Gonioscopy and 3-Mirror Retinal Evaluation Workshop Edeline Lu, O.D., FAAO Benedicte Gonzalez, O.D., MPH, FAAO Tina Zheng, O.D.

Transcription

1 Gonioscopy and 3-Mirror Retinal Evaluation Workshop Edeline Lu, O.D., FAAO Benedicte Gonzalez, O.D., MPH, FAAO Tina Zheng, O.D., FAAO Please silence all mobile devices and remove items from chairs so others can sit. Unauthorized recording of this session is prohibited.

2 Disclosure Statement: Nothing to disclose

3 Indications o Narrow angles Grade 2 or less Positive shadow test o History of closed angle attack o Elevated IOP o IOP asymmetry o Rubeosis irides Secondary to diabetes, vein occlusions, Sturge Webber Syndrome, etc.) o Previous ocular trauma Suspected angle recession o Intraocular foreign body o Iris cysts or tumors o Pigmentary dispersion syndrome o Exfoliation of the lens capsule o Pseudoexfoliation syndrome o Differentiating open vs. closed angle glaucoma

4 Anterior Chamber Angle Anatomy Anterior 0. Iris Posterior Allingham RR. Shields textbook of glaucoma. 6 th ed. Dam KF, Freedman SF, Moroi SE, Rhee DJ. Philadelphia, PA: Lippincott Williams & Wilkins; p.

5 I Can t See This Stuff o Iris o Ciliary body band (CBB) o Scleral spur (SS) o Trabecular meshwork (TM) Posterior TM (PTM) Anterior TM (ATM) o Schwalbe s Line (SL)

6 Alward, WLM. Color Atlas of Gonioscopy. Wolfe; p. CBB

7 Alward, WLM. Color Atlas of Gonioscopy. Wolfe; p. SS

8 Alward, WLM. Color Atlas of Gonioscopy. Wolfe; p. PTM

9 Alward, WLM. Color Atlas of Gonioscopy. Wolfe; p. ATM

10 Alward, WLM. Color Atlas of Gonioscopy. Wolfe; p. SL

11 CBB SS PTM ATM SL Alward, WLM. Color Atlas of Gonioscopy. Wolfe; p.

12 Normal/Open angle

13 Safe to Dilate? o Occludable if at least 180 of the PTM is not visible In primary position of gaze On non-indentation gonioscopy o Need at least 2 quadrants of PTM visible o Convex iris approach increases risk for angle closure Foster PF. The epidemiology of primary angle closure and associated glaucomatous optic neuropathy. Semin Ophthalmol. 2002;17(2):50-8.

14 Set Up

15 Preparing The Lens o Cleaning Enzymatic cleaner or mild ph neutral detergent o Disinfection Soak in 1:10 dilution of household bleach (5.25% NaClO) for minutes Other options: Cidex OPA, Glutaraldehyde, Revital-Ox Resert XL HLD o Sterilization Sterilization Tray with Amsco V-Pro systems o Rinse thoroughly with saline o Follow manufacturer s instructions Abbey AM, Gregori NZ, Surapaneni K, et al. Efficacy of Detergent and Water Versus Bleach for Disinfection of Direct Contact Ophthalmic Lenses. Cornea. 2014;33:

16 Preparing The Lens o Select cushioning solution (if needed) Celluvisc Systane Gel Goniosol o Fill lens about 2/3 full

17 Slit Lamp Set Up o Align outer canthus o Magnification: start at 10x (low) o Beam height: variable o Beam width: diffuse o Beam illumination: moderate o Light house: 0 (straight on)

18 Documentation

19 Gonioscopy Documentation 1. Which eye 2. Dilated or undilated 3. Most posterior structure visible 4. Amount of pigment in the trabecular meshwork (0-4+ scale) 5. Approach of the iris into the angle (flat, moderate, bowed) 6. Angle anomalies ** Orientation: Examiner s perspective

20 Gonioscopy Documentation OD: Undilated Temporal ATM 1+ TM pig Flat Superior PTM 1+ TM pig Flat CBB 2+ TM pig Flat Iris processes PTM 1+ TM pig Flat Nasal Inferior

21 Document this angle: Examiner s view Patient s left eye Undilated Salmon, John F, Glaucoma, 15, Copyright , Elsevier Limited

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23 Document this angle: Examiner s view Patient s right eye Undilated

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25 Document this angle: Examiner s view Patient s right eye Dilated

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27 3-Mirror Retinal Eval Documentation 1. Which eye 2. Quadrant(s) of retina viewed 3. Zone(s) of retina viewed 4. Any normal / abnormal findings Example: No breaks or detachments in the superonasal peripheral and oral retina OS

28 Management of Acute Angle Closure

29 Acute Angle Closure Management Compression gonioscopy Topical ocular hypotensives Oral IOP lowering medication Recheck IOP in minutes. Repeat if IOP still high Rx IOP lowering drop/med & refer for LPI within hours

30 Topical Ocular Hypotensives o Beta blockers Timolol 0.5%, betaxolol 0.5% o Alpha-2 adrenergic agonists Apraclonidine 1%, Brimonidine % o Carbonic anhydrase inhibitors Brinzolamide 1%, Dorzolamide 2% o Pilocarpine 1-2% If phakic and IOP < 40mmHg

31 Oral IOP Lowering Medications o Acetazolamide mg P.O. up to QID o Methazolamide mg P.O. BID-TID o Glycerine 1-2g/kg/dose P.O. o Mannitol g/kg/dose IV over 30 min

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