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Total Detachment and Reattachment of the Retina*
RETINAL DETACHMENT IN HERPES ZOSTER
253
REFERENCES
1. Gonin, J. : Internat. Cong. Ophth., Amsterdam, 2 :661-665, 1929. 2. Thomson, E. : Detachment of the retina reviewed. Ophthalmoscope, 7 -.747-760, 1909. 3. deWecker: Maladies du fond de l'oeil. 1870. 4. Leber: Ber. Versamml. deutsch, ophth. Gesellsch., 1882. 5. Gonin, J. : Talk before Swiss Oculists at Bale, 1919. 6. : Rev. gener. d'ophtal., August, 1923. 7. : Swiss Ophth. Soc, lune, 1926. 8. : Am. d'ocul., 164:816, 1927. 9. : Arch, d'ophtal., 45 :554, 1928. 10. Müller, L. : Klin. Monatsbl. f. Augenh., 41:4S9, 1903. 11. Blaskovics: Szemeszet, No. 2, 1911. 12. Torok, E. : Results obtained with Miiller's resection of the sclera in detachment of retina due to high myopia. Arch. Ophth., 49 :506-S14, 1920. 13. Elschnig, A. : Arch, f. Augenh., 77:6, 1914. 14. Leitner: Szemeszet, No. 2, 1911. 15. Muller, L. : Ophth. Rev., 32 :324, 1913. 16. Koch, C. : Arch. f. Augenh., 98:156, 1928. 17. Holth, S.: Ber. Versamml. deutsch. Ophthal. Gesellsch., 37:293, 1911. 18. Lindner, K. : Undermining in surgical therapy. Ber. Versamml. deutsch, ophth. Gesellsch., 49 :83-92, 1932. 19. Pischel, D. K., snd Miller, M. : Retinal detachment cured by an eyeball-shortening operation. Arch. Ophth., 22:974-979, 1939. 20. Borley, W. E.: Shortening of the eyeball for retinal detachment. Arch. Ophth., 23:1181-1187, 1940. 21. Pischel, D. K., and Kronfeld, P. C. : Scierai resection operation for retinal detachment. Am. J. Ophth., 36:629-639, 1953. 22. Kronfeld, P. C, and Pischel, D. K. : Scierai resection operation for retinal detachment. Arch. Ophth., 51:356-363, 1954. 23. Borley, W. E. : The scierai resection operation. Tr. Am. Ophth. Soc, 47 :462-497, 1949. 24. Lindner, K. : Shortening of the eyeball for retinal detachment. Arch. Ophth., 42:634-643, 1949. 25. Shapland, C. D.: Scierai resection: Lamellar or penetrating. Brit. J. Ophth., 37:177-180, 1953. 26. Berliner, M. L. : Lamellar resection of the sclera in treatment of retinal detachment. Arch. Ophth., 48 :496-601,1952.
TOTAL DETACHMENT AND REATTACHMENT OF THE RETINA* IN H A R V E Y A. L I N C O F F , M.D.,
H E R P E S ZOSTER
OPHTHALMICUS
GEORGE N . W I S E , M . D . ,
AND H U N T E R H . R O M A I N E ,
M.D.
New York Detachment of the retina is not a frequent complication of herpes zoster ophthalmicus.1 Edgerton 2 mentions only one case in his ex haustive review in 1945, that reported by Scott3 in the British literature of 1932. The present paper describes three further cases in which the onset of herpes zoster was fol lowed by retinal detachment. The first case, seen by H. L., was a com plete funnel detachment. The second case, seen by G. W., was a partial detachment. The * From the Department of Ophthalmology, New York University-Bellevue Post-Graduate Medical School.
