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Introduction Goals Angle Anatomy Overview 6/12/2019 Anterior Chamber Angle: Introduction Assessment and Anomalies Native Oregonian and Willamette Bearcat UC Berkeley School of Optometry 2008 San Francisco VA Residency 2009 VA Staff Optometrist – teaching Dave Hicks, OD, FAAO Regular lecturer at AAO and other meetings GWCO No conflicts of interest Portland, OR October 10, 2019 Goals Review anatomy of the anterior chamber angle Review gonioscopy and other imaging techniques for evaluating the angle and anterior chamber Discuss abnormal angle and anterior chamber findings and management www.gettyimages.com Angle Anatomy Overview Iris Ciliary body (CB) Scleral spur (SS) Trabecular meshwork (TM) Pigmented and non-pigmented Schwalbe’s Line (SL) Sampaolesi’s line when pigmented www.oculist.net 1 6/12/2019 Angle Anatomy Overview SL Iris processes TM Fine extensions toward TM or SL Usually still allow a view of the angle SS Differentiate from peripheral ant. synechiae (PAS) CB Greater circle of iris (MAC) Anterior ciliary and long posterior ciliary arteries Iris Both normal, but could mimic NV http://projects.mtmercy.edu/library/Tillage2/allen15.jpg Iris Processes Usually end at SS, but can go to SL Ferreras. Glaucoma Imaging, 2012. Stamper, Lieberman, Drake. Diagnosis and Therapy of the Glaucomas, 2009. www.oculist.net from Wolff E: Anatomy of the Eye and Orbit, 4th ed. Blakiston-McGraw, 1954. Angle Vessels Angle Neovascularization (NVA) Differentiate from normal iris vessels Causes – DM, CRVO, OIS, tumor, etc. Significance Evaluation – gonio Management – depends on etiology http://dro.hs.columbia.edu/circvessels.htm http://glaucomaassociates.com/glaucoma/types-of-glaucoma/#Neovascular Glaucoma 2 6/12/2019 Angle Function Van Herick Estimation (1969) Maintain IOP Angle Limbal AC Depth Grade vs. Corneal Thickness Aqueous outflow pathways 0 Slit Conventional: TM → Schlemm’s canal → intrascleral channels → episcleral veins 1 <1/4 2 1/4 Unconventional (uveoscleral): ciliary muscle fiber spaces → supraciliary and suprachoroidal space 3 1/4 to 1/2 → scleral emissary canals 4 1 or more Gupta D. Glaucoma diagnosis and management, 2005. Stamper, Lieberman, Drake. Diagnosis and Therapy of the Glaucomas, 2009. Gonioscopy Angle Grading Systems Gold standard Sheie: no longer used Technique Lighting: dark room, smallest Shaffer: grades 0-4, widest is 4 possible beam height/width Try to avoid miosis Modified Shaffer: angle structures named Innate variability, prone to error Spaeth Indentation gonioscopy Appositional vs. synechial closure Stamper, Lieberman, Drake. Diagnosis and Therapy of the Glaucomas, 2009. Stamper, Lieberman, Drake. Diagnosis and Therapy of the Glaucomas, 2009. Shaffer System Spaeth System Grade 4 = CB Step 1: Site of iris insertion A = Anterior to TM (i.e. SL) Grade 3 = SS B = Behind SL (i.e. at TM) C = Centered at SS D = Deep to SS (i.e. anterior CB) Grade 2 = TM E = Extremely deep in CB Grade 1 = SL Step 2: Angle width 10 degree increments Grade 0 = No structures (NS) Stamper, Lieberman, Drake. Diagnosis and Therapy of the Glaucomas, 2009. 