Seminars in Ophthalmology, 2013; 28(3): 113–125

! Informa Healthcare USA, Inc.

ISSN: 0882-0538 print / 1744-5205 online
DOI: 10.3109/08820538.2013.777749

REVIEW

Anterior Segment Imaging in Glaucoma

Sarwat Salim, MD, FACS1 and Syril Dorairaj, MD2

1
University of Tennessee Health Science Center, Memphis, TN, USA and 2Mayo Clinic, Jacksonville,
Florida, USA

ABSTRACT
Anterior segment imaging allows objective assessment of the anterior segment of the eye, particularly the
anterior chamber angle. Both qualitative and quantitative analyses are possible and aid in detecting and
managing closed-angle and open-angle mechanisms in various forms of glaucoma. This review focuses
primarily on anterior segment optical coherence tomography and ultrasound biomicroscopy, with emphasis on
principles of technology, commercially available devices, and clinical applications in glaucoma with potential
advantages and disadvantages of each technology.
Keywords: Anterior segment optical coherence tomography, glaucoma, gonioscopy, imaging, scheimpflug
photography, ultrasound biomicroscopy

INTRODUCTION and ultrasound biomicroscopy (UBM). The principles

Gonioscopy remains the reference standard for
visualizing the anterior chamber angle in the eye.
Although this technique is inexpensive and provides
essential information quickly at the slit lamp examin-
ation, it has many limitations. It is a subjective
technique and is highly dependent on the examiner’s
skills, cooperation of the patient, and environmental
conditions. The type of lens used, inadvertent pres-
sure on the cornea, direction of gaze, and room lights
can influence the interpretation of the angle anatomy.
Furthermore, interobserver agreement is limited.1–2
Anterior segment imaging allows objective assess-
ment of the anterior chamber angle and adjacent
structures. In addition, both qualitative and quantita-
tive analyses are possible to monitor change over
time. Since the advent of new imaging devices, our
understanding of various underlying mechanisms of
angle-closure glaucoma has been increased. This
review focuses on the two commonly used imaging
modalities in clinical practice, including anterior
segment optical coherence tomography (AS-OCT)
of these technologies, commercially available devices,
and clinical applications in glaucoma will be
discussed.
ANTERIOR SEGMENT OPTICAL
COHERENCE TOMOGRAPHY
Technology
AS-OCT is a noncontact imaging technology that uses
the principle of interferometry to produce high
resolution, cross-sectional images of the anterior
13
20
segment of the eye.3,4 The principle of optical
coherence tomography (OCT) is similar to that of
ultrasound, in which the time delay of the reflected
wave is used to probe the target tissue structure in
depth. Because the speed of light is much faster than
that of sound, the time delay between the emission
of a light pulse and detection of a reflection is
too brief for direct measurement. Therefore,
rather than a pulse-echo technique, OCT uses a

Received 26 January 2013; accepted 15 February 2013; published online 22 May 2013
Correspondence: Sarwat Salim, MD, FACS, Associate Professor of Ophthalmology, Director, Glaucoma Service, Hamilton Eye Institute/
University of Tennessee, 930 Madison Avenue, Suite 470, Memphis, TN, USA 38163. Tel: 901-448-5883. Fax: 901-448-1260. Cell: 901-351-0777.
E-mail: ssalim@uthsc.edu

