RAISSA VANIANA

 Gonioscopy is an essential diagnostic tool and examination

technique used to visualize the structures of the anterior chamber
angle (sudut iridokornealis)
 Depending on the type of lens employed, the angle can be examined
with :
1. Direct Gonioscopy (eg, Koeppe)
2. Indirect Gonioscopy
(eg, Goldmann or Zeiss)
GONIOSCOPY
 Light from the angle is reflected back into the eye because the critical angle of the cornea–
air interface is exceeded (prevents direct visualization of the angle structures)  Applying a
gonioscopy lenses to the eye can overcome this problem by removing the cornea–air
interface : enable the observer to view the angle)
 Direct gonioscopy  the lens is very convex the critical angle is not reached & light
reflected from the iridocorneal angle passes to the observer’s eye.
 Indirect gonioscopy  a mirror reflects the light through a plano anterior contact lens
surface ensuring that the critical angle is not reached.
 INDICATION FOR GONIOSCOPY CONTRAINDICATION
DIAGNOSTIC THERAPEUTIC
All cases of suspected angle closure Laser trabeculoplasty Dense limbus to limbus corneal
either on the shadow test or Van scars
Herrick test

To study topography of the anterior Excrimer laser trabeculotomy Hyphema

chamber angle

To assess degree of opening of Goniotomy/gonioplasty Collagen vascular disorders with

anterior chamber angle recess corneal melts or peripheral ectasias

To assess risk of closure on Reopening of a blocked Corneal epithelial defects

dilatation of pupil trabeculectomy opening

Classification of glaucoma (primary Laser of suture tied around tube of a Immediate postoperative period
/secondary) glaucoma drainage

To view a peripheral laser iridotomy Indentation gonioscopy to break an Globe perforation

acute attack of PACG

To study patency of trabeculectomy Acute keratitis or conjunctivitis

fistula
DIRECT GONIOSCOPY
 performed with : a binocular microscope, a fiber-optic
illuminator or slit-pen light, a direct goniolens, such as
the Koeppe, Barkan, Wurst, Swan-Jacob, or Richardson
lens.
 The patient must be in supine position (this in itself may
cause the angle to appear more open than it really is).
 The lens is placed on the anaesthetised eye, saline solution
is used to fill the space between the cornea and the lens
(optical coupler)  The lens provides direct visualization of
the anterior chamber angle  A hand-held biomicroscope
is used to view the angle directly through the lens.
 Allows the viewing angle to be varied so that structures that the light ray reflected from the anterior
may otherwise be hidden by a convex iris can be viewed chamber angle is observed directly
INDIRECT GONIOSCOPY
 Light reflected from the angle passes into the indirect gonioscopy
lens  is reflected by a mirror within the lens.
 Indirect gonioscopy may be used with the patient in an upright
position, with illumination and magnification provided by a slit
lamp.
 A goniolens, which contains 1 or more mirrors, yields an inverted
and slightly foreshortened image of the opposite angle. Although
the image is inverted with an indirect goniolens, the right–left
orientation of a horizontal mirror and the up–down orientation of a
vertical mirror remain unchanged.
 The foreshortening, combined with the upright position of the
patient, makes the angle appear a little shallower than it does the light ray is reflected by a
with direct gonioscopy systems. mirror within the lens.
 The Goldmann-type goniolens requires a viscous fluid such as
methylcellulose for optical coupling with the cornea.

 When the goniolens has only 1 mirror, the lens must be rotated to
view the entire angle.

