Presented by:-

Dr. Soumendra Datta 2nd yr PGT.

Angle of the Anterior Chamber

The Angle of Anterior Chamber bounded-

Anteriorly by back of cornea Posteriorly by the anterior surface of iris

The Angle width -

wide in myopic Narrow in hyper metropes

Structures Forming Anterior Chamber Angle

Clinically the angle structure can be visualized by gonioscopic examination. Starting from posterior to anterior, the angle recess is form by following structures:-

1.

Cilliary Body-

Formed by anterior most part of the Cilliary body between its attachment to the

scleral spur and insertion of iris. It is covered by the iris process in varying extent. It is wider in myopes. It appear as grey or dark brown band.

2.

Scleral spuron gonioscopy.

It is the posterior portion of the scleral sulcus and appear as prominent white line

3.

It is seen as band just anterior to the scleral spur. Its anterior non functional spur lies adjacent to the schwalbe line and has whitish color and posterior pigmented functional part lies adjacent to the scleral part and has greyish blue translucent appearance.

Trabecular meshwork-

4.

Schwalbe

line- It is the most anterior structure appearing as opaque line. It demarcatas the peripheral termination of descemet membrane and anterior limit of the trabeculum.

Gonioscopic Appearance of the Anterior Chamber Angle

SL Schwalbe Line TMTrabecular Meshwork SS Scleral Spur CBB Ciliary Body Band

NORMAL VARIABILITY OF THE CHAMBER ANGLE

Blood vessels may normally be visible in the angle. If angle vessel that bridges the scleral spur is seen, it is probably abnormal. Iris processes may be confused with peripheral anterior synechiae.

The canal is located directly anterior to the scleral spur and is normally not seen. However, during gonioscopy, blood may reflux in to the canal exposing its dimensions. Excessive Trabecular pigment at the 12 o'clock position occurs in only 2.5% of individuals and is usually pathologic. This goniophotograph shows excessive Trabecular pigment representing pigmentary dispersion syndrome.

Instruments Used for Anterior Chamber Angle Examination

Torch Light

Slit Lamp

Gonio Lenses

Ultrasound Biomicroscopy

Optical Coherence Tomograph

Pentacam

Torch light Examination

Eclipse sign, which indicates decreased axial anterior chamber depth

(seen in angle closure glaucoma) can be elicited by shining a pen

light across the anterior chamber from temporal side and noting a shadow on the nasal side.

van Herick Technique

Slit-lamp estimation of the limbal anterior chamber depth (LACD) by

the van Herick technique was developed as a non-contact approach

for estimating angle width. To perform this evaluation, the illumination column of the slit lamp is offset from the central axis of the microscope by 60 to the temporal side. A bright, narrow beam of light is directed perpendicular to the ocular surface at the limbus.

LACD measurement is performed by comparing the depth of the

peripheral anterior chamber depth to the thickness of the cornea.

Grading of Limbal Anterior chamber Depth by van Herick Technique

The original description outlined a four-point grading scheme of LACDwith LACD graded as < 25%, >25% to 50%, or >100% Curiously, this original scheme did not include a grade for the category 50--100%. However, gonioscopic angle closure is seen rarely in persons with van Herick >50% Foster proposed a modied scheme with increased precision of LACD measurement. The original grade 1 was sub-divided into 0%, 5%, and 15% corneal thickness, and a grade of 75% CT was added to compensate for the gap between the original grades 3 and 4. The grade < 15% CT gave sensitivity and specicity at 84% and 86% for detection of narrow angles Using a cutoff of < 25% specicity decreased to 65%, but sensitivity increased to 99%.

