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    Gonioscopy

    Dr Vijayasree SDr Arjun S (PG )

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    Definition :

    Gonioscopy describes the

    use ofgoniolens to gain

    the view of anatomical

    angle formed between the

    eye s cornea & iris

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    Purpose

    Whydo I need to perform gonioscopy ?

    Fundamental part of comprehensive

    examination Most imp factor in correct diagnosis (its

    omission is a common cause of misdiagnosis )

    Done in all glaucoma pts & suspects Repeated periodically in pts with angle closure

    glaucoma

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    WhatcanIachievewithgonioscopy?

    1) visualization of anterior chamber angle

    2) view of peripheral iris

    3) differentiation between angle closure ,

    occludable & secondary glaucomas

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    Other ways of evaluating the

    anterior chamber angle

    Scheimpflug photography

    Ultrasound biomicroscopy

    Anterior segment OCT

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    Gonioscopy -History

    Trantas (1907 ) coined the term gonioscopy

    Salsmann (1914) first performed gonioscopy

    Goldmann (1938 ) first introdused gonioprism

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    Indications

    Diagnostic IncreasedIOP

    Normal IOP ; AC shallow ( Von Herricks ) orhistorical evidence of angle closure

    Dx e/w as glaucoma or using anti glaucomamedications

    Family h/o glaucoma

    Patent /partially patent PIdone e/w withincreased / normal IOP

    Classification of glaucoma( primary/secondary

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    Blunt ocular trauma (angle recession ,

    cyclodialysis )

    extent of rubeosis iridis ( CRVO, CRAO, PDR)

    PXF & pigmentary glaucomas

    Visualisation of congenital anomalies

    Neoplastic invasion into angle ( ciliary body

    tumor )

    FB in the angle after open globe injury

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    THERAPEUTIC

    Laser trabeculoplasty.

    Excimer laser trabeculotomy.

    Goniotomy./ gonioplasty

    Laser gonio photocoagulation.

    Indentation gonioscopy to break an acute

    attack PACG.

    Reopening of a blocked trabeculectomy

    opening.

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    Contraindications :

    Open globe injury Fresh concussion injury

    Hyphema

    Early post operative period Corneal edema

    Infections

    Corneal epithelial defect

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    .it is not possible to view theirido corneal angle , because

    light from the angle strikes thecornea at an angle of incidence> 46* , which is the critical angle(cornea air interface ) for total

    internal reflection And there by light from the

    angle are reflected back into theanterior chamber

    Rare exceptions are keratoconus, keratoglobus angle structuresare directly visualized

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    Gonioscope helps to neutralize the air cornea

    interface and allows visualization of the angle

    structures

    Gonioscopy types

    Direct

    Indirect without indentation

    with indentation

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    Types of gonioscopes

    Direct:angle directly viewed

    Indirect :angle viewed in mirror mounted on agonioprism

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    Direct goniolens

    LENSES DESCRIPTION/USE

    Koeppe prototype diagnostic goniolens

    Richardson schaffer small koeppe lens forinfants

    Layden forpremature infants

    Barkan prototypesurgical goniolens

    Thorpe surgical and diagnostic lens forOT

    Swan jacob Surgical goniolens for children

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    Techniques

    Koeppe (50 D concavelens ) is the proto type

    direct gonio lens

    Pt is in recumbent position

    Placed on anaesthetised pts cornea

    Saline or viscous gel is used to fill the interface

    Slit lamp or binocular magnifier used for viewing

    Direct lens is nowadays only employed in

    congenital glaucoma Sx

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    Koeppe Barkans

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    Swan jacob Thorpe

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    Indirect Gonioscopy

    Technique :

    Pt is positioned on slit lamp with

    anaesthetized

    cornea Pt is asked to look down or upward and

    quickly lens is tipped forward against cornea

    Slit lamp is placed

    perpend

    icular to the pupil SL beam should have least possible

    illumination & magnification

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    Advantages

    Convenient to use

    Manipulation & indentation

    possible

    Optical corneal wedge can

    identify angle structures

    Lasers can be applied

    Streoscopical view ofONH

    disadvantages

    Inverted image, opposite

    angle viewed

    Inability to see both angles

    simultaneously

    Needs pt cooperation

    Visco make cornea hazy

    Scleral type lens falsely

    close angle by pressure

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    Indirect gonioscopy

    Types :scleral type & corneal type

    Scleral type ( gold mann )- large area(12mm ),

    steep convex surface (7.38mm )

    Viscous substance needed ( methyl cellulose )

    Cannot be used for indentation gonioscopy

    Perimetry, ophthalmoscopy, fundus

    photography should be performed prior tothis

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    INDIRECT GONIOSCOPY

    INSTRUMENTS : gonioprism &slitlamp

    GOLDMANN singlemirroris a prototype

    mirrorhas a heightof 12mm

    posteriorradiusof 7.38mm

    GOLDMANN 3 MIRROR: has 3 mirrors

    twomirrors forexamination of fundus

    (67 deg , 73 deg)

    and one forant. Chamberangletilted at59 degrees

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    The center lens is the contact Hruby Lens used for viewing the posterior pole,nerve head, and macula.