 The Posner, Sussman, and Zeiss 4-mirror goniolenses allow all 4

quadrants of the anterior chamber angle to be visualized without
rotation of the lens during examination.
 The cornea is anaesthetised (with proxymetacaine 0.5% / tetracaine)
 The lens is cleaned (70% isopropyl alcohol /3% hydrogen peroxide solutions). it is also vital to ensure
that there is no organic matter on the surface of the lens and that any disinfectant is removed prior to
placement.
 A coupling agent, saline or a more viscous artificial tear preparation (carbomer 90/
hydroxypropylmethylcellulose (HPMC) 0.5%) is placed in the central well of the lens that will contact
the eye.
 Gently holding the lids apart and asking the patient to look upwards, the lens is carefully and gently
placed on the eye. The patient is asked to try and avoid squeezing the lids on the lens.
 The angle is viewed through 360º by rotating the lens
 when the mirror is at the top of the eye, the inferior angle is being viewed. If the angle is narrow it
may be necessary to ask the patient to move the eye in the direction of the mirror, but beware: this
may distort the appearance of the angle.
GONIOSCOPIC ASSESSMENT & DOCUMENTATION
 with dim room light and a thin, short light beam in order to minimize the amount of light
entering the pupil.
 must recognize the landmarks of the anterior chamber angle  scleral spur and the
Schwalbe line
 Parallelepiped technique / corneal light wedge  A convenient gonioscopic
technique to determine the exact position of the Schwalbe line
 Using a narrow slit beam and sharp focus, the examiner sees 2 linear reflections, one
from the external surface of the cornea and its junction with the sclera and the other
from the internal surface of the cornea. The 2 reflections meet at the Schwalbe line. The
scleral spur is a thin, pale stripe between the ciliary face and the pigmented zone of the
trabecular meshwork. The inferior portion of the angle is generally wider and is the
easiest place in which to locate the landmarks. After verifying the landmarks, the
clinician should examine the entire angle in an orderly manner
 The most commonly used gonioscopic grading systems are
:
1.The Shaffer system
 describes the angle between the trabecular meshwork
and the iris
2.The Spaeth system : include description of the peripheral
iris contour, the insertion of the iris root, and the effects of
dynamic gonioscopy on the angle configuration
 Shaffer System
 The Spaeth gonioscopic grading system expands this system to
include a description of the peripheral iris contour, the insertion of
the iris root, and the effects of dynamic gonioscopy on the angle
configuration
Spaeth classification
Goniolens
 direct gonisocopy :
Koeppe lens, Hoskins-Barkan, Swan -Jacobs
Indirect gonioscopy :
menggunakan cermin untuk melihat refleksi internal
misal : Goldmann goniolens, Zeiss goniolens, Posner goniolens

PETUNJUK UMUM

- Pemeriksaan slit lamp sebelum gonioscopy

- lakukan tonometri  penekanan berlebihan dpt menurunkan TIO
- anestesi topikal
- pasien / pemeriksa duduk dengan nyaman, gunakan penyangga lengan
- pembesaran slit lamp 10-25 x
- dianjurkan dg sinar pendek dan sempit , panjang sinar 2-3 mm cukup baik
- hindari sinar mengenai pupil krn menyebabkan miosis konstriksi pupil
 sudut lebih terbuka
Goldmann goniolens

- Melihat sudut melalui pantulan cermin

- Three-mirror, two-mirror, one mirror
- Central optic dpt digunakan utk memeriksa pole posterior
 evaluasi PN II dan fundus
- Menggunakan methylcellulosa utk melekatkan lensa ke mata
 hindari adanya gelembung udara :
- botol diletakkan terbalik  keluarkan di atas tissue
- lepas ujung botol
- Pasien melihat ke atas  insersikan tepi bawah goniolens ke
sklera bagian bawah
- Pasien melihat lurus  lensa dilekatkan ( tilting ) pd kornea
- pegang lensa dg 3 jari ( ibu jari, telunjuk, jari tengah ), 2 jari yang
lain bertumpu pada pipi pasien
- Pegang lensa dg lembut ( tanpa menekan) penekanan berlebihan
dpt menyebabkan reflux darah ke can. Schlemm
Suction akibat tarikan lensa dpt membuat sudut mjd tampak lebih dalam
- kadang-kadang lensa sulit dilepas tekan bolamata dg jari telunjuk
Gambaran yg terlihat pd gonioscopy

-Indirect gonioscopy/ slit lamp goniscopy sudut yg dilihat 180o dr cermin

-Illuminasi dapat bervariasi  mempengaruhi gambaran yg terlihat
Sempit, V-shaped corneal wedge

Bulat, corneal wedge memanjang

Permukaan anterior di blk TM

Hanya ujung corneal wedge

yg terlihat, tertutup arcus senilis
Corneal wedge menujukkan Schwalbe’s line
Pada sudut dg pigmentasi ringan