113
114 S. Salim and S. Dorairaj
TABLE 1. Properties of Visante-OCT.
Visante-OCT
Wavelength 1310 nm
Axial Resolution 18 um
Transverse Resolution 60 um
Depth of penetration 6 mm
Acquisition time 0.125 seconds per cross-section
for over all anterior
segment examination
0.25 seconds per cross-section
for high resolution corneal examination
Image size 6 mm in depth by 16 mm wide for overall
view of the anterior segment
3 mm in depth by 10 mm wide for high
resolution Images
Coupling Medium Air
Patient position Upright, Seated
Operator Requirement Simple, Non-contact test
low-coherence light beam (typically a superlumines-
cent diode emitting in the near-infrared region) to
compare the delay of tissue reflections against a
reference reflection.5 The final image is produced by
scanning a light beam laterally, creating a series of
axial scans, and then combining these scans into a
composite image.
OCT technology was initially used to image the
posterior segment of the eye by using a wavelength of
820 nm.6–8 Izatt et al.9 used the same wavelength for
anterior segment imaging but found suboptimal
imaging because of limited penetration through
tissues. The wavelength was later altered to improve
penetration through light-retaining tissues such as
the sclera to improve visualization of the anterior
segment.10,11
The two AS-OCT devices commercially available
are Visante-OCT (Carl Zeiss Meditec; CA, USA) and
slit-lamp OCT (SL-OCT; Heidelberg Engineering
GmbH, Heidelberg, Germany). Only the Vistante-
OCT is available in the United States and will be the
focus of discussion in this review. Briefly, compared
with the Visante-OCT, the SL-OCT has lower axial and
transverse resolution and slower image acquisition
and requires manual rotation of the scanning beam.
High interobserver reproducibility has been demon-
strated with each device with poor agreement
between the two.12 Both devices have been shown to
detect more closed angles when compared with
conventional gonioscopy with better agreement
noted between SL-OCT and gonioscopy, presumably
because of the use of visible light during both
procedures.13 With the advent of Fourier domain
OCT technology with higher resolution, imaging of
the cornea and conjunctiva is possible, but imaging
of the anterior chamber angle remains limited because
of the use of shorter wavelength. Fourier domain OCT
devices with a longer wavelength suited for anterior
Ultrasound Biomicroscopy
35–100 MHz transducer range
25 mm with 12 mm measurement precision on screen
50 mm
5–7 mm depending on the transducer range
25 frames/sec giving real-time two-dimensional
image acquisition in gray scale. Can record 40
secs of video
5 mm in depth by 15 mm wide for overall view of the
anterior segment
5 mm in depth by 5 mm wide for high resolution
Images
Liquid
Upright, Seated or lying down supine or prone
Contact and non-contact modalities available. Need
operator training in image acquisition.
chamber angle imaging have been recently described
but are not yet commercially available in the United
States.14,15
AS-OCT versus Gonioscopy and UBM
The noncontact feature of AS-OCT eliminates the
problem of inadvertent pressure on the cornea
seen with gonioscopy by an inexperienced user that
may lead to a misdiagnosis of an open angle when, in
fact, the angle is narrow or closed. In addition,
gonioscopy requires slit lamp light that may also
produce the illusion of an open angle by constricting
the pupil in an eye with either a narrow or closed
angle. AS-OCT can be performed with room lights on
and off and aids in objective assessment of angle
anatomy. An advantage of gonioscopy over both
AS-OCT and UBM is indentation, which allows
differentiating between appositional and synechial
angle closure.
Advantages of AS-OCT over UBM include a higher
axial resolution, faster sampling rate, ability to image
the entire cross-section of the eye, and noncontact
scanning in a seated, upright position. Unlike UBM,
AS-OCT is limited in its ability to visualize structures
posterior to the iris because of blockage of wavelength
by pigment. Therefore, several mechanisms of angle
closure, including plateau iris, ciliary body cyst or
tumor, ciliary effusion, or lens subluxation, are better
elucidated with UBM. Both AS-OCT and UBM devices
are expensive and image only a single cross-section of
the angle with the potential to miss pathology at other
locations. For quantitative analyses, both require
identification of scleral spur as a reference point,
which may be difficult in about one-quarter of cases.16
The properties of AS-OCT and UBM are listed in
Table 1.
Seminars in Ophthalmology
 Imaging in Glaucoma 115

FIGURE 1. AS-OCT, Raw Image Mode Showing Narrow Angle Qualitatively.

TABLE 2. Biometric parameters which can be measured with the UBM are listed below.

Parameter Abbreviation Unit Description

Angle-opening distance AODn mm Distance from cornea to iris at n mm from the scleral spur (n typically
500 or 750)
Trabecular–iris contact length TICL mm Linear distance of contact between iris and cornea/sclera beginning at
scleral spur
Angle-recess area ARAn mm2 Area of triangle between angle recess and iris and cornea n mm from
scleral spur (n typically 500 or 750)
Trabecular–iris space TISA mm2 Area of trapezoid between iris and cornea from sclera to n mm (n
typically 500 or 750)
Trabecular–iris angle TIA Degrees Angle formed from angle recess to points 500 mm from scleral spur on
trabecular meshwork and perpendicular on surface of iris
Trabecular–ciliary process distance TCPD mm Measured from point on endothelium 500 mm from scleral spur
through iris to ciliary process
Iris–zonular distance IZD mm Distance from posterior iris surface to first visible zonule at point
closest to ciliary body
Iris thickness IT mm Measured from perpendicular 500 mm from scleral spur, and possibly
other points
Scleral spur–iris insertion distance SS-IR mm Linear distance from scleral spur to iris insertion
Iris radius of curvature IRC mm Radius of posterior iris surface using an arc transecting three points:
iris root, pupil margin and point of maximal iris displacement
Iris convexity IC mm Maximum distance from the posterior surface of the iris to the line
from posterior iris at pupillary margin to the iris root
Iris–lens contact distance ILCD mm Length of contact between surfaces of lens and iris
Anterior–posterior chamber depth ACD/PCD Ratio of anterior chamber to posterior chamber depth measured 1 mm
from the scleral spur