Limitations of van Herick Technique

1. Inter-observer reproducibility for the van Herick test may be high

2. It can only be performed if the limbus is clear, so eyes with pterygium or scarred temporal corneas cannot be graded.

Corneal Slit bean Anterior chamber Iris Slit bean Limbal anterior chamber depth Corneal thickness

Limbal anterior chamber depth of 15%

Gonioscopy
When peripheral anterior chamber depth is thought to be shallow (i.e. less than 1/4th of corneal thickness by van Herick technique) , careful gonioscopic examination of angle is required Gonioscopy is performed for several reasons: To determine the mechanism of glaucoma (i.e., open or closed angle, pigment dispersion, plateau iris, etc.); To identify persons at risk of developing angle closure glaucoma; and To monitor changes in the Anterior Chamber Angle over time as part of clinical care or research. Principle of Gonioscopy: The angle of the anterior chamber cannot be visualized directly through the intact cornea because light emitted from the angle undergoes total internal reflection at the anterior surface of the precorneal tear film.The critical angle for the cornea air interface is approximately 46 . In direct gonioscopy, the anterior curve of the contact lens- the goniolens-is such that the critical angle is not reached, and the light rays are reflected at the contact lens- air interface. In indirect gonioscopy, the light rays are reflected by a mirror in the contact lens- the gonioprism - and leave the lens at nearly a right angle to the contact lens-air interface

Principle of Gonioscopy

The Angle of Incidence of Light rays originating from angle structures is greater than the critical angle of the cornea-air interface (46 ) resulting in total internal reflection

Direct Gonioscope

Indirect Gonioscope

Types of Gonio Lenses

Koeppe Direct Gonio lenses (Gonio Prism)

Goldmann Single Mirror

Zeiss Four Mirror

Indirect Gonio Lenses (Gonio Mirrors)- used in conjunction with slit lamp

Advantages and Disadvantages of Direct and Indirect Gonioscopy

Direct Gonioscopy Advantages Patient comfort Disadvantages Second microscope and illumination Space needed Nose can block temporal angle Astigmatic distortion

Indirect Gonioscopy Advantages Uses the slit lamp Disadvantages Bubbles can block the view Plastic can scratch

Possibly better view

Variable magnication No astigmatic aberrations

Need rotating head on slit lamp to get slit view nasally and temporally

Scheies Grading of Anterior Chamber Angle

System
Scheie 1957

System Basis
Extent of angle structures visualized

Angle Structures
All structures seen

Classification
Wide open open

Iris root not seen Cilliary body band not seen

Grade I Grade II

posterior trabeculum obscured only Schwalbe's line visible

Grade III Grade IV closed

Shaffers Grading of Anterior Chamber Angle

System
Shaffer 1960

System Basis
Angular width of the recess

Angle Structures
Wide open (30 degrees to 45 degrees) Moderately narrow (20 degrees) Extremely narrow (10 degrees)

Classification
Grade 34, closure improbable Grade 2 closure possible Grade 1 closure probable open

Partly or totally closed

Grade 0 closure present

closed

Spaeths Grading of Anterior Chamber Angle

System
Spaeth 1971

System Basis
1. Insertion of iris root

Classification

2. Angular width of the recess

This system requires a combination of all three descriptors before deciding on classification.

3. Configuration of peripheral iris

High-Resolution Ultrasound Biomicroscopy

1. In the management of patients with glaucoma, high resolution ultrasound Biomicroscopy is helpful to define the anterior chamber angle anatomy, when it cannot be seen

gonioscopically, as well as structure and relationships among the iris, ciliary body, crystalline lens, intraocular lens and anterior vitreous.

2. Frequencies of 20 to 50 MHz, which are used to image the

anterior segment, are referred to as high resolution ultrasound

Biomicroscopy

Optical Coherence Tomography of Anterior Segment

1.Anterior-segment optical coherence topography, or AS- OCT,

provides a noncontact, noninvasive means to image the anterior chamber angle anatomy. The AS-OCT uses a 1310nm wavelength, compared with the 820-nm wavelength for posterior-segment imaging.

2. The AS-OCT has higher resolution, compared with high

resolution ultrasound Biomicroscopy, for imaging structures

in the iris and the angle anatomy.

