REVIEW

A History of Gonioscopy
Wallace L. M. Alward*
ABSTRACT
The first view of the iridocorneal angle in a living human occurred accidentally in the late 1800s. Lenses were first used
to see the angle in 1914, but practical gonioscopy would not come into existence for many years as the slitlamp and
lenses that could be used at the slitlamp were developed. This article reviews the history of gonioscopy.
(Optom Vis Sci 2011;88:2935)
Key Words: gonioscopy, history, direct gonioscopy, indirect gonioscopy, Salzmann, Trantas, Barkan, Allen
C
linical gonioscopy is just over 100 years old. During those
100 years, some remarkable scientists and astute clinicians
have played roles in the development of this important
examination technique. This review will summarize the develop-
ment of gonioscopy. The illustrations, rather than being of the
people who advanced the field, will concentrate on the angle im-
ages that they produced.
Gonioscopy is considered to have two fathers, and the
primacy of the two innovators is dependent on the views of the
authors. Dellaporta
1
wrote a delightful and detailed history of
gonioscopy that included many charming personal anecdotes. Del-
laporta focused on the contributions of Trantas, with whom he
shares a Greek heritage. Other accounts focus on Salzmann, who
was the first to study the optics behind gonioscopy and the first to
use a lens to view the angle. In their textbook, Gorin and Posner
2
say that Salzmann will always be revered by ophthalmologists as
the father of gonioscopy. This review will consider both fathers
chronologically.
Gonioscopy is required to view the iridocorneal angle, because
light from the angle reflects back into the anterior chamber at the
tear-air interface (Fig. 1). This is because of the total internal
reflectionjust as in a fiberoptic cable. The only circumstances in
which the angle can be seen without special manipulation are in
cases of keratoglobus where the light from the angle strikes the
cornea at an angle perpendicular enough to escape. This is very
rare.
Direct Gonioscopy
To view the iridocorneal angle, one needs to overcome total
internal reflection in some way. We do this today with a variety of
lenses, but the first gonioscopy was performed with an ophthalmo-
scope and indentation. The first person to examine the iridocorneal
angle in a living human was the Greek ophthalmologist Alexios
Trantas
3
in 1898. Trantas was in private practice. He was an out-
standing observerfor example, he first identified the conjuncti-
val infiltrates in vernal conjunctivitis that bear his name (Trantas
dots). Trantas was able to see the angle using a direct ophthalmo-
scope while indenting the sclera with his finger (Fig. 2).
3
He was
actually more interested in viewing the ciliary body, ora serrata,
and anterior retina. His view of the iridocorneal angle was a fortu-
nate accident. In 1900, he described the appearance of a cyclodi-
alysis cleft in a patient with an iridodialysis (his view was made
easier by the iridodialysis, because the iris was not in the way).
1
He
later presented remarkably detailed drawings of the angle (Fig. 3).
4
His descriptions of the angle were an afterthought, included in an
appendix of an article describing the retrociliary region.
4
It was
Trantas who coined the termgonioscopy, meaning observation
of the angle, in his native Greek.
1
Maximilian Salzmann was a brilliant ophthalmologist who,
upon graduating from college at age 15, went on to contribute in
all aspects of eye research. He was also skilled in languages, math-
ematics, geology, and botany. Salzmann was a gifted painter whose
paintings were used in many textbooks of his time.
5
His own
textbook, The Anatomy and Histology of the Human Eyeball in the
Normal State, was a classic in German and was translated into
English. Salzmann was unaware of the work of Trantas, because
the descriptions of gonioscopy in the articles of Trantas did not
appear in the titles or abstracts.
1
He first recognized the concept of
total internal reflection.
6
He also determined that total internal
reflection could be overcome with a highly convex lens (Fig. 4).
Salzmann was the first to viewthe angle through a contact lens and,
in 1915, published an article with excellent drawings of the angle
obtained by means of a Fick contact lens (a lens designed to treat
keratoconus).
7
He was not satisfied with the viewthrough the Fick
*MD
Department of Ophthalmology, University of Iowa Carver College of Medi-
cine, Iowa City, Iowa.
