off the lights, constriction of the pupil get relaxed, that there is no light going through the and then that convinces them with a to lose the effect of accommodation. pupil. They sit there—the patient and, lot more certainty. Paul Foster, do you When the pupil is in the middilated usually, the husband, not the lawyer— have a technique that you use in the position, that is when you see the angle and watch the angle close over a course U.K. to convince patients, or do they closed, and that has really allowed me of about eight to 10 seconds in the take your word for it? to diagnose a lot more of these narrow dark. And then, because they have seen With OCT. Dr. Foster: I’ve found angles than before. I do exactly the it, they believe it. (See Fig. 1.) that it’s difficult to illustrate the angle same thing as Bob and Paul, putting You can show them how dynamic closure to the medical layman. So I the parallelepiped light into the mir- it is and why it was that one doctor on agree that anterior segment OCT is ex- ror, avoiding the pupil altogether. one occasion and one at another time tremely useful, with scans made in the Dr. Ritch: I’ve concluded that 10 might actually have seen different light and in the dark, often showing an seconds is not enough in some cases. things, depending on the state of hy- open angle in the light and closed in Sometimes I have to wait two minutes. dration and certainly on the technique the dark. And as soon as patients see And after two minutes, they finally get with light through the pupil. So if any those images, they become convinced. narrower and narrower and then close one doctor does see the angle close, up to the trabecular meshwork. that trumps the observations of others. Expert Tips for Gonioscopy Dr. Palmberg: I guess that’s the In that way, patients don’t feel judg- Dr. Asrani: Bob, you pioneered the point of it, Bob, that if you see it stead­ mental against the other doctors. concept of doing gonioscopy in the ily narrowing, you wait to see where Dr. Asrani: I certainly agree, and dark and promoted it. Unfortunately, it’s going to finish. that’s why I asked the question. I have very few people have adopted it. Would Getting Started. Dr. Ritch: I started

been seeing patients who come in for you be able to share a few more tips on doing indentation gonioscopy when I paul palmberg, md, phd

32 january 2015 Glaucoma was a fellow, and I found that you have do is wrap my little finger around the des. About a third of my patients have to look at about 100 patients before slit-lamp bar. exfoliation syndrome. The fellow will you stop sliding off the cornea and get Dr. Palmberg: That can help stabi- look and call it a grade 4 open angle, to where you can manipulate the lens lize the fingers—stabilizes you, too. but even without indentation, you can comfortably without having to watch see that what they think is pigment on your hand. Importance of Compression the trabecular meshwork is pigment on You should start with coopera- Dr. Asrani: I find that there is one Schwalbe’s line as Paul said. And then tive young patients with open angles technique that most of my fellows have you indent, you open up, and you see who can look straight ahead without not learned: When they see an open the trabecular meshwork and the scler- squeezing [their eyelids]. Verify the angle, they don’t feel the need to com- al spur. That’s very, very important. angle structures in the superior mirror, press. And I insist that they should al- The Parallelepiped Method. Dr. and then look at the peripheral , ways perform compression gonioscopy Palmberg: And you could get a clue which should be slightly convex, and [also called indentation or dynamic by using the parallelepiped method. press lightly and watch the peripheral gonioscopy], even if they think that When you shine a very thin, narrow iris become concave. Then, back off the angle is open. beam over the cornea, the light will the iris with the gonio lens until the Many times, because of the pig- appear three dimensional, and it will iris no longer changes configuration mented Schwalbe’s line, the angle may penetrate the cornea. but you can still see the structures. appear open when it’s actually totally When you get down to Schwalbe’s And now you know that you’re just closed. And to the surprise of many line, it will become a two-dimensional resting on the cornea. And once you’re of my fellows, they find, “Oh, this figure of light over the trabecular used to the superior mirror, you can go patient has two scleral spurs.” But it’s meshwork, and it will be a little less on and do the other mirrors. only because they’ve never compressed bright over the trabecular meshwork Dr. Palmberg: It’s also helpful to and couldn’t detect the true trabecular because the pores in the trabecular look a little bit in the direction of each meshwork. meshwork—the openings between mirror—about 15 degrees so that Whys and Hows of Compression. the beams—are allowing some of that you’re seeing over any curvature of Dr. Palmberg: Compression gonios- light to get in there and scatter and not the iris. copy is very important in being able to come back to you. And then of course, Avoid Inadvertent Pressure. Dr. decide whether the angle closure, once it becomes bright again down at the Palmberg: I find it very important to you see it, is appositional or synechial. scleral spur if the insertion of the iris is have both the patient and examiner But it’s also very important for just behind the scleral spur. This can really sitting upright. It’s also important to detecting angle closure because in a help to identify the landmarks. n support the weight of your elbow and lot of African-American or darkly pig- your hand and to have a couple of fin- mented Hispanic patients, the iris is Sanjay G. Asrani, MD, is professor of ophthal- gers on the patient’s cheek to avoid in- thicker and flatter, even when there’s mology at Duke Eye Center, Durham, N.C. advertent pressure on the cornea. And angle closure. It can look like a grade Financial disclosure: Is a lecturer for Alcon, it keeps you from sliding off into the 3 angle, but it isn’t. It’s a Sampaolesi Heidelberg, and Lumenis. nostril or something and embarrasing line that’s changing curvature from the Paul J. Foster, FRCS, is professor at University yourself with the lens. cornea to the angle so that you have a College London Institute of Ophthalmology Dr. Ritch: I tell my fellows to back shelf on which the large pigment gran- and at Moorfields Eye Hospital, London. Fi- off until you just see an air bubble ules can sit. nancial disclosure: Is a consultant for Alcon coming under the gonio lens, and then But the character of that pigment is and receives research support from Heidelberg. you know you’re resting on the cornea. different. It looks like fine, powdered Paul F. Palmberg, MD, PhD, is professor of And you do not want any inadvertent brown sugar over the trabecular mesh- ophthalmology at Bascom Palmer Eye Insti- compression because if you press too work, or more like salt and pepper. It’s tute, Miami. Financial disclosure: Is an advi- hard, then you can open the angle. So a little discontinuous over the Sam- sor to Allergan, Merck, and Pfizer. the back-off step is very important. paolesi line (Fig. 2). So, particularly in Robert Ritch, MD, FACS, is the Shelley and Stabilize the Hand. Dr. Palmberg: people with dark-colored irides, even Steven Einhorn Distinguished Chair, professor of Making contact with the patient with if it looks open, you really should push ophthalmology, Chief of Glaucoma Services and the side of your hand lets you apply the because you could be surprised that Surgeon Director Emeritus, New York Eye and lens, holding it with your thumb and there was a fuller line here, as Sanjay Ear Infirmary, New York, N.Y. Financial dis- a couple of fingers—you don’t do it just pointed out. And that is another closure: Is a consultant for iSonic and Sensimed automatically. It takes a little time and one of the major reasons that people and has a patent interest in Ocular Instruments. thought about how to get your hand miss angle closure. up there so that you can touch with no Dr. Ritch: Yes, I agree with both of MORE ONLINE. See this article EXTRA pressure. you on that. But I find that they don’t at www.eyenet.org for a video and Dr. Ritch: Another thing I like to have to be patients with really dark iri- further discussion.

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