    The Trapezoid mirror(73 deg) is used to view the retina slightly posterior to the

    equator.

    The Half Round mirror (67 deg) is used to view the peripheral retina fromthe equator out to the ora serrata.

    The Finger Nail mirror(59deg) is used to view angle and the most anterior retina

    and ciliary body.

    GOLDMANN 3

    MIRROR GONIOSCOPE

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    Corneal ( ziess ) type : diameter 9 mm

    Radius of curvature =7.72 mm approxcorneal radius of curvature

    So can be used for indentation gonioscopy

    coupling fluid not needed uses tear film

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    LENSES DESCRIPTION/USE

    ZEISS 4 MIRROR has a 9mm corneal segment and

    Radius of curvature 7.72mm

    All 4 mirrors are inclined at 64 degrees

    allows examination of 360 deg

    No fluid bridge required

    requires holder

    POSNER 4 MIRROR modified zeiss with attached handle

    SUSSMANN hand held zeiss type

    THORPE 4 MIRROR 4 gonioscopy mirrors inclined at 62

    degrees,requires fluid bridge

    RITCH TRABECULOPLASTY

    LENS 4 gonioscopy mirrors 2 inclined at 59

    degrees and other 2 at 62 degreeswith convex lens over two

    Because of smaller diameter used for

    Indentation or compressive gonioscopy.

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    Suss mann Posners

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    Technique (ziess) goniolens Do an external Ex first Perform tonometry before gonioscopy Use topical anaesthesia

    Pay attention to Pt comfort Pay attention to alignment

    Use dark room pupillary constriction makes a narrow angleappear more open

    Position pt at SL with illumination coaxial with viewing system& low magnification ( x 10 )

    Lateral canthal marker to center vertical range of slit lamp, No coupling fluid is used

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    Use vertical parallelopiped beam which is 2-3

    mm wide (fairly short & narrow beam )

    Examiner should remember that he is viewing

    the opposite angle

    The slit beam should not have much

    illumination & not cross pupillary margin

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    While the looks straight ahead the lens is gentlyguided onto the corneal apex so that the edges

    do not indent the cornea

    Do not press too hard ,( DM folds appear)

    Mirrors should be placed in the 12, 3, 6, 9 o clockposition

    If air bubbles appear , slightly rock, rotate or

    remove & reapply

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    Examine first the inferior quadrant ( widest &

    more pigmented , which implies that thestructures are easy to recognize )

    Then nasal , superior , temporal (so that atany point the beam should not cross the pupil)

    Always compare the findings in one eye withfellow eye before commenting on angle

    characteristics

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    Sterilization& disinfectionofgoniolens

    Washing with soap &water, sodium

    hypochlorite

    3% H2O

    2 1% formaldehyde

    70% isopropyl alcohol

    Ethylene oxide gas (surgical lens )

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    What shouldI look for in gonioscopy ?

    Recognize angle land marks & consider:

    1. Level of iris insertion

    2. Shape & profile of peripheral iris3. Estimated width of angle

    4. Degree of trabecular pigmentation

    5. Areas of iridotrabecular apposition /synechiae

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    Starting from the root of iris the following

    structures are present in a normal ad

    ult angle1. Ciliary body band

    2. Scleral spur

    3. PigmentedTM

    4. Non pigmentedTM

    5. Schwalbe s line

    for identification of angle , the scleral

    spur & schwalbes line are the mostconsistent land marks

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    Sample View of Wide Angle

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    ANGLE STRUCTURES

    it iseasierto identifythe anglestructures fromposterior(irisside) to

    anterior(cornea side).

    Start from pupil , follow the plane of iris , identify root of iris

    1.) Ciliary body - (CB)

    isthemostposteriorstructure in the angle .