1040-5488/11/8801-0029/0 VOL. 88, NO. 1, PP. 2935
OPTOMETRY AND VISION SCIENCE
Copyright 2011 American Academy of Optometry
Optometry and Vision Science, Vol. 88, No. 1, January 2011
lens and, so, had Zeiss build him a lens with a smaller radius of
curvature.
2
Although Trantas was the first to see the angle, Salz-
mann was the first to really study the angle. Salzmann stressed the
importance of gonioscopic examination in the fellow eye of pa-
tients who had suffered an attack of acute glaucoma.
2
He recog-
nized that the development of synechiae in the angle did not always
lead to increased intraocular pressure.
2
Salzmann was also the first
to describe blood in Schlemms canal.
1
Salzmann produced won-
derful drawings of the iridocorneal angle (Figs. 5 and 6).
6,7
Through the courtesy of S. Karger AG, Basel, all of Salzmanns
gonioscopy paintings are reproduced at: http://gonioscopy.org/
salzmann/salzmann.html.
Mizuo examined the inferior angle in patients by everting the
lower lid and filling the cul-de-sac with saline. The saline meniscus
acted like a contact lens.
8
He described this technique in 1914.
Elschnig had verbally reported to Salzmann the same technique
using the patients own tears.
2,7
The technique was difficult to
perform because the saline lens was lost whenever the patient
blinked.
8
Many events occurred around 1920 that brought gonioscopy
into clinical relevance. Zeiss developed the modern slitlamp at
about this time, which permitted significant advances in gonios-
copy. In 1920, Curran
9
published his landmark article that recog-
nized that angle-closure glaucoma was caused by forward bulging
of the iris and that surgical iridectomy (which had been used in-
discriminately for glaucoma) would only work for angle closure
cases. He recognized that the iridectomy worked by reestablishing
flow from the posterior to anterior chambers, not by uncovering
the trabecular meshwork. In 1919, Koeppe
10
used the Zeiss slit-
lamp to examine the angle with his newly developed direct contact
lens, which was thicker and more convex than the lenses used by
FIGURE 1.
Total internal reflection occurs when the light from the iridocorneal angle
strikes the tear-air interface at a shallow enough angle that all the light is
reflected back into the eye. Reproduced with permission from Color Atlas
of Gonioscopy, 2nd ed: San Francisco, American Academy of Ophthal-
mology, 2008.
24
FIGURE 2.
One can overcome total internal reflection by indenting the limbus to
make the light from the angle exit the cornea at a steep enough angle that
it is not reflected back into the eye. This is the technique that was used by
Trantas. Reproduced with permission from Color Atlas of Gonioscopy,
2nd ed: San Francisco, American Academy of Ophthalmology, 2008.
24
FIGURE 3.
Trantas made the first drawings of the iridocorneal angle. This shows
remarkable detail given the limitations of his technique. Published in
1918.
1,4
FIGURE 4.
Direct lens. This lens changes the approach of the light from the iridocor-
neal angle so that it is more perpendicular, thus overcoming total internal
reflection. Reproduced with permission from Color Atlas of Gonioscopy,
2nd ed: San Francisco, American Academy of Ophthalmology, 2008.
24
FIGURE 5.
Painting by Salzmann, 1915. Right eye, inferior and temporal-temporal
portion, male, 37 y/o, traumatic cataract, (case VII) (goniolens). Circum-
scribed and incomplete peripheral synechiae, pigmentation of the trabec-
ular meshwork. Reproduced with permission from Z Augenheilkd, 34,
2649, 1915.
31
30 A History of GonioscopyAlward
Optometry and Vision Science, Vol. 88, No. 1, January 2011
Salzmann. Gonioscopy was performed with the patient seated at
the slitlamp. A knotted bandage rested on a central depression in
the lens to secure it to the patient. This technique was effective only
for evaluating the nasal and temporal portions of the angle. The
Koeppe lens and modifications of the Koeppe lens (Barkan, Swan-
Jacobs, etc.) are still used today for direct gonioscopy.