third case, seen by H. R., was a partial de tachment with a peripheral hole in the su perior nasal retina. The question arises immediately as to whether the detachments were incidental to the herpes or resultant therefrom. In the first two cases, severe iridocyclitis was pres ent and spontaneous reattachment occurred without an operative procedure. In neither case was a hole found. These cases suggest that an exudative choroiditis was the mecha nism of detachment. The third case also showed iridocyclitis but differed from the first two in that a hole was found and re paired. Reattachment followed repair of the
254
HARVEY A. LINCOFF, GEORGE N. WISE AND HUNTER H. ROMAINE
hole; however, the gradual character of the reattachment suggested that here, too, an exudative choroiditis was operative in the detachment. It is thought that the mechanism of de tachment was a lifting of the retina by an extravasation from the choroid, secondary to a histamine reaction in the choriocapillaris. This might be caused either by direct infec tion of the choroid by the herpes zoster virus, or by antidromic impulses from an infected gasserian ganglion4 In this connection it is interesting to con sider the known pathology of herpetic skin lesions. In the skin, a tense vesicle is formed by a collection of serous exudate beneath a firmly bound tissue. Eventually the vesicle ruptures and secondary infection occurs, producing the weeping lesion typical of the disease. Beneath the retina, an exudate from the choroid would not be contained as be neath the skin, but would be free to spread with little resistance from the ora to the disc ; thus, instead of localized vesicles, a diffuse elevation, that is, a detachment, would result. CASE 1
The case of H. L. was that of a 40-yearold woman purse inspector, who was ad mitted to the medical service on May 19, 1952, with a typical history of acute herpes zoster. Three days previously she had suf fered a chill and headache, followed in a few hours by a rash on the face. Upon admission she was in acute distress with high fever and massive edema of the face. Both eyes were closed by the edema. There were numerous small vesicles over the entire body. The diag nosis was herpes zoster generalitivus. The next morning the patient was seen by the eye service. The vesicles were noted to be chiefly on the right side of the face along the course of the ophthalmic di vision of the fifth nerve. Vesicles extended to the tip of the nose. The cornea and the conjunctiva were grossly edematous, and the globe deeply injected. The pupil was static and very small. The fundus could not be
seen, due to the corneal edema and the con stricted pupil. To the medical diagnosis was added : herpes zoster ophthalmicus ( 1 ) keratitis, (2) iridocyclitis. Local treatment was started and consisted of cortisone solution (O.S-percent every two hours), aureomycin ointment (three times daily), and atropine solution (one percent, twice daily). On this therapy the pupil dilated to five mm. and the patient was more comfortable. By June 2nd, 12 days after ad mission, the cornea had cleared somewhat, although it was still thickened and had folds in Descemet's membrane. Slitlamp examina tion of the anterior chamber showed consid erable precipitation of pigment on the cornea and lens, indicative of the severity of the iridocyclitis which by now had been largely suppressed by steroid therapy. The patient was observed daily, and the skin and anterior segment were noted to improve steadily. No attempt was made to examine the fundus until the patient re ported that she had no vision in the right eye. Testing confirmed this ; there was not even light perception. Examination with a five-volt ophthalmo scope revealed a funnel-shaped detachment with the retina lying against the lens. To the previous diagnosis was added massive detachment of the retina, secondary to an exudative choroiditis. Direct treatment of the detachment was not considered feasible at this time. Atropine and topical cortisone were continued, in an attempt to quiet further the diseased eye and to reduce the photo phobia in the uninvolved eye of which the patient complained. At one point subconjunctival cortisone was started, but this was abandoned because of difficulty in adminis tering the injection. When the patient was discharged to the out-patient service, after 27 hospital days, the right eye was still moderately injected and without light perception, and photo phobia was still present. During the next six months, the patient was seen regularly and frequently and
RETINAL DETACHMENT IN HERPES ZOSTER
showed a gradual lessening of the ciliary in jection. Treatment with cortisone, four times daily, and atropine (one percent, three times daily) was continued. In May, 1953, the pa tient stated that she could see shadows. Visual testing confirmed that light perception had returned in the right eye. Ophthalmoscopic examination revealed that the retina was no longer against the lens, but a very cloudy media prevented any visualization of the retina itself. In October, 1953, the media, although still hazy, had cleared sufficiently so that the retina could be seen. It seemed to be flatly detached above, but largely in place inferiorly. In February, 1954, this opinion was confirmed through a greatly cleared media and the patient counted fingers at one foot. A field examination with a bright light at this time showed an irregular 15-degree field with poor fixation. Through the remainder of the year the vitreous continued to clear, until, with the exception of a few small floaters, it was en tirely transparent. Vision improved to finger counting at five feet, and the field steadily enlarged, until a nearly full peripheral field for light was obtained in February, 1955, (fig. 1). Central fields showed an absolute central scotoma of four degrees. On ophthalmoscopic examination the retina was now seen to be completely at tached. The areas of relative scotoma me dially and laterally were due to areas of retinal degeneration that were clearly defined by pigment deposits. The macular area also showed degeneration. It had evidently been out of contact with the choroid too long to survive. CASE 2
The case of G. W. was that of 58-year-old Negro, who had suffered a severe attack of herpes zoster ophthalmicus on the right side in September, 1950. There was an associated paresis of the third and fourth cranial nerves, punctate keratitis, iridocyclitis, and secondary glaucoma. In October an iriden-
255
Fig. 1 (Lincoff, Wise, and Romaine). Case 1. Visual fields in February, 1955, almost three years after the attack of herpes zoster ophthalmicus.'