Optical Coherence Tomography Image VS Ultrasound Biomicroscopy Image

Side-by-side comparison of optical coherence tomography image of the angle (left) and ultrasound Biomicroscopy image (right)

Pentacam
Basically it is 3-D rotating Scheimpflug camera. Pentacam is a diagnostic unit able to perform following five functions in 2 seconds: Scheimpflug Image of Anterior Segment Three-dimensional anterior chamber analyzer Pachymetry Corneal topography Cataract analyzer

Principle of measurement
The Scheimpflug law says: To get a higher depth of focus, move the three planes, provided that the picture plane, the objective plane and the film plane has to cut each other in on line or one point of intersection. The Pentacam captures Scheimpflug images of the anterior segment through a rotating measurement

Responses of the ACA to External Stimuli (Light-Dark Changes, Corneal Indentation, and Pilocarpine)
LIGHT--DARK CHANGES

Angle appearance can change dramatically depending on the amount of illumination that strikes the eye. When light shines on the eye the iris sphincter contracts and the peripheral iris moves centrally away from the angle. The result is in many cases a more open angle appearance. Friedman reported that the fellow eyes of persons with unilateral acute attacks have more substantial angle narrowing in the dark than normal controls indicating that the dynamic response to external stimuli may play a role in the pathologic process.

UBM images of the same patient with the lights on (left) and the lights off (right image) showing marked angle narrowing in the dark.

Responses of the ACA to External Stimuli (Light-Dark Changes, Corneal Indentation, and Pilocarpine)

CHANGES WITH CORNEAL INDENTATION There is widening of the Anterior Chamber Angle with indentation according to the report publish by Matsunaga and colleagues

PILOCARPINE EFFECTS CONFIGURATION

ON

Anterior

Chamber

Angle

The effect of pilocarpine on ACA conguration remains unclear, with some persons appearing to have shallower ACA after pilocarpine and others having greater angle opening. Hitchings demonstrated that when persons had a shallowing of the central anterior chamber depth in response to 4% Pilocarpine, the peripheral anterior chamber also shallowed, whereas if the central ACD did not shallow, the peripheral ACD widened.

Measurement of IOP (Tonometry)

Goldmann Applanation Tonometry
Tonometry is the objective measurement of IOP based on the force required to flattened the cornea or the degree of corneal indentation produce by a fixed force. Goldmann Applanation Tonometry is based on the Imbert-Fick principle which states that pressure inside in ideal sphere is equal to the force necessary to flattened its surface divided by area of flattening. The capillary attraction of tear meniscus and corneal rigidity cancel each other when the flattened area has a diameter of 3.06mm, as in Goldmann Applanation Tonometry.

Imbert-Ficks principle

Fluorescein-stained semicircles during Applanation

Contact Tonometers
1. Goldmann Tonometer

4. Tono-pen

2. Perkins Tonometer 5. Schiotz Indentation Tonometer

3. Pascal Dynamic Contour Tonometer

6. Rebound Tonometer

Non-Contact Tonometers
These are based on the principle of Applanation but, instead of using a prism, the central part of the cornea is flattened by a jet of air.

1. Portable Air puff tonometer

3. Keelers hand-held Pulsair intelliPuff Tonometer 2. Auto Non-Contact Tonometer

4. Portable Cordless Non-Contact Tonometer

Comparison of Tonometers

Clinical Condition
Regular Cornea

Tonometer Preferred
Goldmann Tonometer

Irregular Cornea
Eyes with Bandage contact lens

Non-contact Air Puff Tonometer, Tonopen

Non-contact Air Puff Tonometer

Gas Filled eyes

Children under Anaesthesia

Tono-pen
Perkins, Tono-pen, Rebound Tonometer

Measurement of Intra Ocular Pressure

Normal value 11- 21mmHg
Relationship between prevalence of POAG and IOP IOP (mmHg) 16-21 22-29 30 or more

POAG (%) 1.5 8.0 25.0

Diurnal Fluctuation in IOP 24 hrs measurement of IOP at 3 to 4 hrs apart is more significant than single reading. Asymmetry in the IOP measurement between the two eyes of 5mmHg or more should arouse suspicion of glaucoma irrespective of single IOP reading and above 8mmHg is diagnostic of glaucoma. According to the Chennai glaucoma study an 100m increase in central corneal thickness is associated with 1.96mmHg increase in IOP in rural population and 2.45mmHg increase in IOP in urban population. Thus it is important to measure corneal thickness before instituting therapy in a patient with ocular hypertension. Target pressure of 12mmHg is to be achieved after treatment in patients with glaucoma (According to advanced glaucoma intervention trial)