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Different Mechanism of

Angle Evaluation
• Honorable Chairperson: Prof. Dr. Iftekhar Md. Munir
Dept. of Glaucoma
NIO&H.

• Moderator: Asst. Prof. Dr. Samarendranath Adhikary


Dept. of Glaucoma
NIO&H.

• Speaker: Dr. M. Abdullah Sakib


FCPS Part II Course Student
NIO&H.
Primary angle-closure glaucoma.
Anterior uveitis.
Iridocorneal endothelial (ICE) syndrome. Angle recession.
Trabecular dialysis.
Trauma Cyclodialysis.
Peripheral anterior synechiae
Foreign bodies.

Neovascularization Why
Angle
Neovascular glaucoma.
Fuchs heterochromic cyclitis. Evaluation? Physiological variant.
Pigment dispersion syndrome.
Chronic anterior uveitis.
Pseudophakic pigment dispersion.
Pseudoexfoliation syndrome.
Blunt ocular trauma.
Hyperpigmentation Anterior uveitis.
Following acute angle-closure glaucoma.
Blood in the Schlemm canal Following YAG laser iridotomy.
Physiological variant. Iris or angle melanoma or naevus.
Carotid–cavernous fistula Iris pigment epithelial cysts.
Sturge–Weber syndrome Naevus of Ota.
Structure of Anterior Chamber Angle

From Posterior to Anterior


Ciliary body band (CB)
Scleral spur (SS)
Trabecular meshwork “band” (TM)
ATM
PTM
Schwalbe’s line (SL)
Structure of Anterior Chamber Angle
Different Ways to Asses Angle

• Van Herick Method


• Gonioscopy
• Anterior segment OCT
• Ultrasound Biomicroscopy (UBM)
• Pentacam
Van Herick method for anterior chamber angle assessment
Van Herick method for anterior chamber angle assessment
Anterior chamber depth Description Grade Comment
as a proportion of
corneal thickness
≥1 Peripheral AC space equal 4 Wide open
to full corneal thickness or
larger
1/4–1/2 Space between one- 3 Incapable of closure
fourth and one-half
corneal thickness
1/4 Space equal to 1/4 2 Should be gonioscoped
corneal thickness
<1/4 Space less than 1/4 1 Gonioscopy will usually
corneal thickness demonstrate a
dangerously narrowed
angle
GONIOSCOPY PRINCIPLE

• Critical angle 46°


• Light rays from the AC strike
the anterior corneal surface at
an angle greater than the
critical angle & are totally
internally reflected.
• Gonio lens eliminates corneal-
air interface.
• Indirect gonioscopy reflect
light from AC.
Gonioscopic View
SCHLEMM’S CANAL
• Lies within the TM
• 0.2 mm to 0.3 mm wide
• Cannot be detected by gonio unless it is filled
with blood (pinkish band ant to SS)
• Pressure within the canal is lower than the
pressure in the AC
• Connects with the venous system & drains the
aqueous

Blood can sometimes be seen in the canal


either physiologically (sometimes due to
excessive pressure on the episcleral veins
with a goniolens), or in the presence of low
intraocular or raised episcleral venous
pressure.
Gonioscopy Indications
Diagnostic Therapeutic
 For visualization of anterior chamber  Argon laser Trabeculoplasty
angle prior to pupil dilatation if needed  Laser Goniotomy
 Narrow peripheral anterior chamber  Reopening of trabecular
 (Van Herrick grade 2 or less). opening
 Historical evidence of angle closure.
 extent of neovascularization.
 To asses angle recession.
 History or evidence of inflammation.
 Recent or previous CRVO
 For evidence of neoplastic activity.
 Degenerative or developmental anomaly.
 Suspected K-F ring
 Others
Gonioscopy

Direct
Indirect
(Goniolense
s)

Non indentation Indentation(Dynamic)

Koeppe Swan–
Jacob

3 mirrors single mirror Zeiss goniolens


Goldmann goniolens
Procedure
3 Mirror

• Room- ambient illumination is very low


• Size and intensity of the slit beam should be reduced
• Explanation
• A drop of local anaesthetic
• Coupling fluid on the lens
• Patient is asked to look upwards, lens is inserted
• The patient then looks straight ahead
• Increasing the level of illumination after initial exam
• 3-Mirror Goldmann:
• Central lens-macula
• Trapezoid-Posterior pole to equator
• Rectangular- Equator to beginning of ora
serrata
• Thumbnail- Ora serrata (dilated), anterior
chamber and iris (undilated)

• Note: Viewing the angle 180 degrees away


from the mirror -view is inverted or reversed
All quadrants should be inspected and graded
independenly
Advantages & Disadvantages Of Goldmann & Zeiss Lens