In 1925, Manuel Uribe Troncoso
11
developed a selfilluminat-
ing monocular gonioscope that permitted examination of all parts
of the angle. The handheld device combined the examining oculars
with an illumination system. He also improved on the Koeppe lens
by using polymethylmethacrylate instead of glass.
2
In 1942, he
created a handheld stereoscopic gonioscope.
In 1927, Thorburn first photographed the angle in a case of
angle closure brought on by mydriatics and subsequently reversed
by physostigmine. He also observed that the majority of his pa-
tients with glaucoma had open angles.
12
Barkan et al.
13
used a binocular slitlamp suspended from the
ceiling and a handheld illuminator to view the angle through a
Koeppe lens. His technique had the advantage of bright illumina-
tion and sufficient magnification. The flexibility of the ceiling-
mounted handheld slitlamp enabled the entirety of the angle to be
evaluated with the Koeppe lens in a supine patient. Barkans appa-
ratus brought gonioscopy into practical clinical application.
Barkan
14,15
was also the first to describe goniotomy under direct
visualization for primary congenital glaucoma. Before Barkan, go-
niotomy had been performed without visualizing the angle. He
developed a special variation of the Koeppe lens in which one side
was flattened to permit passage of the knife through the temporal
cornea. Barkan felt that the eyes of children with congenital glau-
coma had a membrane covering the iridocorneal angle (Barkans
membrane) because of the glistening appearance of the angles of
babies with glaucoma.
16
It is now recognized that there is no Bar-
kans membrane, simply compressed trabecular beams.
17
Clinical use of direct gonioscopy is nowlimited to the operating
room for examining babies under general anesthesia and for per-
forming angle surgery. Direct gonioscopy is required for some
surgical techniques such as for goniotomy for infantile glaucoma
angle and for the Trabectome for open-angle glaucoma. Direct
gonioscopy is rarely used in the clinic because it is inconvenient.
The patient needs to be supine in a special room with a ceiling-
mounted counterbalanced slitlamp. Any examination technique
that is inconvenient is less likely to be performed. The Van Herick
estimation of angle depth was developed because it was not prac-
tical to perform direct gonioscopy on every patient, and it was
helpful to have a means of identifying worrisomely narrow angles
at the slitlamp. To quote Van Herick et al.,
18
In the routine
examination of nonglaucomatous patients, it is impractical to per-
form gonioscopy; it is only done of the angles are thought to be
narrow. In 2010, indirect gonioscopy is easy and convenient
enough that the Van Herick technique should simply be an ad-
junct to gonioscopy.
Indirect Gonioscopy
Modern indirect gonioscopy was introduced in 1938 with the
Goldmann mirrored contact lens.
19
The Goldmann lens uses a
FIGURE 7.
Indirect gonioscopy lens. Light from the iridocorneal angle is reflected by
a mirror so that it is visible to an observer at a slitlamp. Reproduced with
permission from Color Atlas of Gonioscopy, 2nd ed: San Francisco,
American Academy of Ophthalmology, 2008.
24
FIGURE 6.
Painting by Salzmann 1915. Left eye, temporal quadrant, male, 37 y/o,
small rupture of the corneoscleral border (case XIV). Displacement of the
iris because of the vitreous coming forward and radial tear. Visible corona
ciliaris (pars plicata). Reproduced with permission from Z Augenheilkd,
34, 2649, 1915.
A History of GonioscopyAlward 31
Optometry and Vision Science, Vol. 88, No. 1, January 2011
mirror to redirect the light from the iridocorneal angle, so that it is
visible to the examiner viewing through a slitlamp (Fig. 7). Gold-
mann was another polymath whose name is familiar because of the
gonioscopy lens, tonometer, and perimeter that bear his name. His
contributions to the understanding of the eye in health and disease
were too numerous to list here.
20
With the Goldmann lens at a
slitlamp, one could readily examine the entire angle using the
readily available slitlamp, rather than a separate apparatus. Gonios-
copy was no longer reserved for those with suspiciously narrow
angles on slitlamp examination. The Allen lens, developed a few
years later, used totally refractive prisms rather than a mirror.