    It appears as a grey or dark brown bandIts width Dependsupon thelevelof iris insertion it is widerin myopes

    and narrowerin hypermetropes

    2.) Scleral spur - (SS)

    istheposteriorportion ofscleral sulcus

    Appears as a prominent whitelinebetween CBB and functional TMW.

    finepigmented strandsseen crossing thespurfrom irisrootto

    TMW are irisprocesses.

    Blood in schlems canallies just anttothescleral spur. 38

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    3.TRABECULAR MESH WORK: is seen as a band just anterior to scleral spur

    posterior pigmented functional TMW band

    anterior non pigmented TMW band seen

    .

    it has no pigment at birth and develops pigmentwith increasing age and appears faint tan to dark brown.

    4 SCHWALBES LINE: it forms the anterior limit of the angle structures

    formed by prominent end of descemets membrane of cornea.

    it appears as a faint dark line.

    An optical cut through the cornea with

    Slitlamp beam has 2 reflections from

    Bowmans and descemets they meet at

    Schwalbes line. Corneal wedge technique

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    Normal angle

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    Dynamic gonioscopy

    Indentation gonioscopy

    Manipulative gonioscopy

    Biometric gonioscopy

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    INDENTATION GONIOSCOPY

    1.SHALLOW AC

    2.OPEN ANGLE

    3.CLOSED ANGLE WITHPAS.

    Increased pressure

    indents centralcornea anddisplaces

    fluid in to the angle

    opening it wider

    should the angle be

    closed it

    differentiates

    between

    appositional (

    reversed )&

    synechial

    (irreversible )closure

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    When no angle is directly visible before

    indentation , the closure can be due to 3

    reasons 1) synechial

    2) appositional

    3) optical ( apparent closure due to steepcurvature of peripheral iris )- a moretangential viewing of the angle aids inidentification of angle .Ask the pt to look

    in thed

    irection of the mirror /move themirror towards the angle being viewed manipulative gonioscopy

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    Sample View of Narrow Angle

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    Steep iris , narrow angle

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    When no angle structure is directly before

    indentation , 4 things can happen on

    indentation

    1) iris moves peripherally backwards ,assumes a

    concave conf & angle recess widens

    - appositional closure

    2) The angle widens but iris strands remain

    attached to the outer wall of angle- synechial closure

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    Sample View of Anterior Synechiae

    with Indentation Gonioscopy

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    3) the iris moves peripherally backwards, but

    the periphery of the iris bulges out & assumes

    a concave configuration , this represents ananteriorly displaced ciliary body & iris root

    - plateau iris

    4) Iris moves only slightly & evenly backwards ,

    but retains a convex profile , this can occur in

    anteriorly displaced lens / large diameter lens

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    VAN HERICKS GRADING :

    Is a slit lamp technique use

    dforEstimating the depth of PAC by

    Comparing it with the adjacent

    Cornel thickness.

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    SHAFFERS GRADING: based on the angular width of angle recess.

    GRADE ANGLE WIDTH CONFIG. CHANCES OF CLOSURE

    IV 35-45 WIDE OPEN NIL

    III 20-35 OPEN ANGLE NIL

    II 20 MODERATELY

    NARROW POSSIBLE

    I 10 VERY NARROW HIGH

    SLIT ANGLE

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    SCHEIES GONIOSCOPIC CLASSIFICATION :

    Based on the extent of visible angle structures

    CLASSIFICATION GONIOSCOPIC APPEARANCE

    Wide open all structures visible

    GRADE I hard to see over iris root

    in to recess

    GRADE II ciliary body band obscured

    GRADE III posterior trabecula obscured

    GRADE IV (closed) only schwalbes line visible

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    SPAETH SYSTEM OF GRADING b d 3 i bl

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    SPAETH SYSTEM OF GRADING:based on 3 variables

    a.

    Angularwidth of

    angle

    recess

    b.Periph

    eral iris

    Configuration

    c.Appare

    nt

    insertion

    Of the irisroot

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    Iris

    Normal iris has radial markings with crypts Featureless iris past attack of ant uveitis

    Asymmetric appearance FHIC

    Peripheral concentric rolls May obscure angle plateau iris

    Abnormal convexity pupillary block , thick

    lens , tumors / cysts of iris pigment epithelium& ciliary body

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    The three major features that must be examined

    include Contour of the iris ( concave , convex , flat )

