history ologist). place’ (Albert Terson, 1867-1935, French ophthalm- day onwhichcataractswere putintheir correct eyes (asopposedtoprevious histopathologicfindings as well as wide-open angles in previously unoperated and the clinical recognition of synechial angle-closure, ophthalmic practice. The introduction ofgonioscopy constitutes anessentialdiagnostic toolineveryday innermost layer of the , the endothelium) and it fluid filledspaceinsidetheeye between theirisand examine structures intheanteriorchamberangle(the Gonioscopy isaclinicaltechniquethatused to Gonioscopy The Invention and Evolution of throughout the world. people and is the leading cause of irreversible blindness incidence of the rises dramatically inolder Caribbeans ofthesameage. The prevalence and and four times higherin African-Americans and African- but itisaround 2% in Caucasians over 40years of age The prevalence of varies indifferent studies, raised intraocularpressure. that are associated frequently, but not invariably, with and specific pattern of visual field defects neuropathy with characteristic appearances of the years. lensfor thefollowing severalthe crystalline hundred BC.century However, itwasconsidered adiseaseof mentioned intheHippocratic Aphorisms inthe5th ‘glaukos’, which means blue’.‘watery It is first The termglaucomaisderived from theGreek word Introduction Declaration ofInterestsNo conflict of interest declared dots Keywords to ophthalmology. coined theterm ‘gonioscopy’. contributions Hemadeanumber ofotherimportant ophthalmologist Alexios Trantas wasthefirsttovisualiseangleinvivo and ophthalmic practice, inthediagnosisofglaucoma. particularly In1899, theGreek innermost layer of the cornea, the endothelium). It is an essential tool in chamber angle(thefluidfilledspaceinsidetheeye between theirisand ABSTRACT Gonioscopy isatechniqueusedtoexaminestructures intheanterior and his contributionto ophthalmology The invention of gonioscopy by Alexios Trantas 226 1 1,2 Paper Athens University, Greece University, Greece; Department ofOphthalmology, St James University Hospital,UK; Leeds, G Kalantzis, 1 of glaucoma began the ‘The scientific history 2 Nowadays, glaucoma is defined as an optic anterior chamberangle, Alexios Trantas, glaucoma, gonioscopy, Trantas 3 3 I Georgalas, Department ofOphthalmology, Athens GeneralHospital, Athens, Greece; 4

3 4 C Tsiamis, 1 N El-Hindy, 2 E Poulakou-Rebelakou closure . basis for the differentiation of open-anglefrom angle- from surgically treated and end-stage eyes), provided a inflammatory cornealthinningdisorder characterised by inflammatory 1899 inaneye withkeratoglobus (arare non- Greek ophthalmologist Alexios Trantas (Figure 1)in the angle in vivoThe first person to observe was the Figure 1 2 Department ofHistoryMedicine,Medical School, Athens Alexios Trantas(1867–1961) 4 Department ofMicrobiology, Medical School, 5

© 2015Royal Collegeof Physicians of Edinburgh e-mail Greece Athens 115-27 75 Mikras Asias of Athens University Athens Medical School ofMicrobiology Department Correspondence to CTsiamis http://dx.doi.org/10.4997/JRCPE.2015.311 J R Coll Physicians Edinb2015; 45: [email protected] 226–8 A history of gonioscopy