21
This was later modified into the Allen-Thorpe gonioprism, which
had four prisms and permitted most of the angle to be viewed
without rotation of the lens (Fig. 8).
22
The Allen-Thorpe lens had
flanges that held it in place allowing the examiner time and free
hands to make detailed drawings of the findings. Four-mirrored
lenses, such as the Zeiss, Posner, Sussman, and Volk G-4 lenses, are
commonly usedtoday. Unlike the Goldmannlens, these lenses do not
require a methylcellulose coupling solution. The remarkable angle
paintings of Lee Allen were created with the Allen-Thorpe lens (Figs.
9 and 10). Many of the Lee Allens paintings are included in the Color
Atlas of Gonioscopy,
23,24
and all of his gonioscopy paintings are avail-
able at: http://gonioscopy.org/leeAllenPaintings.html.
There have been no major developments in lens design over the
last several decades. There have been modifications to the Gold-
mann and Allen-Thorpe/Zeiss lenses. Variations of the Goldmann
lens include lenses with one to four mirrors. In the three-mirror
lens, two of the mirrors are for viewing the peripheral retina. Other
FIGURE 8.
Allen-Thorpe lens. This was the original four-mirror lens. It actually used
prisms instead of mirrors and had a flange to hold it into place. The prisms
were replaced by mirrors in subsequent lenses (Zeiss, Posner, etc.).
FIGURE 9.
A Lee Allen painting and sketch of a normal iridocorneal angle with deep trabecular pigmentation. Reproduced with permission from the University
of Iowa.
FIGURE 10.
A Lee Allen painting showing blood in Schlemms canal. Reproduced with
permission from the University of Iowa.
32 A History of GonioscopyAlward
Optometry and Vision Science, Vol. 88, No. 1, January 2011
Goldmann-style lenses (such as the Ritch lens) are specially de-
signed and coated with antireflective material for the delivery of
laser energy. Others have mirrors that magnify slightly. The Zeiss
style lenses are nowavailable in plastic or glass with mirrors that are
less fragile than the original Zeiss lens. These are available with
handles (e.g., Posner and Volk G-4 with optional handle) or with-
out handles (e.g., Sussman and Volk G-4), and there is even a
six-mirror version (Volk G-6). However, the recent changes in
gonioscopy lenses have been evolutionary, not revolutionary.
A major advance in gonioscopy technique was the introduction
of the technique of indentation gonioscopy. First taught by Drs.
Becker and Moses at Washington University with a handheld Zeiss
goniolens, it was refined by using the Zeiss lens on an Unger handle
by Max Forbes in 1966.
25
Indentation gonioscopy requires the use
of a gonioscopy lens with an area of contact smaller than the cornea
(e.g., Zeiss, Posner, Sussman, Volk G-4, etc.). By using one of
these lenses, the examiner pushes against the cornea, which drives
the lens-iris diaphragm posteriorly. This permits the examiner to
determine whether areas of angle closure are because of apposition
or synechiae. Indentation gonioscopy can also reveal a peripheral
iris hump in plateau iris syndrome. Lenses with large areas of
contact (such as the Goldmann lens) are not ideal for this.
Grading Systems
The first system to grade the angle was that of Gradle and
Sugar
26
in 1940. They used an Ulbrich drum mounted on the
slitlamp to measure the chamber depth in millimetersnot some-
thing that could be practically used in the clinic. Scheie
27
devel-
oped a grading system based on the visible structures. The Scheie
system was opposite of our current systems. In the Scheie system,
there was a category called Wide followed by grade I, which was
FIGURE 11.
An illustration by Emil Bethke from Troncosos textbook. Reproduced with permission from Gonioscopy: Philadelphia, FA Davis, 1947.
32
TABLE 1.
