Clinical Scorecard: Gonioscopy Still Matters

At a Glance

Key Highlights

• Gonioscopy remains the only technique for direct visualization of the iridocorneal angle despite advances in imaging.
• Imaging modalities like anterior-segment OCT and ultrasound biomicroscopy provide indirect structural information but do not replace gonioscopy.
• Gonioscopy is underperformed and underdocumented, with less than half of Medicare patients having documented gonioscopy before glaucoma surgery.

Guideline-Based Recommendations

Diagnosis

• Perform gonioscopy to directly assess angle structures for accurate glaucoma classification and identification of secondary pathology.
• Use imaging modalities as adjuncts to supplement but not replace gonioscopy.

Management

• Incorporate gonioscopy findings in procedural planning and ongoing glaucoma care.
• Consider handheld imaging devices to assist in documentation and overcome variability in gonioscopy performance.

Monitoring & Follow-up

• Document gonioscopy findings consistently across all four quadrants during glaucoma evaluations.
• Use imaging tools to support monitoring but maintain direct gonioscopic examination for comprehensive assessment.

Risks

• Failure to perform or document gonioscopy may lead to incomplete assessment and suboptimal glaucoma management.

Patient & Prescribing Data

Medicare beneficiaries and general glaucoma patients

Only about 49% of Medicare patients had documented gonioscopy prior to glaucoma surgery, indicating a gap in standard care practices.

Clinical Best Practices

• Prioritize gonioscopy as a routine part of glaucoma evaluation to ensure direct visualization of the angle.
• Train clinicians and trainees to perform comprehensive gonioscopy including all four quadrants and indentation techniques.
• Utilize adjunctive imaging technologies to complement gonioscopy, improve documentation, and aid patient education.
• Address challenges in image quality and consistency when using automated or handheld gonioscopic imaging devices.

Related Resources & Content

• Use of gonioscopy in Medicare beneficiaries before glaucoma surgery
• A survey of current gonioscopy practice in the United Kingdom
• Patterns and disparities in recorded gonioscopy during initial glaucoma evaluations in the United States
• Feasibility of automated gonioscopy imaging in clinical practice
• Gonioscopic angle imaging - American Academy of Ophthalmology EyeWiki