CLINICAL APPLICATIONS OF AS-OCT helpful in assessing and monitoring changes in the

IN GLAUCOMA configuration of the iris and angle after laser iridot-
omy.19 Figure 2 demonstrates an open angle after
peripheral laser iridotomy in an eye with narrow angle.
Qualitative Analysis

Qualitative analysis of the anterior chamber angle Quantitative Analysis

and adjacent structures can be performed by AS-OCT
for both closed- and open-angle mechanisms.
Qualitatively, angle closure is assessed by position
of the iris relative to the scleral spur. If the iris
is posterior to the scleral spur, the angle is open.
If the iris is anterior to the scleral spur, the angle is
either narrow or closed (Figure 1*). Better detection of
closed angles with AS-OCT when compared with
gonioscopy has been demonstrated, particularly in
the superior and inferior quadrants.17–18 AS-OCT is
Quantitative analysis of the anterior chamber angle
can be performed by AS-OCT and UBM with built-in
software but requires accurate identification of the
scleral spur as an important landmark before other
parameters can be measured.20–22 Important angle
parameters include angle opening distance, angle
recess area, trabecular-iris space area, and trabecular-
iris contact length. The description of these biometric
parameters is provided in Table 2. Scleral spur

*Figures 1–4: Courtesy of Sarwat Salim, MD, FACS.

! 2013 Informa Healthcare USA, Inc.

116 S. Salim and S. Dorairaj
location is reported to be successful in approximately
72% of images obtained with AS-OCT.18 The difficulty
in visualizing the scleral spur was mostly seen in
areas where images were superior or inferior to the
nasal and temporal quadrants. AS-OCT and UBM
have been reported to produce similar quantitative
measurements of angle anatomy by using the afore-
mentioned biometric parameters.11
Narrow Angles and Angle Closure
Anatomically narrow angles can be diagnosed with
AS-OCT both qualitatively and quantitatively
(Figures 2 and 3). Radhakrishnan et al.11 imaged 31
FIGURE 2. AS-OCT, Raw Image Mode High Resolution: Open
Drainage Angle after Full Thickness Peripheral Iridotomy.
FIGURE 3. AS-OCT, Raw Image Mode Showing Deep Anterior Chamber and Iris Concavity in an Eye with Pigment Dispersion
Syndrome.
eyes, including both normal subjects and subjects
with narrow angles, with AS-OCT and UBM and
demonstrated similar values for angle opening dis-
tance, angle recess area, trabecular-iris space area, and
trabecular-iris contact length with both devices.
The same investigators also showed high specificity
and sensitivity in detecting narrow angles with these
two devices when compared with gonioscopy. Nolan
et al.17 reported higher sensitivity in detecting angle
closure with AS-OCT than with gonioscopy. Widening
of the angles after laser iridotomy and quantitative
assessment in eyes with narrow angles has been
demonstrated with AS-OCT.19
Open-Angle Glaucoma
AS-OCT is also useful in identifying pathology in
some forms of secondary open-angle glaucoma. AS-
OCT can be used to assess the iris contour and reverse
pressure gradient between the anterior and posterior
chambers in eyes with pigment dispersion syndrome
(Figure 3). Aptel et al.23 used AS-OCT to demonstrate
increased iridolenticular contact and reverse pressure
gradient in eyes with pigment dispersion syndrome.
Although laser iridotomy was successful in reversing
these structural alterations, whether this favorably
influences the long-term course of the intraocular
pressure in these patients remains unknown. The
noncontact nature of AS-OCT makes it a valuable tool
in identifying angle pathology in posttraumatic eyes,
including angle recession or cyclodialysis cleft.24
Seminars in Ophthalmology

