1.Review of Angle closure Glaucomas Fritz Allen MD Visionary Ophthalmology November 10th 2013

2. Angle-Closure GlaucomasAcute Primary Angle-Closure GlaucomasNeovascular Glaucoma2 3. DetectionGonioscopy Pentacam/ Anterior segment OCT 4. Gonioscopy Indications Overcomes problem of total internal reflectivity to see angle structuresIndirect gonioscopy (e.g., Goldmann or four mirror lens) Essential diagnostic tool in glaucoma (viewing the iridocorneal angle) Most common cause of incorrect diagnosis is omission of gonioscopy Omission causes overlooking secondary glaucomas and other glaucomas Periodically performed can detect secondary emergence of mixed mechanism 4 5. GonioscopyIdentification of angle recession, foreign bodies, abnormal pigmentation, tumors, angle neovascularization, angle synechiaeGlaucoma treatment in the angle Laser trabeculoplasty Goniosynechialysis Treatment and evaluation of internal ostium of trabeculectomy site Gonioplasty/iridoplasty 5 6. Gonioscopy Contraindications Inability of patient to cooperateCorneal abrasion or disease precluding application of corneal lensPre-procedure evaluationIndirect gonioscopy View angle with slit-lamp using a gonioscopic lensTechnique 6Indirect gonioscopy Produces inverted image 180 away from originationTwo types of lenses are in common use 7. GonioscopyGoldmann type Goldmann lens requires clear fluid to fill space between cornea and goniolensLens is brought toward patients eye and tipped forward quickly enough to trap the clear fluid4 mirror type Requires only drop of anestheticIndentation gonioscopy can be performed7Rests solely on cornea / tear filmTechnique to differentiateappositional and synechial angle-closure 8. GonioscopyComplicationsCorneal abrasion Considerations in interpretationNormal angle landmarks (best viewed with parallelepiped method) 8Prevention: moist cornea, topical anesthesia, minimize movement of lens on corneaAnterior to posterior: cornea, Schwalbes line, non-pigmented trabecular meshwork, pigmented trabecular meshwork, scleral spur, ciliary band, iris root 9. Gonioscopy9 10. Gonioscopy10 Direct 11. Gonioscopy Indirect11 12. Gonioscopy12 13. Gonioscopy13 14. GonioscopyDrawing showing gonioscopic view in combination with microscopic cross-section. Corneal wedge (arrow)Drawing by Lee Allen 14 15. Gonioscopy15 Drawing by Lee Allen 16. Gonioscopy16 17. Gonioscopy17 18. Gonioscopy18 19. Gonioscopy19 20. Pentacam 21. Pentacam 22. Pentacam 23. Pentacam: open angle 24. Pentacam: narrow angle 25. Pentacam The Anterior Chamber Volume (ACV) has been fond to good screening tool for the diagnosis of narrow angles. With ACV of 110 mm3 as cut off : sensitivity of 88.32%, specificity of 90.62%, positive predictive value 92.7 Any patient with an ACV of