Goldmann Zeiss Lens


Needs coupling solution Does not need
Coupling fluid produces suction– abrasion No suction effect,
difficult to stabilize
With rotation continuous-view of angles Slight rotation - whole of angle
Large diameter, Small radius of curvature Small diameter, lens can be
minimizes chances of inadvertent moved over the cornea
indentation
Cannot be tilted with visual axis – Can be tilted without altering
falsely closing angles pt’s gaze
Different Grading System of Angle by Gonioscopy

• Shaffer System
• Scheie system
• Spaeth system
Shaffer system
Shaffer system

Grade 4 35–45° ciliary body can be visualized without tilting the lens
Grade 3 25–35° scleral spur is visible
Grade 2 20° trabeculum but not the scleral spur
Grade 1 10° only the Schwalbe line
top of the trabeculum
Slit angle no obvious iridocorneal contact
no angle structures can be identified
Grade 0 0° closed due to iridocorneal contact

Indentation will distinguish appositional from synechial angle closure


SCHEIE CLASSIFICATION

Wide open: All structures visible


Grade I: Iris root visible
Grade II: Ciliary body obscured
Grade III: Posterior trabeculum
obscured
Grade IV: Only Schwalbe’s line
visible
* Angle depth system based on structures
visualized.
SPAETH GONIOSCOPIC GRADING SYSTEM

Angular Pigmentation of Trabecular


Iris Insertion Peripheral Iris
Approach Meshwork
SPAETH GONIOSCOPIC GRADING SYSTEM

Iris Insertion Angular Pigmentation of


Approach Peripheral Iris Trabecular
Meshwork
A Anterior to Schwalbe’s line r regular f flat 0 no pigment
B Between Schwalbe’s line s steep b bowed anteriorly 1+ minimal
and scleral spur
C Scleral spur visible q queer p plateau iris 2+ mild
D Deep with ciliary body 0° to 50° c concave 3+ moderate
Visible
E Extremely deep with 4+ intense
>1 mm of ciliary body
Visible
* Evaluating iris insertion, angular approach, peripheral iris configuration, and degree of trabecular meshwork
pigmentation.
International Coding for Gonioscopy Documentation
Record results for each quadrant (X)
Primary view, secondary view (tilt lens)
Describe:
◦most posterior structure visible per quadrant
(CB, SS, TM, SL or none)
◦presence of pigment? (grade 0-4)
0 (no pigment in the trabecular meshwork)
to 4 (extremely dense pigment in the trabecular
meshwork).
◦iris insertion (concave, convex or flat approach)
◦iris processes? anomalies?
Angle depth:
i. Inferior angle is widest
ii. Superior angle is the narrowest
Comment:
When is gonioscopy contraindicated?
• Penetrating injury
• Orbital fracture
• Known Recurrent Corneal Erosion
• Corneal abrasions
• Ocular Surface Disease With Epitheliopathy or Recalcitrant
healing
• Bullous keratopathy
• Recent Corneal Trauma Or Intraocular surgery
Anterior Segment OCT

Optical coherence tomography (OCT) is an imaging technique that uses


coherent light to capture micrometer-resolution, two- and three-dimensional
images from within optical scattering media such as biological tissue.

Coherent light - two wave sources are coherent if they have a constant phase
difference and the same Frequency, and the same wavelength

Based on low-coherence Inferometry.


AOD : Angle opening distance
TISA: Trabecular Iris surface area at 500 and 750 µm.
TIA : Trabecular-Iris Angle
Ultrasound Biomicroscope

The depth of tissue structures is determined by directly measuring the


time delay of returning ultrasound signal

In UBM, imaging probe is 50-MHz


Ultrasound Biomicroscope
UBM

Ultrasound biomicroscopy of a ciliary body tumor extending up to the pars plana


AS OCT VS UBM

AS OCT UBM
commonly used for appositional angle- Plateau iris, ciliary effusion syndrome,
closure lens subluxation, ciliary body cyst, or
tumor is suspected
Non Contact Contact- liquid coupling medium
Higher Axial resolution Lower Axial resolution
Faster acquisition time Slower acquisition time
Wide field view Smaller field of view
Sitting upright Sitting upright or supine
Clear cornea Can image opaque cornea
Limited ability behind iris pig. Epi. Visualize structure post. to IPE
IJO Year : 2015 | Volume : 63 | Issue : 8 | Page : 630-640
Anterior segment imaging in glaucoma: An updated review
Jessica S Maslin1, Yaniv Barkana2, Syril K Dorairaj3
Oculus Pentacam
Oculus Pentacam
Gonioscopy Video Examples
Take Home Mesasage

• There are many ways to evaluate angle but among these Gonioscopy
is the most convenient, easily applicable, cost effective method.

• Everyday practice of Gonioscopy makes the diagnosis more easier


clinically.
Thanks To Almighty
Thanks to all