Postsurgical Applications
Bleb morphology is often assessed clinically after
glaucoma filtration surgery and often noted as cystic,
encapsulated, or flat. At times, these descriptions may
be subjective and not accurately reflective of bleb
function. AS-OCT allows intrableb visualization. Its
noncontact imaging provides a significant advantage
over UBM by minimizing trauma to the bleb or risk of
potential infection. Leung et al.25 performed AS-OCT
analysis of bleb morphology after trabeculectomy.
Diffuse blebs were noted to have subconjunctival
fluid collections with presence of suprascleral fluid
space in some cases. Cystic blebs were characterized
by a large hyporeflective space with multiple areas of
fluid collection covered by thin conjunctiva.
Encapsulated blebs had thicker bleb walls with high
reflectivity. Flat blebs demonstrated high scleral
reflectivity with no elevation. The authors proposed
the role of AS-OCT in such cases as an opportunity to
understand wound healing and remodeling process
inside the blebs. AS-OCT also can be used to visualize
proper position or potential occlusion of glaucoma
drainage devices, especially in cases of corneal path-
ology or in the presence of keratoprosthesis. Figure 4
demonstrates a functioning bleb after trabeculectomy.
Measurement of Central Corneal Thickness
Although ultrasound pachymetry is routinely per-
formed and considered the gold standard for measur-
ing central corneal thickness (CCT), it is a contact
technique and may introduce errors with a misplaced
probe or corneal compression. AS-OCT has built-in
analysis software to measure the CCT without contact
with the eye. In contrast to ultrasound pachymetry,
AS-OCT allows both central and regional pachymetry.
Literature comparing CCT measurements with ultra-
sound pachymeter and AS-OCT has been conflicting.
Li et al.26 demonstrated a smaller difference in
measurements with AS-OCT and ultrasound
FIGURE 4. AS-OCT, Raw Image Mode: Functioning Bleb after Trabeculectomy.
! 2013 Informa Healthcare USA, Inc.
Imaging in Glaucoma 117
pachymetry when averaging the measurements over
the central 2 mm rather than using a single focal
measurement. Other investigators have reported a
reproducible systematic difference in CCT measure-
ments when ultrasound pachymeter measurements
were compared to those obtained with SL-OCT and
Visante-OCT and have concluded that measurements
obtained by different devices are not interchange-
able.27–29
Limitations of AS-OCT
Image acquisition with AS-OCT can be affected at
times by the superior eyelid, and oblique angles may
allow cross-sectional images. In addition, image dis-
tortions may result from off-axis measurements,
requiring special software correction to eliminate the
influence of scanning angle and refractive index of
the cornea.30 Image quality may be suboptimal in the
setting of anterior surface abnormalities, given lack of
a coupling medium.31,32 The major limitation of AS-
OCT is its inability to visualize structures posterior to
the iris because of blocking wavelength by pig-
ment.33,34 This blocking limits its application in
discerning several secondary causes of angle closure,
such as plateau iris, ciliary body cyst or tumor, lens
subluxation, or ciliary effusions. These disease pro-
cesses are better delineated with UBM and are
discussed later.
ULTRASOUND BIOMICROSCOPY
The development of UBM in the early 1990s intro-
duced high-resolution, cross-sectional, objective ima-
ging for assessing the angle and ciliary body. Electric
signals are converted by a radiofrequency signal
generator coupled to a piezoelectric transducer into
50-MHz frequency ultrasonic sound waves, which are
transmitted to the eye via saline solution that is held
in a cup reservoir or within the end of a probe on
118 S. Salim and S. Dorairaj
FIGURE 5. UBM, Raw Image Mode: UBM image of occludable angles depicting the importance of evaluating anterior chamber angles
in total darkness. C:Cornea, AC; Anterior chamber, S: Scleral spur, PC: Posterior capsule, I: Iris,CB: Ciliary Body, L: Lens.
which the transducer is mounted. These sound waves
travel at different speeds through the eye as they