Figure 2 Troncoso’s diagnostic for examination of Figure 3 Otto Barkan’s goniotomy lens for of anterior chamber angle the anterior chamber angle globular protrusion of the cornea). He devised a method Schlemm’s canal (the drainage canal of aqueous humour using direct ophthalmoscopy combined with digital from the anterior chamber).12 In 1920, Koeppe developed pressure on the limbus (anatomically, the area at the his direct-view gonioscopy lens and used it in conjunction union of the cornea and ); with this method he with the newly developed Zeiss slit lamp.13 Ascher was examined the , the ora serrata and the the first to use the Koeppe lens with the patient supine, anterior .6 In 1900 he described the ophthalmoscopic giving him a view of the entire angle.14 appearance of the normal and the abnormal angle and was the first to use the term ‘gonioscopy’, noting In 1925, Troncoso designed a handheld microscope with instances of dense pigmentation of the trabecular a source to overcome the lack of magnification with meshwork, processes and cyclodialysis clefts.7,8 He the Koeppe lens, and published the first book devoted to also described the retrociliary region following his gonioscopy in 1947 (Figure 2).15,16 Others involved in observations on human anterior chamber angle.9 Trantas developing techniques of gonioscopy and examining the continued to make further observations and described angle included Thorburn, Werner, Elschnig and Vannas.17 the angle of the anterior chamber as seen with and without digital pressure with the direct ophthalmoscope, In the 1930s, Otto Barkan, a dominant figure in glaucoma and the assistance of a +4D to +15D lens on a patient in the USA for a decade, initiated major advances in suffering of congenital .9 Over almost two clinical gonioscopy. He used a Koeppe lens with the decades, Trantas recorded a wealth of valuable clinical patient in a supine position and devised the Barkan observations regarding the appearance of the angle in illuminator to enhance his view of the angle. This device various conditions. The gonioscopic appearance of the incorporated binocular microscopy using articulated anterior chamber angle in his drawings was surprisingly arms on floor and ceiling supports. He termed this accurate. His work and its potential usefulness went method ‘microgonioscopy’ because of the magnification largely unrecognised as others devised and improved obtained. Barkan invented goniotomy for congenital techniques of examining the angle.10 glaucoma and devised a gonioscopy lens with a slabbed- off face to allow insertion of instruments at the limbus. Although Trantas was the first to see the angle, Salzmann (Figure 3)18,19 Leading ophthalmologists in Europe, was the first to really study it.11 Without indentation, the including Duke-Elder, refused to accept gonioscopy as a history anterior chamber of the eye cannot normally be necessary diagnostic tool in glaucoma as late as the early visualised due to total internal reflection of light rays at 1960s. It was Goldmann, finally, who popularised it in the inner aspect of the cornea. In 1913, Salzmann solved Europe, convincing François of the concept of pupillary this problem and indirectly visualised the angle using a block. Thus, the introduction of indentation gonioscopy modified contact lens made for the correction of in 1966 by Forbes was the most important diagnostic (a non-inflammatory condition causing advance since the development of the mirrored progressive bulging and thinning of the cornea). He goniolens, as it enabled clinical differentiation of relative described various pathologic conditions including angle pupillary block from other angle-closure glaucomas.17 recession. He was also the first to describe blood in the

J R Coll Physicians Edinb 2015; 45: 226–8 © 2015 RCPE 227 G Kalantzis, I Georgalas, C Tsiamis et al.

Trantas’ Scientific Work blindness and in 1895 described an operation for treating and (conditions causing Alexios Trantas was born in Epirus, Greece, in 1867 misdirection of lashes), which was the evolution of and studied medicine in Athens, where he received his the surgical technique used before by Panas and doctorate in 1891, under the supervision of the Anagnostakis.22 Trantas was recognised in 1948 by the eminent Professor Andreas Anagnostakis. Between Belgian Society of Ophthalmology as the ‘Father of 1891 and 1893 he undertook further education in Gonioscopy’, although the majority of his colleagues ophthalmology in Paris under (1832– believed that Manuel Troncoso was the founder of this 1903), Louis de Wecker (1832–1906) and Xavier method as he had established, in numerous publications, Galezowski (1832–1907), and in 1894 established an the importance of the method in 1925.22 Although ophthalmological clinic at the Greek hospital Saint Trantas’s technique, involving direct digital pressure George in Constantinople. He was director of this on the limbus, is quite different to modern day institute until 1922. From 1924 he was chief ophthalm- prismatic examination of the anterior chamber angle, ologist at the Therapeutrion of St Spyridion in Piraeus. the wealth of information from his investigations He was also founder and director of the first special undoubtedly paved the way to modern gonioscopic pavilion for trachomatous patients in Constantinople, examination methods. the so-called ‘Skouloudeion ophthalmiatreion’.20 Acknowledgements His work covers a wide scope of eye disorders. He wrote mainly about eye symptoms in systemic We thank Richard Keeler, Honorary Curator of The (leprosy, syphilis, tuberculosis etc.) and recognised the Royal College of Ophthalmologists, for his interest and white dots in vernal as patho- permission to reproduce Figures 2 and 3. gnomonic. These small, white-yellow chalky concretions of the around the limbus are known today as the Horner-Trantas spots or Trantas dots.21 He also re-established the Hippocratic treatment of night

References

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