cleisis was done and the intraocular pressure reduced. G. W. first saw the case in December, 1950. At that time vision was 20/200 in the involved eye. In addition to the complications already noted, a large inferior bullous de tachment was observed. No hole could be found. Intraocular pressure measured 37 mm. Hg in the right eye and 19 mm. Hg in the left. Pilocarpine (two percent, three times daily) controlled the elevated pressure in the right eye, and was continued through out the following year. This was the only medication used. No treatment of the de tachment was attempted. By February, 1952, 14 months after the detachment was first noted, and 18 months after the onset of the herpes zoster ophthal micus, the retina had spontaneously reattached and vision of the right eye was 20/30. When last seen in February 1953, the retina was noted still to be completely attached, and vision in the right eye was 20/20. CASE 3
The case of H. R. was that of a 58-yearold man who developed herpes zoster oph thalmicus in the right eye in July, 1950, with typical skin lesions along the course of the first division of the trigeminal nerve. During the first two weeks the nasociliary branch was considered not to be affected. Vision was unimpaired, and examination of the anterior and posterior segments of the globe was negative, as was a field examination. Due to the severe pain, X-ray radiation of
256
ROBERT N. SHAFFER AND ROBERT L. TOUR
the gasserian ganglion on the right side was carried out. At the beginning of the third week the eye became inflamed and cells and a flare were noted in the anterior chamber. The diagnosis of anterior uveitis secondary to herpes zoster ophthalmicus was made. Ex amination of the fundus at that time was negative. One week later the patient complained of a flashing light and a curtain in the lower nasal field. Ophthalmoscopic examination now showed a large bullous detachment in the superotemporal area, with a hole in the far periphery. A surgical procedure was car ried out to seal the hole ; however, the retina
did not reattach immediately after this pro cedure but reattached very gradually over several months, after which normal visual acuity was restored. SUMMARY
Three cases of retinal detachment as a complication of herpes zoster ophthalmicus are presented. All were characterized by the presence of iridocyclitis, bullous detachment, and the tendency for spontaneous reattachment. In only one case was a hole found and treated. The mechanism of detachment is thought to be an exudative choroiditis. 2 Fifth Avenue (11).
REFERENCES
1. Allen, J. H. : Lids, lacrimai apparatus, and conjunctiva : Review of the recent literature. Arch. Ophth., 57:87 (Jan.) 1952. 2. Edgerton, A. E. : Herpes zoster ophthalmicus : Report of cases and review of the literature. Arch. Ophth., 34:40 (July) 1945; 34:114 (Aug.) 1945. 3. Scott, A. A. B. : Retinal detachment occurring probably after herpes zoster ophthalmicus in a case of simple glaucoma. Brit. J. Ophth., 16 :358 (June) 1932. 4. Duggan, W. F.: Vascular basis of allergy of the eye and its adnexa. Arch. Ophth., 36:55 (Nov.) 1946.
A COMPARATIVE STUDY O F GONIOSCOPIC METHODS* ROBERT N. SHAFFER, M.D.,
AND ROBERT L. TOUR,
M.D.
San Francisco, California I. INTRODUCTION
Opinions vary as to the best method of gonioscopy. Each variety of equipment has its own particular merit, its specific disad vantages, and, needless to say, its own ardent proponents. The purpose of this paper is to discuss the methods for gonioscopy which are now available, and briefly to describe the optical principles involved. We hope that this * From the Department of Ophthalmology, Uni versity of California Medical School. This work was supported in part by a grant from the McKee Fund. Presented at the 91st annual meeting of the Ameri can Ophthalmological Society, White Sulphur Springs, West Virginia, June, 1955. This paper will appear in the Transactions of the American Oph thalmological Society. It is printed here with the permission of the American Ophthalmological So ciety and the Columbia University Press.