encounter tissues of varying acoustic impedance and
are reflected at differing time intervals. UBM probe
provides a scan rate of 8 Hz, giving real-time imaging,
with scans consisting of 256 lines of sight (vectors)
over a 5  5-mm field. UBM has lateral and axial
resolutions of 50 mm and 25 mm, respectively.35–36
These resolutions allow imaging of anatomic areas
of interest in the anterior segment but not the whole
anterior segment in a single scan. A computer system
collates and magnifies these reflected sound waves
and provides a high-resolution B scan image. (Table 1)
Pavlin and coworkers carried out the first clinical
UBM studies of the anterior segment in glaucoma in
the early 1990s.37,38 They demonstrated the utility of
UBM in characterizing several forms of glaucoma,
including plateau iris syndrome39 and pupillary
block40, which together constitute the most common
forms of primary angle-closure glaucoma.41 In add-
ition, UBM’s ability to visualize posteriorly located
structures such as the ciliary body, lens zonules, and
anterior choroid puts it at an advantage over other
modalities, especially for investigating the mechan-
isms behind angle closure. Mechanisms include anter-
ior rotation of the ciliary body in plateau iris,
iridociliary masses causing secondary angle closure,
and choroidal effusions.35,42 Additionally, UBM may
also play a role in evaluating certain types of secondary
glaucoma, such as pigment dispersion43 (posteriorly
bowed, causing iris pigment shaffing) and assessing
for a tilted or subluxed lens in exfoliation syndrome.44
Studies comparing UBM to gonioscopy have found
a high agreement between the two modalities when
both are performed in a completely dark room
(Figure 5y).45 UBM is sufficiently sensitive such that
significant differences among the mean UBM meas-
urements (angle-opening distances at 250 mm and
500 mm from the scleral spur and trabecular mesh-
work-ciliary process distance) of each angle grade
estimated by gonioscopy can be detected (Figure 1).46
yFigures 5–12: Courtesy of Syril Dorairaj, MD.
Principle of Ultrasound Biomicroscopy
A-scan represents the reflectivity along one line of
sight. In UBM, a B-scan is formed from an A-scan by
rotating the transducer around a fixed axis and
writing new lines of sight in correct registration.47–48
The final video image presents a two-dimensional
cross-section through the eye (Figure 6). The essential
components of UBM are identical to those of a
conventional B-mode imaging system except with a
higher frequency. A standard speed of 1530 m/s is
used by the instrument to determine distance meas-
urements for most internal ocular tissue. The UBM
contains internal calipers for distance measurements.
The technique of ultrasound biomicroscopy is
similar to that of B-scan ultrasound. The probe is
placed opposite the area of interest in a water bath,
and the image is observed on the screen. Sterile
methylcellulose is generally used as a coupling fluid,
as its viscosity prevents fluid from running out of the
bottom of the cup. Although subjective gonioscopic
assessment occasionally resulted in an overestimation
of the angle width as compared with the UBM values
in eyes with occludable angles,49angle dimensions
measured by UBM correlated significantly with
gonioscopy in general.46
In 1992, Pavlin described UBM biometric criteria
that could be used for reproducible measurement of
various anterior segment structures.37 Tello et al.
reported on the reproducibility of these measures in
1994.52 These criteria are important in defining repro-
ducible criteria for characterizing different glaucoma
types and for documenting change over time or with
treatment. Marchini, for instance, used UBM to
biometrically compare different forms of angle closure
glaucoma,53 and Sihota et al. applied these criteria to
compare subtypes of primary angle-closure glau-
coma.54 Ramani used UBM to compare anterior-
segment biometry between primary angle-closure
suspects and age-matched controls, including param-
eters such as trabecular-ciliary process distance and
Seminars in Ophthalmology
 Imaging in Glaucoma 119

