Starting Gonioscopy

[Luxman]

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Hello!

I am starting to get some confidence with gonioscopy made with a 3-mirror Goldmann-like contact lens. The drawback performing this exam with it, as you know very well, is that one must use some kind of gel between the lens and the patient's corneal surface, thus making the overall procedure longer.
After watching some videos at gonioscopy.org (i love that site) I discovered the advantages of using a 4-mirror Zeiss-like contact lens, like the Posner, Sussman and Volk G-4 lenses. I would like to buy one of those but I have two issues to solve:

1) Should I get a lens with or without an handle? One of the video on gonioscopy.org says that for tall clinicians (I'm 186 cm and I have long arms) might be better a lens without the handle like the Sussman and the G-4.

2) Nobody that I know of in my clinic use such a lens (most of the times the Goldmann is used instead). Would it be too risky to try to learn how to use it, very carefully, by myself?

I'd really like to read your opinions!

Thanks 🙂

 

[PBEA]

Hello!

I am starting to get some confidence with gonioscopy made with a 3-mirror Goldmann-like contact lens. The drawback performing this exam with it, as you know very well, is that one must use some kind of gel between the lens and the patient's corneal surface, thus making the overall procedure longer.
After watching some videos at gonioscopy.org (i love that site) I discovered the advantages of using a 4-mirror Zeiss-like contact lens, like the Posner, Sussman and Volk G-4 lenses. I would like to buy one of those but I have two issues to solve:

1) Should I get a lens with or without an handle? One of the video on gonioscopy.org says that for tall clinicians (I'm 186 cm and I have long arms) might be better a lens without the handle like the Sussman and the G-4.

2) Nobody that I know of in my clinic use such a lens (most of the times the Goldmann is used instead). Would it be too risky to try to learn how to use it, very carefully, by myself?

I'd really like to read your opinions!

Thanks 🙂

I only use it with a handle (maybe because I'm only 5'9"🙂), and much prefer it over 3 mirror. Only good for angle observation, but much faster, and easier on the pt. Only downside is the quality of the image as compared to 3 mirror. good luck

 

[orbitsurgMD]

Hello!

I am starting to get some confidence with gonioscopy made with a 3-mirror Goldmann-like contact lens. The drawback performing this exam with it, as you know very well, is that one must use some kind of gel between the lens and the patient's corneal surface, thus making the overall procedure longer.
After watching some videos at gonioscopy.org (i love that site) I discovered the advantages of using a 4-mirror Zeiss-like contact lens, like the Posner, Sussman and Volk G-4 lenses. I would like to buy one of those but I have two issues to solve:

1) Should I get a lens with or without an handle? One of the video on gonioscopy.org says that for tall clinicians (I'm 186 cm and I have long arms) might be better a lens without the handle like the Sussman and the G-4.

2) Nobody that I know of in my clinic use such a lens (most of the times the Goldmann is used instead). Would it be too risky to try to learn how to use it, very carefully, by myself?

I'd really like to read your opinions!

Thanks 🙂

I think it is largely a matter of personal preference. I happen to like the Sussman lens with the large ring. I don't think height has much to do with it.
Using a non-goniosol-coupled lens is far more efficient in a busy office and the view afforded is more than adequate. These days, I rarely use goniosol, the exception mostly being for laser procedures, capsulotomy, trabeculoplasty and iridotomy.

 

[Wolverine98]

I think it is largely a matter of personal preference. I happen to like the Sussman lens with the large ring. I don't think height has much to do with it.

That's my favorite as well. With patients who have narrow palpebral fissures or squeeze a little, the ones with handles can be harder to get completely onto the eye without compressing. I also feel like I have better control of compression when I'm trying to deepen things, and it's easier to tell how hard I'm pressing.
My second choice is the Sussman without the big ring.
Third choice is a Zeiss with the handle
Fourth choice is a Goldman; I also like to avoid having to use a coupling agent and I also like to be able to do this without having to rotate the lens.

 

[Luxman]

Thanks for these first opinions! I guess that between the Sussman and the Volk G-4 there aren't many differences... anybody have tried the latter one? How to choose between small ring and large ring lens?

 

[Wolverine98]

Thanks for these first opinions! I guess that between the Sussman and the Volk G-4 there aren't many differences... anybody have tried the latter one? How to choose between small ring and large ring lens?

You're right, there's not much difference between the Sussman and Volk G-4. The size difference is just a matter of grip size and personal preference. For me, the larger lenses are more comfortable to hold. The smaller one is around the size of a Volk 90D lens, and the larger about the size of a Volk 78D lens or a Superfield. I find the latter to be more comfortable, but that's purely personal opinion. People with small hands might find the smaller one fits better (to give an idea of where we're starting, I can just palm a basketball).

 

[toulouselautrec]

The drawback performing this exam with [the 3-mirror Goldmann]...is that one must use some kind of gel between the lens and the patient's corneal surface, thus making the overall procedure longer.

The other drawback is that you can't really do indentation gonioscopy with the 3-mirror. You can with the Zeiss, Sussman, Volks.

I find the non-handled lenses easiest to indent with. However you have to be careful about how much posterior pressure you're applying when you keep the lens on--it can give you a more falsely open angle than in actuality.

The newer 4-mirrors often come with a handle that's detachable.

I rarely use the Goldmann 3-mirror for gonio purposes now, but if I do use it, I do find the central lens useful for looking at the optic nerve.

Now, if only I can get my hands on a Koeppe lens...

 

[7ontheline]

My favorite by far is the Volk 4-mirror with the angled handle. Seems like I may be the only one though. . .

In any case, it's nice because it's angled enough that you can rest your fingertips on the patient's brow/forehead and hold the lens nicely in place. I find it's really nice in people with deep orbits as well. I am tall with nice long forearms though, so I am able to rest my elbow on the slit lamp table and hold the handle above the patient's eye, angled downward. That way I'm not trying to hold the handle out in space, which is tricky at times. Eh, that wasn't very well described.

 

[Luxman]

Once more, thanks for giving your point of view!

... The smaller one is around the size of a Volk 90D lens, and the larger about the size of a Volk 78D lens or a Superfield. I find the latter to be more comfortable, but that's purely personal opinion. People with small hands might find the smaller one fits better (to give an idea of where we're starting, I can just palm a basketball).

That's really helpful, since I have rather big hands too and I find myself comfortable with a Superfiled!
What about point 2 of my first post?!? 🙂

 

[Wolverine98]

To point (2), I wouldn't worry too much about that. Gonioscopy can only be learned by practice, and I'd be shocked if you ever got reprimanded for practicing it. Sure, there's the potential to give a corneal abrasion, but that's pretty hard to do.
Also, as toulouselautrec mentioned, you can't do proper compression with a 3-mirror, and that can be critical to telling the difference between a narrow angle with PAS from one without.

 

[Luxman]

Great! Then I will start practicing with this new kind of lens as soon as I choose one. I think the G-4 without flange and handle might be a good choice.
Thank you all for your precious advice! 😉