Tanuj Dada
Associate Professor Clinical Ophthalmology Dr Rajendra Prasad Centre for Ophthalmic Sciences All India Institute of Medical Sciences
New Delhi
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
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Gonioscopy: A Text and Atlas
© 2006, Tanuj Dada
All rights reserved. No part of this publication and interactive DVD ROM should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher.
First Edition: 2006
9788180616464
Typeset at JPBMP typesetting unit
Printed at Replika
Dedicated to the Revered Sufi Saint Hazoor Maharaj Gurmeet Ram Rahim Singh Ji Dera Sacha Sauda Ashram Sirsa, Haryana, India
7Foreword
Gonioscopy is a much underused diagnostic technique. This is possibly due to the difficulty of the technique and the considerable experience that is required to come to a proper evaluation of the anterior chamber angle. Dr. Dada lists a large number of indications for gonioscopy in his first table. In terms of numbers, the diagnosis of angle closure is of great importance. Millions of people are at risk of glaucoma through angle closure. The discovery of this condition depends largely on gonioscopy. Newer techniques for anterior chamber angle evaluation like Ultrasound Bio-Microscopy, Optical Coherence Tomography and others hold great promise. They may even be able to perform quite well for narrow angle screening. They will, however, not provide the fine structured details that can be seen with the expert eye in gonioscopy. The potential problem of gonioscopy as of many other diagnostic techniques is the intra - and interexaminer variability. It is for that reason that a thorough training in gonioscopy is so important. This book by Dr. Dada will certainly help in acquiring a reliable technique of gonioscopy. It is written in a clear and concise style and well illustrated. The grading systems of Shaffer and Spaeth are explained, as are types of lenses, techniques and - of course - pathology. The reader will find this book instructive and practical. Dr. Dada is to be congratulated for the completion of this work which required initiative, knowledge, experience and energy.
Prof Dr Erik L Greve
Executive Vice President
Association of International Glaucoma Societies
Editor, International Glaucoma Review
9Foreword
It is with great pleasure that I am writing this foreword.
Glaucoma is a common disease in India, and a leading cause of irreversible blindness. There is no simple algorithm or equation by which this disease can be managed, e.g. reduce the intraocular pressure below 18 mmHg. There are many questions that are still unanswered. The causation of glaucomatous optic neuropathy is being unravelled in a small way and the pathogenesis of the rise of IOP is still not completely understood. Like all of medicine, a systematic approach requires the ophthalmologist to know the reason for a raised intraocular pressure, so that therapy can be individualized to each patient.
Gonioscopy is therefore a cornerstone to the scientific management of glaucoma, but was neglected because most textbooks were written in countries where glaucomatologists largely see and treat only primary open angle glaucoma. In India, a third of the glaucomas seen at hospitals are primary angle closure glaucomas and a third are secondary glaucomas, both open and closed angle types.
Proper gonioscopy is imperative for us to diagnose correctly and manage the glaucoma cases we see. I would like to commend Dr Tanuj Dada on this compendium of gonioscopy, presenting a complicated subject, simply and with a clinical emphasis.
Prof Ramanjit Sihota
Past President, Glaucoma Society of India
Head, Glaucoma Service
Dr Rajendra Prasad Centre for Ophthalmic sciences
11Preface
Gonioscopy is one of the basic examination techniques in ophthalmology. It provides an insight into the basic pathophysiology of various anterior segment disorders, that affect the anterior chamber angle. It is a vital tool in the assessment of glaucomatous disorders, as it establishes the cause for the obstruction to aqueous flow and gives an idea about the risk of developing glaucoma in the future. Gonioscopy is also used while performing glaucoma laser therapy and incisional treatment in congenital glaucoma.
However gonioscopy is not routinely performed by most ophthalmologists as a part of routine clinical practice. The main reason for this is a lack of training and expertise in this specialized procedure. Many of those who do perform gonioscopy, are often not conversant with the anatomical variations, method of reporting the gonioscopic findings and dynamic gonioscopic techniques. There are very few texts available on this topic which give information that is easy to assimilate for the uninitiated clinician.
This small book has been conceived to serve as an office companion for practicing ophthalmologists and residents to train them in the art and science of gonioscopy. It covers the basic principles of gonioscopy, indications for use, various types of gonioscopes, technique of gonioscopy, normal angle anatomy, special techniques for dynamic gonioscopy and includes various pathological conditions which can alter the anatomy of the anterior chamber angle.
In addition to a detailed text with schematic diagrams, colour photographs of the anterior chamber angle are given in the text, so that the reader can have an in depth understanding of normal and abnormal anterior chamber angle.
I hope that this book will provide a useful reference text and practical information for all those interested in mastering the art of gonioscopy and help in improving the standard of care for glaucoma patients.
13Acknowledgements
Words are not enough to thank my parents for their unconditional love and inspiration. This work was only possible with their blessings. I wish to thank my sweet soulmate Geeta and sister Rima for their understanding and help at all times.
I would like to thank my teacher and guide, Prof. Ramanjit Sihota who has taught me the art and science of glaucoma practice.
I would like to thank Prof. Supriyo Ghose, Chief Dr RP Centre for Ophthalmic Sciences and Prof. Anita Panda for their constant support and encouragement in the preparation of this manuscript.
I would like to acknowledge the sincere effort and time put in by Dr Rajamani Muralidhar, one of the best Senior Registrars of Dr RP Centre for Ophthalmic Sciences that I have had the privilege to work with. It was his dedicated effort that made this book possible. He has contributed to the text in Chapters 3-7 and helped in the selection and labelling of numerous photographs required for this book.
I would like to express my heartfelt gratitude towards the following junior residents who helped me at all times during the preparation of the manuscript:
Dr Anand Aggarwal, Dr Munish Dhawan, Dr Chandra Shekhar Kumar, Dr Sunil Choudhary, Dr Bhuwan and Dr Sujit Vengayil
The video recording was possible with the efforts of Dr Ankur Sinha and our photographers, Mr Harminder Singh and Mr Mohan.
I would also like to thank our expert artist, Mrs Shakti Mahajan for making all the schematic diagrams and Dr Viney Gupta and Mr Ajay Sharma for helping in taking the goniophotographs.