FIGURE 6. UBM, Raw Image Mode: UBM image of open angles depicting normal structues. C:Cornea, AC; Anterior chamber,
S: Scleral spur, PC: Posterior capsule, CB: Ciliary Body, L: Lens.

iris thickness and angle width (in degrees).55

Nonaka et al. described the use of UBM for measuring
iris convexity in primary angle-closure glaucoma.51

UBM IN NORMAL EYE

UBM is capable of imaging the anterior segment, as

well as the peripheral retina. The scleral spur is an
important landmark as it provides a fixed reference
point that can be used to measure various distances
(Figures 6).37 The ciliary zonules are best seen when
near the focal zone of the transducer. Schlemm’s canal
can be imaged occasionally but is too small to be
imaged consistently on the UBM.
ULTRASOUND BIOMICROSCOPY IN
GLAUCOMA
Pupillary Block in Phakic Eyes
Gonioscopy has traditionally been used to diagnose
cases prone to angle closure. The hallmark of pupil-
lary block is an anterior convexity of the iris
(Figures 7). The anterior chamber is usually shallow
in these eyes, with the lens surface being anterior to
the iris root. It may be difficult to ascertain the true
degree of opening of an iridocorneal angle on
gonioscopy because of the difficulty of seeing over
the iris bombé. A cross-sectional UBM image allows
visualization of the degree of open angle. Eyes with
pupillary block have a reduced angle opening dis-
tance, an open ciliary sulcus, and an increased
posterior chamber depth between the iris and the
zonule/peripheral lens (Figure 7). Previous studies
have defined the iris profile in pupillary block by
using both a theoretical analysis56 and an optical
technique with Scheimpflug photography.57
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FIGURE 7. UBM, Raw Image Mode: UBM image depicting
relativ pupillary block with convex iris configuration. C:
Cornea, AC; Anterior chamber, S: Scleral spur, PC: Posterior
capsule, CB: Ciliary Body, L: Lens.
Plateau Iris
Eyes with plateau iris configuration have an anterior
positioning of the ciliary processes that closes the
ciliary sulcus and structurally prevents the peripheral
iris from moving posteriorly after pupil block is
eliminated by iridotomy. However, the anterior cham-
ber depth in eyes with plateau iris is deeper than in
eyes with relative pupillary block. In plateau iris
syndrome, the ciliary body is anteriorly positioned
and possibly enlarged, compressing the iridocorneal
angle and placing the peripheral iris in apposition to
the trabecular meshwork and impairing outflow in
presence of a patent iridotomy. Peripheral laser
iridoplasty will open up the angles in plateau iris
syndrome patients (Figure 8).5,58 UBM and AS-OCT
demonstrate little iris bowing but rather a steep rise in
the iris near its point of insertion. Anterior positioning
of the ciliary processes and absence of the sulcus are
best visualized with UBM (Figure 8).
120 S. Salim and S. Dorairaj
FIGURE 8. UBM, Raw Image Mode: UBM image depicting plateau iris configuration with anteriorly positoned ciliary body, placing
the peripheral iris in apposition to the trabecular meshwork. C: Cornea, AC; Anterior chamber, S: Scleral spur, PC: Posterior capsule,
CB: Ciliary Body, L: Lens.
FIGURE 9. UBM, Raw Image Mode: UBM image depicting
pigment dispersion syndrome with concave iris configuration,
consistent with the hypothesis that iris-zonular chafing is
responsible for the dispersion of pigment particles. C: Cornea,
AC; Anterior chamber, S: Scleral spur, PC: Posterior capsule, I:
Iris, CB: Ciliary Body, L: Lens.
In some cases, multiple ciliary body cysts, also
detectable by UBM, can cause a similar effect on the
angle.59–61 UBM has shown that iridociliary cysts are
more common than initially thought and allows their
progression to be followed over time. Although ciliary
body cysts are common and generally benign,
impaired outflow may result when multiple cysts
further narrow an angle that is already compromised
by age-related anterior-chamber shallowing.62
Pigment Dispersion Syndrome
Pigment dispersion glaucoma results from the dis-
semination of pigment granules from the posterior of
the iris as a result of friction between this surface and
the zonules and/or lens. The deposition of particles
in the trabecular meshwork can impair outflow and
lead to an increase in intraocular pressure. The UBM
appearance of pigment dispersion glaucoma was first
described by Pavlin.63 Pigment dispersion syndrome
typically demonstrates an open angle and iris con-
cavity, consistent with the hypothesis that iris-zonular
chafing is responsible for the dispersion of pigment
particles (Figure 9).64,65 A reverse pupillary block may
account for concave iris geometry, as the concavity
can often be reversed with iridotomy.66
Malignant Glaucoma
Malignant glaucoma is an unusual form of angle
closure that can occur following filtering surgery.
UBM can be useful for the diagnostic imaging of
malignant glaucoma, which is characterized by a
forward movement of the iris-lens diaphragm and a
very shallow anterior chamber, typically following
glaucoma surgery for chronic angle-closure glaucoma
(Figure 10). The primary consideration in the differ-
entiation of pupillary block and malignant glaucoma
is the presence of a formed posterior chamber in the
former, which can be demonstrated by UBM. UBM
shows supraciliary fluid, anterior rotation of the
ciliary processes, and closure of the fistula by either
ciliary processes or the lens margin in such cases.
Kumar67 and Sakai68 used UBM to document the
presence of choroidal effusion in patients with pri-
mary angle-closure glaucoma and acute angle closure,
both pre- and postiridotomy. Gazzard et al. were
among the first to describe the association of primary
acute angle-closure with suprachoroidal fluid.69
Angle Recession
Angle recession is defined by a split in the longitu-
dinal and circular muscles of the ciliary body. UBM
Seminars in Ophthalmology

