Eyeworld

74 | EYEWORLD | WINTER 2024 G UCOMA References 1. Lee JH, et al. Patterns and dis- parities in recorded gonioscopy during initial glaucoma evalua- tions in the United States. Am J Ophthalmol. 2024:264;90–98. 2. Xu BY, et al. Ocular biometric risk factors for progression of primary angle closure disease: the Zhongshan Angle Closure Prevention Trial. Ophthalmology. 2022;129:267–275. Dr. Shareef listed the different purposes gonioscopy still provides. It 1) differentiates whether the angle is anatomically open or closed; 2) assesses for neovascularization of the angle in patients with diabetic retinopathy; 3) aids in surgical planning of angle-based surger- ies; 4) assesses for angle recession in those who have sustained ocular trauma clinically observed as a widening of the ciliary body band; 5) mon- itors glaucoma suspects and glaucoma patients; 6) evaluates the outflow pathway in high hyper- opes who are at risk for acute angle closure; and 7) facilitates laser trabeculoplasty for the oph- thalmologist to aim the laser beam and deliver targeted energy to help lower the eye pressure in patients with open angle glaucoma. Limitations of office-based gonioscopy Dr. Xu said the most inconvenient aspect of go- nioscopy is it requires putting a contact lens on the patient's eye typically prior to dilation. "This can be uncomfortable for the patient. It can be time consuming. It can be disruptive to clinical workflows," he said. "As a clinical assessment, it is not very convenient to perform gonioscopy." Another limitation is that there is a high de- gree of variability between clinicians. "It's qual- itative and not terribly reproducible, so there is also that inherent limitation of the technique," Dr. Xu said. Regarding the Lee et al. study, of which Dr. Xu was the corresponding author, he said he and the co-authors were surprised at how few gonioscopies were performed. "Perhaps it speaks to the need for new technology, some- thing that's more convenient," he said. Modern angle imaging In lieu of or in conjunction with manual go- nioscopy, Dr. Shareef said imaging technologies like anterior segment OCT (AS-OCT) and/or ultrasound biomicroscopy (UBM) can play an important role. He offered this example: "If an asymptom- atic patient has anatomically narrow or closed angles determined during an eye exam, the imaging obtained would enable the physician to educate and counsel the patient of their condition, including intervention, as it would be difficult to explain to the patient otherwise. The image demonstrating angle closure would enable a provider to offer the patient options in- cluding 1) observation if asymptomatic; 2) laser iridotomy to open the drain as a preventative measure or if symptoms warrant the drain to be opened; 3) if appropriate, the need to perform cataract surgery to anatomically open the drain. This could also be a discussion in the setting of a patent iridotomy, yet the drain remains closed, and the patient is symptomatic with elevated eye pressure that needs to be lowered." From a diagnostic standpoint, Dr. Shareef said imaging technologies can be helpful for pa- tients who cannot have office-based gonioscopy, such as those who have a shallow or hypotonus eye. Imaging can help identify the location and size of cyclodialysis cleft for surgical planning, continued from page 73 High-resolution cross-sectional image, temporal to nasal; note narrow angle inlets measuring 15 degrees (nasal) and 7 degrees (temporal) Source: Shakeel Shareef, MD

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