Corneal wedge menunjukkan dua garis pigmen

terletak di anterior SL
Sinekia dpt menyebabkan TM tertutup iris
Grs pigmen dpt disebabkan oleh kontak kronis
iris dg cornea atau inflamasi
- Corneal wedge lebih mudah dilihat dg posisi sinar vertikal
( pemeriksaan kwadran superior dan inferior )
- Mulai dg memeriksa kwadran inferior  searah jarum jam
- Pd pasien dg iris cembung disuruh melihat ke arah cermin
 dapat melihat melewati iris  ke sudut
- Gonioscopy  utk menilai sudut/ TM, sebaiknya jg memperhatikan
iris dan cornea
Indentation Gonioscopy

- Untnuk membedakan penutupan sudut karena aposisional atau sinekia

 berpengaruh pd diagnosis/ tindakan
- Paling baik dilakukan dg goniolens dg area kontak lebih kecil daripada
diameter kornea ( Zeiss, Posner, Sussman, Allen-Thorpe )
- Indentasi dg Goldmann atau Koeppe goniolens ( area kontak lebih lebar
dari diameter cornea ) dpt membuat sudut menjadi tampak lebih dangkal
- Pada indentasi
- penutupan aposisional akan terbuka
- penutupan krn sinekia tidak dpt terbuka/ terbuka sebagian
- dpt melihat : angle recess pd iridodialisis, benda asing, celah
cyclodialisis

Indentasi dg Zeiss goniolens menyebabkan

Sudut lebih dalam
Gonioscopy pd pasien dg iris bombe’  indentasi
 TM dapat terlihat

Mata dg penutupan aposisional  indentasi tdp PAS,

Sebagian TM terlihat
Gonioskopi sudut tertutup
Peripheral Anterior Synechia ( PAS )
Iris

2 zona utama : - central pupillary zone

- peripheral ciliary zone
keduanya dipisahkan oleh zona yg bergelombang ( kripte )

Tempat insersi bervariasi, pd permukaan corpus ciliaris

Ciliary body face

Di belakang iris

 fungsi : - membentuk humor aquos
- akomodasi
- regulasi outflow HA
- sekresi hialuronat ke dalam vitreus
- mempertahankan blood-aqueous barrier

 m. ciliaris :
- sirkular  akomodasi
- longitudinal  kontrol outflow HA dg menarik/membuka
TM dan can. Schlemm
 -Ciliary body face : bagian corpus ciliaris yg berbatasan dengan COA.
Pd gonioskopi dpt terlihat/ tidak, tgt level dan sudut insersi iris
- 10% outflow HA melalui ciliary body face  suprachoroidal face
Pilocarpine  uveoscleral outflow↓ ( corpus ciliaris memadat )
Atropin  uveoscleral outflow ↑ mll ciliary body face

Scleral spur

-Serabut-serabut kolagen yang berjalan sejajar

dg limbus, terlihat sbg garis putih kekuningan
- menandai batas posterior TM
- tempat melekat m. longitudinal
 membuka TM dg menarik spur
Trabecular Meshwork

• terletak diantara scleral spur dan garis Schwalbe

• mengalirkan 90% HA ( pressure dependent )
• Tdr 3 lapisan :
- uveal meshwork :
dr corpus siliaris  grs Schwalbe
colorless, kadang-kadang padat dan berpigmen shg
TM tampak kasar, dpt menutupi scleral spur
tidak terdapat hambatan aliran HA
- Corneoscleral meshwork :
meluas dr scleral spur  dinding depan sulcus sclera
tdr 5-9 lapis kolagen yang ditutupi endotel
tidak terdapat hambatan aliran HA yg bermakna
- jar. Juxtacanalicular
 hambatan aliran HA terbesar
bagian posterior meshwork seringkali banyak tdp pigmen
sedang bagian anterior relativ tidak berpigmen
 Canalis Schlemm

 tdr tubulus-tubulus, di dasar sulcus sclera

 mengumpulkan HA  sistem vena
 dipermukaan yg berhubungan dg TM tdp vacuole-vacuole
yg memindahkan HA ke endotel canalis Schlemm
 Obat-obat kolinergik ( pilocarpin )  menarik scleral spur 
membuka canalis Schlemm  tahanan ↓  outflow ↑

Schwalbe’s line

- daerah transisi antara TM dengan endotel kornea.

- merupakan batas anterior TM dan batas posterior membran Descemet
- transisi scleral curvature dg corneal curvature bisa tdpt pigmen