FIGURE 10. UBM, Raw Image Mode: UBM image depicting
aqueous misdirection (malignant glaucoma) characterized by a
forward movement of the iris-lens diaphragmwth CB rotation
associated with a shallow peripheral anterior chamber. C:
Cornea, AC; Anterior chamber, S: Scleral spur, PC: Posterior
capsule, I: Iris, CB: Ciliary Body, L: Lens.
can be used to image the tear into the ciliary body that
occurs with angle recession. This can be helpful if
anterior opacities and blood prevent visualization of
the anterior chamber angle. Ozdal compared UBM
with gonioscopy following such trauma and reported
UBM to be diagnostically useful in imaging angle
recession, cyclodialysis, zonular deficiency, lens dis-
location, and synechiae.70
Postglaucoma Surgery Imaging with UBM
Ultrasound biomicroscopy is superior to slit lamp for
evaluating bleb function and failure, allowing a
demonstration of flattened, encapsulated, and cystic
avascular thin-walled blebs. The height, wall thick-
ness, apposition of the scleral flap to sclera, and the
patency of the internal ostium can be assessed. Bleb
assessment with UBM can influence clinical decision-
making regarding laser suture lysis following trabe-
culectomy.71 Bochmann et al.50 described the use of
UBM to identify narrow-diameter (5100 mm) iridot-
omy sites, which were then retreated based on UBM
findings. Ishikawa et al. demonstrated that indenta-
tion of the cornea by a small eyecup can result in
angle widening.72 Following this work, Matsunaga
et al. described the use of a special UBM eyecup that
allowed simultaneous corneal compression with UBM
observation of the angle configuration before and
after compression.73 This eyecup allowed a differen-
tiation between appositional angle closure and syne-
chial closure. Carillo demonstrated the usefulness of
UBM to diagnose obstruction of an Ahmed valve by
the iris (Figure 11).74 UBM may also potentially offer
intraoperative guidance in the anterior segment as a
! 2013 Informa Healthcare USA, Inc.
Imaging in Glaucoma 121
FIGURE 11. UBM, Raw Image Mode: UBM image depicting
obstruction of glaucoma drainage device tube by iris.
FIGURE 12. UBM, Raw Image Mode: UBM image showing
synechial angle closure (small downward directed arrows). C:
Cornea, AC; Anterior chamber, S: Scleral spur, PC: Posterior
capsule, I: Iris, CB: Ciliary Body, L: Lens.
supplement to gonioscopy and intraocular
microendoscopy.75
Postpenetrating keratoplasty glaucoma is a major
cause of graft failure and one of the most common
causes of irreversible visual loss after keratoplasty.
UBM allows imaging of anterior-segment anatomy in
the presence of corneal opacity. The visualization of
synechiae and secondary angle closure by UBM in
such cases can be a valuable tool for planning filtering
surgery or implanting drainage devices (Figure 12).76
UBM is able to evaluate glaucoma tube shunts
placed beneath the sclera or iris plane. The position of
the tube of artificial drainage devices can be ascer-
tained using UBM (Figure 11). Rothman et al. demon-
strated that UBM is instrumental in diagnosing the
presence and cause of tube obstruction, as UBM can
detect focal obstructions of Baerveldt tubes caused by
kinking at the scleral entry site after pars plana
insertion.77 Numerous clinical studies using AS-OCT
and/or UBM have used biometric parameters. Using
122 S. Salim and S. Dorairaj
UBM, Dada et al. compared changes in anterior
chamber anatomy in patients with primary angle
closure and primary angle-closure glaucoma follow-
ing iridotomy, demonstrating widening of the anterior
chamber angle and a deepening of the anterior
chamber in eyes with primary angle closure but no
significant change in eyes with primary angle-closure
glaucoma.78 Dada also described the UBM changes
occurring during a Valsalva maneuver: narrowing of
the anterior chamber angle recess and thickening of
the ciliary body and iris. In eyes anatomically
predisposed to primary angle closure, the Valsalva
maneuver may lead to angle closure. Also, studying
the effect of iridotomy on angle-closure suspect eyes,
He et al. found iridotomy to result in a significant
increase in angle width but with some iridotrabecular
contact in 59% of eyes with a patent iridotomy.79 Their
findings were associated with smaller angle dimen-
sions and a thicker iris, both of which may play a
causative role in maintaining angle closure after
iridotomy. Kaushik et al. compared UBM and gonio-
scopy in evaluating changes in angle anatomy fol-