Important textbooks and atlases of gonioscopy
Year Authors Title Publisher
1947 Troncoso Gonioscopy FA Davis
1955 Van Beuningen Atlas der Spaltlampengonioskopie Thieme
1957 Gorin and Posner Slit Lamp Gonioscopy Williams & Wilkins
1962 Shaffer Stereoscopic Manual of Gonioscopy CV Mosby
1973 Kimura Color Atlas of Gonioscopy Igaku Shoin
1994 Alward Color Atlas of Gonioscopy CV Mosby
2008 Alward and Longmuir Color Atlas of Gonioscopy, 2nd ed. American Academy of Ophthalmology
A History of GonioscopyAlward 33
Optometry and Vision Science, Vol. 88, No. 1, January 2011
slightly narrowed through grade IV, which was completely closed.
Today, some still use a system in which they describe the visible
structure such as open to the ciliary body face etc. Importantly,
Scheie introduced a scale of grading the pigmentation of the pos-
terior trabecular meshwork (from none to grade IV) that is used
today.
The most widely used systems nowadays are the Shaffer and
Spaeth systems. The Shaffer
28
grading technique was described in
his 1962 textbook. Shaffer determined an angle width in degrees
(e.g., grade 1 10 and grade 4 3545). It has the advantage of
being widely recognized and easy to understand. A disadvantage is
that it provides only angular width information and tells nothing
about the iris shape or the level at which the iris inserts.
Spaeth
29
modified the Shaffer system to provide information
regarding the level of iris insertion (on a scale of A to E, with A
being anterior to Schwalbes line and E being extremely deep into
the ciliary body), the angle of iris approach (in degrees), and the
configuration of the iris (b for bowed forward, f for flat, c for
concave, and p for plateau). To this, one adds the angle pigmen-
tation. For example, the Spaeth system would grade the angle in
the Lee Allen painting in Fig. 9 to be D45f, with 2pigmentation.
The Spaeth system also permits information on indentation go-
nioscopy findings. This system is somewhat harder to learn but
provides much more information than any other alphanumeric
grading system.
Textbooks of Gonioscopy
In 1947, Troncoso published a comprehensive 306-page text-
book entitled Gonioscopy. The text contains comparative anatomy
and gonioscopy as well as beautifully illustrated descriptions of the
angle in health and disease. Many of the illustrations were painted
by Emil G. Bethke (Fig. 11). Interestingly, Bethke had been a
medical illustrator at the University of Iowa where he roomed with
a fellow artist, E. Lee Allen. When Bethke left the University, Lee
Allen became the artist for the Department of Ophthalmology and
developed a life-long interest in gonioscopy (see Figs. 8 to 10).
Since Troncosos book, there have been a handful of gonioscopy
texts and atlases; the most important of which are included in
Table 1.
Shaffers Stereoscopic Manual of Gonioscopy is a wonderful re-
source, now out of print.
28
His book includes beautiful drawings
by Joan Esperson and three-dimensional photographs viewed
through a View-Master. Kimuras Color Atlas of Gonioscopy has
beautiful photographs of the angle.
30
Kimuras atlas was out of
print when my book of the same name was published in 1994.
23
Because gonioscopy is a dynamic examination, it may be best
taught with video, instead of still images. I created a webpage to
teach gonioscopy (www.gonioscopy.org). The site is free and is not
industry supported. It includes detailed descriptions of basic and
advanced examination techniques as well as hundreds of video
examples of pathology.
There are new ways to evaluate the iridocorneal angle, such as
ultrasound biomicroscopy and optical coherence tomography. These
techniques can describe the width of the angle and perhaps the risk
of developing angle closure. They are excellent tools, but they
cannot replace gonioscopy, which tells us so much more than
whether the angle is open or closed. We are fortunatethrough
the efforts of Trantas, Salzmann, Zeiss, Barkan, Goldmann, Allen,
and othersto be able to actually look at the dysfunctional mesh-
work rather than having to rely on imaging.
Received April 26, 2010; accepted August 11, 2010.
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34 A History of GonioscopyAlward
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Wallace L. M. Alward
Department of Ophthalmology
University of Iowa Carver College of Medicine
200 Hawkins Drive
Iowa City, Iowa 52242
e-mail: wallace-alward@uiowa.edu
A History of GonioscopyAlward 35
Optometry and Vision Science, Vol. 88, No. 1, January 2011