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Editors Selection IGR 9-4

Angle assessment: Gonioscopy and illumination

Comment by Wallace Alward on:

19897 Agreement between gonioscopy and ultrasound biomicroscopy in detecting iridotrabecular apposition, Barkana Y; Dorairaj SK; Gerber Y et al., Archives of Ophthalmology, 2007; 125: 1331-1335

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Sadly, ophthalmologists perform gonioscopy less frequently than they should. Moreover, when gonioscopy is performed the technique might not be ideal. Too often, gonioscopy is performed in a brightly lit room employing a diffuse bright beam of light. It has long been felt that excessive illumination could artifactually open the iridocorneal angle, making the examiner miss people at risk for pupillary block angle closure glaucoma. A paper by Barkana et al. (1357) and colleagues addresses this issue. One of the authors performed gonioscopy in a dark room with a short beam of light (1 mm) that did not enter the pupil, and identified 18 eyes with at least one quadrant of appositional angle closure. When these same eyes were studied with dark-room ultrasound biomicroscopy (UBM), 17 (94%) were found to have apposition by this technique as well. However, when UBM was performed in a brightly lit room, only ten (56%) eyes were found to have appositional angle closure. Therefore, an examiner employing excessive illumination could have missed 44% of dangerously narrow iridocorneal angles. This paper nicely provides scientific evidence for the need to avoid excessive illumination during gonioscopy. Ophthalmologists who perform gonioscopy in a bright room or with a slit lamp beam entering the pupil risk failing to identify occludable iridocorneal angles.

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