Gonioscopy Remains Essential Despite Advances in Imaging

Overview

Gonioscopy continues to be the only method for direct visualization of the iridocorneal angle, crucial for glaucoma diagnosis and management. Despite the availability of advanced imaging modalities like anterior-segment OCT and ultrasound biomicroscopy, gonioscopy is underperformed and underdocumented in clinical practice.

Background

Glaucoma care relies heavily on assessing the anterior chamber angle to classify disease and plan treatment. While imaging technologies have expanded, they provide indirect views and cannot fully replace gonioscopy. Studies reveal that a significant proportion of patients lack documented gonioscopy, and many clinicians find it challenging to perform comprehensive angle examinations. New handheld imaging devices offer supplementary views but have limitations in consistency and coverage.

Data Highlights

Key Findings

• Gonioscopy is the only technique that allows direct visualization of the iridocorneal angle.
• Advanced imaging modalities such as anterior-segment OCT and UBM provide indirect structural information but cannot replace gonioscopy.
• Only about half of Medicare patients have documented gonioscopy prior to glaucoma surgery, indicating underutilization.
• Many ophthalmologists, especially trainees, report difficulty performing comprehensive gonioscopy including all quadrants and indentation techniques.
• Handheld imaging devices like Goniopen, EyeCam, and GS-1 can supplement gonioscopy but face challenges in capturing consistent, high-quality images across all quadrants.
• Gonioscopy remains critical for glaucoma classification, procedural planning, and detecting secondary angle pathology despite technological advances.

Clinical Implications

Clinicians should prioritize performing and documenting gonioscopy as part of comprehensive glaucoma evaluation to ensure accurate diagnosis and management. While adjunctive imaging tools can aid assessment and patient education, they do not replace the need for direct angle visualization. Training programs should emphasize gonioscopy skills to overcome current challenges and variability in practice.

Conclusion

Despite rapid advances in anterior-segment imaging, gonioscopy remains indispensable in glaucoma care for direct angle assessment. Renewed focus on this technique is essential to optimize patient outcomes.

Related Resources & Content

1. Coleman AL et al., 2006 -- Use of gonioscopy in Medicare beneficiaries before glaucoma surgery
2. Khan SA et al., 2024 -- A survey of current gonioscopy practice in the United Kingdom
3. Lee JH et al., 2024 -- Patterns and disparities in recorded gonioscopy during initial glaucoma evaluations
4. Barbour-Hastie C et al., 2023 -- Feasibility of automated gonioscopy imaging in clinical practice
5. Akkara JD et al., 2026 -- Gonioscopic angle imaging, American Academy of Ophthalmology EyeWiki