Literature Review

August, 15th 2019

Van Herick and Gonioscopy

Examinations in Ocular Patients
Fajar Ahmad Prasetya*

Consultant:
dr. Prima Maya Sari, Sp.M

Ophthalmology Department
Medical Faculty Of Sriwijaya University
Dr. Moh. Hoesin Hospital Palembang
2019
BACKGROUND
01 Anterior Chamber Angle
Important structure  Aqueous humor outflow,
diseases, diagnose, and management
It can be examined using van Herick and
gonioscopy

02 Van Herick
Measurement technique to
estimate anterior chamber angle
using slit lamp

03 Gonioscopy
Gold standard for examining the
anterior chamber angle
objective
Van Herick
examination

Objective

Gonioscopy Structures
examination involved
Anatomy and Structures
Anterior Chamber Angle

• Schwalbe’s line
• Trabecular meshwork
• Schlemm’s canal
• Collectors channel
• Scleral spur
Anatomy and Structures
Anterior Chamber Angle

• Schwalbe’s line
• Trabecular meshwork
• Schlemm’s canal
• Collectors channel
• Scleral spur
Schwalbe’s line Scleral spur

Trabecular meshwork
Iris Processes
 •Principle
Van Herick •Technique
Examination •Results
 Principle

to estimate the depth of anterior chamber angle

Comparing the thickness of slit ray when it hits the cornea and the
chamber between cornea and iris, at the periphery
 Technique

1. Informed consent
2. Patient and examiner sit on slitlamp setting
3. His/her chin and head stay comfortably on chinrest and headrest
4. Slit rays from illumination system make 600 angle to observation system
5. Slit rays hit temporal side of limbus, perpendicular to the cornea
6. Look at corneal thickness
7. Look at blank chamber between the rays on cornea and rays o the iris, it is
the peripheral anterior chamber
8. Compare anterior chamber thickness to corneal thickness.
9. Move to the other eye
10. Record the findings
 RESULTS

Grade 4 : AC/CT =
1
Grade 3 : AC/CT =
½-¼
Grade 2 : AC/CT =
¼
Grade 1 : AC/CT =
<¼
Shaffer Principle

Scheie Results

Spaeth

Gonioscopy Types
Examination

Lenses
Technique
 Principle

Since total internal reflection phenomenon, we are unable see the

structure directly

To overcome this limitations gonioscopy instrument is required

 • Risk of angle closure as indicated by V.H.
When to do • To classify glaucoma cases
Gonioscopy?
• To asses the risk of angle closure in
mydriatics admission
• To identify post trauma angle closure
• To find abnormalities in the anterior
chamber angle; tumors; I.O.L. haptics

• active infections; keratitis,

When not to? conjunctivitis
• Hyphema
• perforation of the globe
• corneal defect
• any recent intraocular surgeries
 TYPES of gonioscopy

Direct Indirect
Gonioscopy Gonioscopy
• Koeppe lens • Goldmann-single mirror

• Swan-Jacob lens • Zeiss

• Posner
 Technique

1. Informed consent
2. Topical anaesthesia
3. Patient and examiner sit on slitlamp setting
4. His/her chin and head stay comfortably on chinrest and headrest
5. Prepare goniolens, use viscous material as needed, avoid air bubbles
6. Pull lower eyelid with left thumb
7. Ask him/her to look up and put goniolens to lower eyelid
8. Put the rest of goniolens contacting cornea, ask patient to look forward
9. Look using observation system of slitlamp, use 10x magnification
10. Learn at upper goniolens (inferior), note the findings
11. Rotate the lens clockwise to learn the other quadrants
12. Note the findings
 Technique

14. When finished, ask patient to squeeze his her

eyes
15. Gently pull lower eyelid to let air in
16. Then the lens become easier to be pulled off
17. Clean the lens, and topical antibiotic as
prevention of infection
18. Study the other eye with the same steps
19. Always do first gonioscopy with supervision of
the experienced
Results
 Shaffer System Results

Grade Angle Risk of

Angle
Closure
Grade IV 35-45o Closure
impossible
Grade III 20-350 Closure
impossible
Grade II 200 Narrow-
closure
probable Shaffer : comparing the angle
formed by peripheral iris insertion
Grade I 100 Extremely
narrow- at the trabecular meshwork.
closure
probable.
Grade 0 00 Angle closed
 Scheie System
Results
Grade Structure Risk of
Visible Angle
Closure
WIDE All structure, Closure
including Ciliary impossible
body
Grade I Ciliary body- Closure
narrow impossible
Grade II Scleral Spur Closure
seen, unlikely
Ciliary body not
seen.
Grade III Posterior Closure likely Scheie : based on most posterior
trabecular
anatomical structure seen.
meshwork not
seen.
Grade IV No structure Angle closed
visible
 Spaeth Results
System
Spaeth : based on iris
insertion, angular
approach, peripheral
iris, and pigmentation
of T.M.
 Iris Angular Peripheral Iris Pigmentation of
Insertion Approac Trabecular
h Meshwork

Spaeth System A Anterior

to
r regular f flat O no pigment

Schwalbe’s
Spaeth : based on iris
line
insertion, angular
approach, peripheral B Between b bowed 1+ minimal
iris, and pigmentation Schwalbe’s anteriorl
line and y
of T.M.
scleral spur
s steep
C Scleral 00 p 2+ mild
spur visible to plateau
500 iris
Example :
D Deep with q queer c 3+ moderate
D40f 1ptm, A40f 1ptm,
ciliary body concave
(B)D30p 0ptm visible
E Extremely 4+ intense
deep with >
1 mm of
ciliary body
visible
 Van Herick and Gonioscopy Relations

Gonioscopy
Van Herick
• Easier to do • More accurate
• Fast • All quadrants can be
visualized directly
• Non invasive • Harder to master

Sometimes, both examination results can correspond to each other, but its
not always the case.
 Conclusion

1. Van Herick examination emphasize slit lamp to estimate and

predict the depth of anterior chamber angle.

2. Gonioscopy is the gold standard to measure and visualize the

structures of anterior chamber angle, using goniolens, directly
and indirectly, with various grading system established.

3. The fast, ease and non invasive examination of Van Herick can
be used as adjuvant before Gonioscopy is undertaken by the
physician.
Thank You
Thank You
Total internal reflection

• Occurs when light strikes a medium boundary at an angle larger than the
critical angle
• If light strikes at angle lower then critical angle, partial light will be refracted
and part will be refrelcted
• Can only occur when light travels from higher refractive index medium to
lower one
Peripheral Anterior Chamber

• Van herick test.

• The slitbeam is placed almost perpendicular to the peripheral corneal
surface and the angle opening is viewed at a 60- degree angle from the
light beam

• The slitlamp beam must be as narrow as possible in slitlamp

examination.
• The area of measurement is located just before the point of
disappearance of the corneal-iris space at the periphery.
 Direct Goniolens

• Direct visualization
• Using domed gonioscope
• Using Handheld biomicroscope
• Patient in supine position, mostly
pediatric setting
• Most popular : Koeppe lens
• Koeppe lens : 50+D, inner radius 7.5mm,
outer radius 12.5mm
• Other lens : Swan-Jacob
Indirect goniolens

• 2 types of indirect gonioscopes

• the scleral type (Goldmann) lenses
• the corneal type (Zeiss, Posner,
Sussman) lenses
Methylcellulose is used for indirect gonioscopy, in such as Goldman
lenses.
Visual acuity and posterior examination must be done before this
examination done.
Indentation Gonioscopy
Plateau iris