51 EyeWorld Asia-Pacific | March 2025 GLAUCOMA In August 2024, Lee et al. published a paper that looked at nearly 200,000 initial glaucoma evaluations, finding that 20.4% and 29.5% had a gonioscopy performed on the day of diagnosis or within 6 months of their evaluation, respectively.1 Statistics like this might prompt questions like, “Is gonioscopy dead?” While glaucoma specialists who spoke with EyeWorld said gonioscopy remains a vital and valuable tool in the clinic, newer imaging systems can help visualize the angle as well, overcoming some limitations of gonioscopy and becoming a complementary technology. “Office-based gonioscopy is alive and well. It forms an integral part of an eye exam … but [is] unfortunately underutilized in clinical practice,” said Shakeel Shareef, MD. Benjamin Y. Xu, MD, PhD, said he could see how someone who performs gonioscopy regularly, experiencing its limitations frequently, might ask whether gonioscopy is dead or still necessary. He assures those in the field that it still has a place. by Liz Hillman, Editorial Co-Director Is Gonioscopy Dead? High-resolution cross-sectional image, nasal to temporal; note appositional angle closure of iris scroll abutting the angle structures (red arrow) and the slit opening of the angle (right side) with a 4-degree inlet. Source: Shakeel Shareef, MD Why Office-Based Gonioscopy Remains Important Dr. Xu said gonioscopy remains important for patients with glaucoma evaluations. “The management of open angle glaucoma and angle closure glaucoma differ, so to misclassify a patient means you may not be offering the optimal or ideal treatments,” he said. In the Lee et al. study, Dr. Xu, who was the corresponding author, said patients with an open angle diagnosis were 10 times less likely to have a gonioscopy compared to angle closure glaucoma. If patients are not receiving gonioscopy, they’re less likely to be diagnosed with angle closure. “Angle closure glaucoma is a very treatable and preventable form of glaucoma early on. You can provide laser and surgery and effectively eliminate the risk of glaucoma, whereas if you presume the patient has open angle glaucoma and treat with eye drops alone, the angle closure can worsen and become difficult to control,” Dr. Xu said. “My general advice is to still perform gonioscopy in all patients receiving glaucoma evaluations because it provides valuable information to guide management.” He also pointed out that gonioscopy can reveal other abnormalities in the angle, such as neovascularization and iris or ciliary body tumors. “These are devastating to miss early on. In the absence of a more convenient assessment like OCT … we should still continue to perform gonioscopy so we can provide our patients with the standard of care,” Dr. Xu said. Dr. Shareef listed the different purposes gonioscopy still provides. It 1) differentiates whether the angle is anatomically open or closed; 2) assesses for
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