3 6/12/2019 Spaeth System Spaeth System Step 3: Configuration of peripheral iris Original New s = steep/convex b = bows 1 to 4+ r = regular or flat p = plateau q = quixotic/queer f = flat or deeply concave c = concave E40c, 4+TMP – very deep Step 4: TM pigmentation A10b – very narrow Grade 1-4 D40f, 2+ TMP – normal Stamper, Lieberman, Drake. Diagnosis and Therapy of the Glaucomas, 2009. Stamper, Lieberman, Drake. Diagnosis and Therapy of the Glaucomas, 2009. Normal Open Angle Stamper, Lieberman, Drake. Diagnosis and Therapy of the Glaucomas, 2009. Anomalous Angle Findings Common pigment Age-related Pigment dispersion syndrome Pseudoexfoliation Concerning pigment Uveal or ring melanoma 4 6/12/2019 Melanoma Features Unilateral Pigmented aqueous cells Iris displacement and heterochromia Subluxed lens Sectoral cataract Shallow AC or closure Choroidal: 69-90% NVI Iris/CB: 4-8% Variable IOP, usually elevated Dark angle pigment Prominent episcleral vessels Lee, et al. BJO, 1999; 83: 194-198. Warner and Pasquale. Sem in Ophthalmol, 2006; 21: 181-189. Warner and Pasquale. Sem in Ophthalmol, 2006; 21: 181-189. 5 6/12/2019 Anomalous Angle/AC Findings Deep angles Iris to TM angle 20-45 degrees PDS Angle recession Can be sectoral or Melanoma circumferential Trauma Stamper, Lieberman, Drake. Diagnosis and Therapy of the Glaucomas, 2009. Angles At Risk Iris to TM angle <20 degrees TM 2-6% of Caucasians SS Irido-trabecular contact preferred term over “narrow” or “occludable” 1800 vs. 2700 CB Iris ACA deemed closed if iris touches cornea anterior to SS Photo: Dave Yang, OD, FAAO Hu, et al. J Glaucoma, 2016;25;177-183. Stamper, Lieberman, Drake. Diagnosis and Therapy of the Glaucomas, 2009. 6 6/12/2019 Primary Angle Closure (PAC) Primary Angle Closure (PAC) PAC suspect PAC glaucoma (PACG) >2700 of irido-trabecular contact >2700 of irido-trabecular contact Shaffer grade 2 or less Elevated IOP No PAS Optic nerve and VF damage Normal IOP, optic nerve, and VF PAC >2700 of irido-trabecular contact Either elevated IOP or PAS Normal optic nerve and VF Stamper, Lieberman, Drake. Diagnosis and Therapy of the Glaucomas, 2009. Stamper, Lieberman, Drake. Diagnosis and Therapy of the Glaucomas, 2009. Closure impossible Closure possible Closure probable Angle closed Closed angle Stamper, Lieberman, Drake. Diagnosis and Therapy of the Glaucomas, 2009. Safe Dilation Shaffer grade 3 or 4 Less than 1800 of irido-TM contact High resolution ultrasound Risk of angle closure with dilation Non-invasive, two-dimensional Rotterdam: ~1 in 3,380 (Caucasians) Quantitative and qualitative Others: ~1 in 20,000 with both trop/phenyl Not as deep as B-scan Minimal to no risk with just tropicamide Takes training – eye cup, water bath Pandit, Taylor. Diabetic Med, 2000; 17:693-699. Wolfs, et al. IOVS, 1997; 38:2683-2687. Dada, et al. Surv Ophthalmol, 2011 Sept-Oct; 56(5);433-450. 7 6/12/2019 AC Angle Deep Closure http://synemed.com/ultrasound.html www.accutome.com Dada, et al. Surv Ophthalmol, 2011 Sept-Oct; 56(5);433-450. UBM terminology UBM of CB tumor ARA – angle recess area TIA – trabecular iris angle AOD 250/500 – angle opening distance TCPD – trabecular-ciliary process distance ICA – iridociliary angle PAS in same pt ID1 to ID3 – iris thickness measurements ICPD – iris-ciliary process distance ILCD – iris-lens contact distance (a) Ultrasound biomicroscopy of a ciliary body tumor extending up to the pars plana. C: Cornea, S: Sclera, CB: Ciliary body. (b) Peripheral anterior synechiae on gonioscopy in the same patient IZD – Iris zonular distance Dada, et al. Eye, 2007; 21;956-961. Masslin, et al. IJO, 2015 Aug; 63(8);630-640. Dada, et al. Surv Ophthalmol, 2011 Sept-Oct; 56(5);433-450. UBM of LPI Plateau Iris Posterior iris turns sharply to insertion Widening of ACA in PAC, not in PACG (Dada) Iris inserts to anterior CB 28% of PACS convert to PAC after LPI (Ramani) Flat or concave iris, deep central AC H. Quigley Dada, et al. Eye, 2007; 21;956-961. Ramani, et al. J Glaucoma, 2009;18;521-527. He, et al. Ophthalmol, 2007;114 (8);1513-1519. Steiger, et al. Clin Exp Ophthalmol, 2007 Jul; 35(5):409-413. 8 6/12/2019 Plateau Iris UBM of ALPI Plateau Iris Configuration Plateau Iris Syndrome – post LPI Compression gonio “double hump” sign Treatments LPI ALPI Cataract surgery Steiger, et al. Clin Exp Ophthalmol, 2007 Jul; 35(5):409-413. Masslin, et al. IJO, 2015 Aug; 63(8);630-640. Anterior Segment OCT Hu, et al. J Glaucoma, 2016 Feb; 25(2);177-83. Angmo, et al. OJO, 2016 Jan-Apr; 9(1);3-10. AS-OCT Basics AS-OCT Terminology Time domain at 1310nm Single scan of entire AC SL-angle opening distance (SL-AOD) Fourier domain at 830nm AOD 500/750 Can see SS, SL, etc SL-trabecular iris space area (SL-TISA) ACV – Anterior chamber volume Swept source at 1310nm ACD – Anterior chamber depth 3D angle analysis ACA – Anterior chamber area ACW – Anterior chamber width May identify more PAC than gonio Iris thickness at 750um LV – Lens vault Radhakrishnan. Curr Opin Ophthalmol 2014, 25:98–103. 9 6/12/2019 PAC Swept Source (HD) PAS Need to identify angle structures Time Domain Radhakrishnan. Curr Opin Ophthalmol 2014, 25:98–103. Masslin, et al. IJO, 2015 Aug; 63(8);630-640. APAC Appositional Angle Closure Phacomorphic AC Moghimi, et al. IOVS, Masslin, et al. IJO, 2015 Aug; 63(8);630-640. 2015;56;7611-7617. AS-OCT vs. UBM Non-contact Contact, coupling 1 eye of 50 pts Minimal training Skilled operator 60% women Better resolution Lower resolution 64% Caucasian Faster Slower All phakic Wider FOV Shorter FOV POAG, ACG, OHTN, Upright Supine or upright or PXG Limited ability to Can visualize Visante and Cirrus OCT may have limited visualize structures posterior to iris ability to identify angle closure because of posterior to iris difficulty identifying angle structures Masslin, et al. IJO, 2015 Aug; 63(8);630-640. Hu, et al. J Glaucoma, 2016;25;177-183. 10 6/12/2019 Iris to TM angle <20 degrees Still at risk Lack of visibility more superior and inferior Hu, et al. J Glaucoma, 2016 Feb; 25(2);177-83. Image: Zeiss Anomalous Angle and AC Findings Iridodialysis Retained lens fragments after CE Literature review for PAC Anterior chamber intraocular lenses UBM, AS-OCT, Scheimpflug, SPAC None of these imaging methods provides Hyphema/microhyphema sufficient information about the ACA anatomy to be considered a substitute for gonioscopy Smith, et al. Ophthalmol, 2013; 120: 1985-1997. 11 6/12/2019 Iridodialysis Traumatic, iatrogenic, or congenital Can be asymptomatic Glare, diplopia, photophobia IOP issues TM damage, PAS, CB damage Need to rule out melanoma SS CB Retained Lens Fragments Almost always in inferior angle Can require gonio to visualize Cortical vs.
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