    Site of iris insertion

    Angular width of angle recess

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    Normal angle

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    Concave iris conf

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    Narrow angle

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    Ciliary body bandCBB

    Iris inserts into concave face ofCB leavingsome portion visible

    Usually gray /dark brown

    The width of the band level of iris insertion

    Wider myopia

    Narrow hypermetropia

    Broadened ciliary body band ( compared to

    fellow eye ) angle recession

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    Schlemm s canal

    Not normally visibleBlood in schlems canal is seen in

    supine posture

    with increased episcleral venous pressure

    hypotony

    struge weber syndrome

    or if gonioscopy lens compress the limbal vessels

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    Iris processesNormal in 30 % population

    Fine , finger like , gray/ brown ,

    Extensions of the peripheral iris , follow theconcavity , insert into SS or PTM

    Mostly in nasal Q, do not interfere with aqueousout flow

    Contract on light stimulus

    Do not block the movement of iris on IND GonioAngle recession iris processes may be broken

    Often confused with PAS

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    P i h l i hi PAS

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    Peripheral anterior synechiae PAS

    Irregular , broader , tent shaped

    Bridge angle recess , instead of following it

    Do not follow the concavity

    Obscures angle structures

    Inhibit post movement of iris on IND G

    Drag normal radial iris vessels

    Ass with anterior pigmentation angle closure

    & uvietis

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    Location of PAS

    Superiorly first in ACG Inferiorly in uveitis

    Anterior to SL in ICE syndrome

    Any location in post traumatic case Rubeosis iridis

    Delayed reformation of AC after penetrating

    corneal injury

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    PAS

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    ICE syndrome

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    axenfeld rieger anomaly

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    Plateau iris

    Axially normal central ACdepth , flat iris

    plane on direct Ex , but narrow angle on

    gonioscopy in eye with angle closure

    Anteriorly positioned ciliary processes , push

    peripheral iris forward & block the angle

    Pupillary block & bunching up of peripheral

    iris blocking the TM when pupil dilates

    Acute / chronic angle closure

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    Suspect 1.when angle closure occurs , despite

    a patent iridotomy due to peripheral iris conf

    2.If angle closure occurs in younger ptswith myopia

    confirmed on gonioscopy & UBM

    PAS extend posteriorly from SL to TM , SS,CBB ( reverse is seen in pupillary block

    glaucoma extend from post to anterior )

    May be missed if one relies solely on SLE / vonherricks method of angle Ex

    Rx : long term miotic

    Laser iridoplasty71

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    Iridodialysis

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    FB in angle

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    Angle recession

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    Angle recession

    Blunt injury

    Tear in longitudinal & circular muscles ofCB BroadenedCBB ( compared to fellow eye )

    Per se does not cause glaucoma , only marker

    for trabecular injury Glaucoma ,when recession > 180,270 *

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    Angle recession

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    I d i t ti l

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    Increased pigmentation , angle

    recession

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    Pi t l

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    Pigmentary glaucomaliberation of iris pigment as it rubs against zonules , deposited thru out

    anterior segment

    Angle-open , deep

    Iris marked concave configuration , mid

    periphery Pig ant to schwalbes line ( sampaolesi line)

    Homogenous , dense pig ,very dark band

    (mascara line ) covering TM

    Severity of glaucoma related to amt of pig of

    angle

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    Pigmentary glaucoma

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    Pseudo exfoliative glaucoma

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    Pseudo exfoliative glaucomaPXF material deposited on endothelium , lens, iris , pupillary margin zonules

    ciliary body

    Open , (narrow 30 % with PAS in 20%)

    Flecks of PXF on TM

    pigm TM uneven , blotchy, less black ,segmented

    Glaucoma severity does not correlate with

    amt of PXF

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    Pseudo exfoliative glaucoma

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    Uveitic glaucoma

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    Uveitic glaucoma

    O

    pen / closed

    inflammatory ppts on TM

    PAS broad based , closed angle , inferior

    Iris bombe pupillary block NV of angle (chronic )

    FHIC fine vessels , bleed on gonioscopy , no

    PAS

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    Silicon bubbles in angle

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    Summary

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    y

    Gonioscopic Ex is an imp tool in Examining pts

    with ocular disorders

    Must be incorporated as routine ophthalmic

    evaluation as a standard protocol

    It provides a clear insight into the

    pathogenesis of glaucoma & facilitatesappropriate medical , laser , surgical Rx

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    M t i i i l

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    Mastering gonioscopy is also a necessary

    requirement for the performance of laser

    procedures on the angle structures

    It is an art & science aquired only thru

    experience as it requires considerable hand eye co ordination & a knowledge of the

    normal & abnormal gonioanatomy & the

    abitily to avoid artifactual observations

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