lowing laser iridotomy.80 They reported that the angle
significantly widened in the quadrant with iridotomy
and in the quadrant furthest away in patients with
chronic angle closure and established glaucomatous
damage. This change was much better appreciated by
UBM than by gonioscopy.
Limitations of UBM
Limitations of UBM include the requirement of a
coupling medium and supine position for scanning,
which might theoretically lead the iris diaphragm to
fall back and change the depth of the anterior
chamber and the angle opening. Ishikawa et al.72
demonstrated that inadvertent pressure on the eyecup
while scanning can influence the angle configuration.
In addition, UBM might be more time consuming and
require a skilled operator to obtain high-quality,
precision images. Nevertheless, these limitations are
outweighed by the benefit of UBM for visualizing the
ciliary body, zonules, and posterior chamber, thereby
making it an essential tool in defining the mechanism
of closure in angle-closure glaucomas. UBM remains
the gold standard in cases of plateau iris configuration
and imaging of ciliary processes. Its accuracy and
ability to visualize behind a clouded cornea makes it
very useful in the preoperative assessment of anterior
segment pathology, thereby contributing to optimal
surgical planning.
Scheimpflug (Pentacam) Photography
The Scheimpflug principle describes the change in
focal plane that occurs when the film plane is tilted
such that the focal, lens, and film planes are not
parallel, thereby shifting the plane of sharp focus to
the intersection point of the film and lens planes and
allowing slit images of the anterior segment of the eye
that retain depth to be obtained. Using a rotating
camera, commercial devices based on the
Scheimpflug principle can obtain multiple images,
which are then reconstructed into a 3-dimensional
image and enabling a rapid assessment of the anterior
chamber. Semiautomated analysis of angle width
requires the user to determine the iris plane and
plane of corneal curvature by placing up to 10 marks
on the corneal endothelium, from which the angle
width is measured. Although subjective, this fast and
noncontact method of anterior chamber angle assess-
ment has been previously reported to be highly
reproducible, at least in eyes with open angles.81–84
Scheimpflug photographic techniques, however,
have not been documented to reliably image a variety
of angle configurations. The anterior chamber angle
details cannot be entirely visualized, and only the
angle approach can be photographed as light is
unable to penetrate to the angle recess. A major
limitation is that the user has to define the iris plane.
Doing so in a straight line leads to inaccuracies in
angle width measurement. Comparing anterior cham-
ber angle width measurements using Scheimpflug
photography and UBM revealed only moderate cor-
relation, with Scheimpflug images having a much
lower resolution.85 In addition, one study found that
angle measurements from Scheimpflug images were
less sensitive to changes in illumination compared
with those obtained using UBM.86 In a recent study,
Scheimpflug photography was reported to provide
insufficient detail of the angle for assessment of angle
anatomy, with limited agreement existing between
gonioscopy, Scheimpflug photography, and UBM.87
Scheimpflug photography also does not display the
retroiridal structures or the ciliary body, which are of
great interest in glaucoma diagnosis.88
CONCLUSION
AS-OCT and UBM are useful technologies for imaging
the anterior chamber angle and offer the advantages
of objective, reproducible, and quantitative analyses
with rapid image acquisition and storage capacity for
future comparisons. These tools also facilitate anterior
segment imaging in the presence of corneal opacities,
which may not be possible with gonioscopy. While
none of these new devices, individually, can replace
conventional slit-lamp biomicroscopy and gonio-
scopy, these new devices and techniques of anterior
segment and angle imaging can complement existing
methods in clinical practice, particularly when gonio-
scopy is difficult or additional information is required
Seminars in Ophthalmology

to assess pathology in structures adjacent or posterior
to the iris.89,90
DECLARATION OF INTEREST
The authors report no conflicts of interest. The authors
alone are responsible for the content and writing of
this article.
The authors report no financial disclosures related
to this topic.
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