may help the ophthalmologist to choose the equipment which may best fulfill his indi vidual requirements, within the limits of his resources and facilities. The essence of satisfactory gonioscopy is the obtaining of a highly magnified and bril liantly illuminated view of the anterior cham ber angle. For reasons which will be pres ently considered, the first requirement is a contact lens. This should be capable of easy insertion, and should stay properly positioned without the need of additional support. There should be no discomfort to the patient during the examination, and the lens itself should produce no mechanical injury to the globe. The lens should be of perfect optical quality to minimize distortion, should be durable, and, in addition, should be capable of being
253
REFERENCES
1. Gonin, J. : Internat. Cong. Ophth., Amsterdam, 2 :661-665, 1929. 2. Thomson, E. : Detachment of the retina reviewed. Ophthalmoscope, 7 -.747-760, 1909. 3. deWecker: Maladies du fond de l'oeil. 1870. 4. Leber: Ber. Versamml. deutsch, ophth. Gesellsch., 1882. 5. Gonin, J. : Talk before Swiss Oculists at Bale, 1919. 6. : Rev. gener. d'ophtal., August, 1923. 7. : Swiss Ophth. Soc, lune, 1926. 8. : Am. d'ocul., 164:816, 1927. 9. : Arch, d'ophtal., 45 :554, 1928. 10. Müller, L. : Klin. Monatsbl. f. Augenh., 41:4S9, 1903. 11. Blaskovics: Szemeszet, No. 2, 1911. 12. Torok, E. : Results obtained with Miiller's resection of the sclera in detachment of retina due to high myopia. Arch. Ophth., 49 :506-S14, 1920. 13. Elschnig, A. : Arch, f. Augenh., 77:6, 1914. 14. Leitner: Szemeszet, No. 2, 1911. 15. Muller, L. : Ophth. Rev., 32 :324, 1913. 16. Koch, C. : Arch. f. Augenh., 98:156, 1928. 17. Holth, S.: Ber. Versamml. deutsch. Ophthal. Gesellsch., 37:293, 1911. 18. Lindner, K. : Undermining in surgical therapy. Ber. Versamml. deutsch, ophth. Gesellsch., 49 :83-92, 1932. 19. Pischel, D. K., snd Miller, M. : Retinal detachment cured by an eyeball-shortening operation. Arch. Ophth., 22:974-979, 1939. 20. Borley, W. E.: Shortening of the eyeball for retinal detachment. Arch. Ophth., 23:1181-1187, 1940. 21. Pischel, D. K., and Kronfeld, P. C. : Scierai resection operation for retinal detachment. Am. J. Ophth., 36:629-639, 1953. 22. Kronfeld, P. C, and Pischel, D. K. : Scierai resection operation for retinal detachment. Arch. Ophth., 51:356-363, 1954. 23. Borley, W. E. : The scierai resection operation. Tr. Am. Ophth. Soc, 47 :462-497, 1949. 24. Lindner, K. : Shortening of the eyeball for retinal detachment. Arch. Ophth., 42:634-643, 1949. 25. Shapland, C. D.: Scierai resection: Lamellar or penetrating. Brit. J. Ophth., 37:177-180, 1953. 26. Berliner, M. L. : Lamellar resection of the sclera in treatment of retinal detachment. Arch. Ophth., 48 :496-601,1952.
TOTAL DETACHMENT AND REATTACHMENT OF THE RETINA* IN H A R V E Y A. L I N C O F F , M.D.,
H E R P E S ZOSTER
OPHTHALMICUS
GEORGE N . W I S E , M . D . ,
AND H U N T E R H . R O M A I N E ,
M.D.
New York Detachment of the retina is not a frequent complication of herpes zoster ophthalmicus.1 Edgerton 2 mentions only one case in his ex haustive review in 1945, that reported by Scott3 in the British literature of 1932. The present paper describes three further cases in which the onset of herpes zoster was fol lowed by retinal detachment. The first case, seen by H. L., was a com plete funnel detachment. The second case, seen by G. W., was a partial detachment. The * From the Department of Ophthalmology, New York University-Bellevue Post-Graduate Medical School.
third case, seen by H. R., was a partial de tachment with a peripheral hole in the su perior nasal retina. The question arises immediately as to whether the detachments were incidental to the herpes or resultant therefrom. In the first two cases, severe iridocyclitis was pres ent and spontaneous reattachment occurred without an operative procedure. In neither case was a hole found. These cases suggest that an exudative choroiditis was the mecha nism of detachment. The third case also showed iridocyclitis but differed from the first two in that a hole was found and re paired. Reattachment followed repair of the
254
HARVEY A. LINCOFF, GEORGE N. WISE AND HUNTER H. ROMAINE
hole; however, the gradual character of the reattachment suggested that here, too, an exudative choroiditis was operative in the detachment. It is thought that the mechanism of de tachment was a lifting of the retina by an extravasation from the choroid, secondary to a histamine reaction in the choriocapillaris. This might be caused either by direct infec tion of the choroid by the herpes zoster virus, or by antidromic impulses from an infected gasserian ganglion4 In this connection it is interesting to con sider the known pathology of herpetic skin lesions. In the skin, a tense vesicle is formed by a collection of serous exudate beneath a firmly bound tissue. Eventually the vesicle ruptures and secondary infection occurs, producing the weeping lesion typical of the disease. Beneath the retina, an exudate from the choroid would not be contained as be neath the skin, but would be free to spread with little resistance from the ora to the disc ; thus, instead of localized vesicles, a diffuse elevation, that is, a detachment, would result. CASE 1
The case of H. L. was that of a 40-yearold woman purse inspector, who was ad mitted to the medical service on May 19, 1952, with a typical history of acute herpes zoster. Three days previously she had suf fered a chill and headache, followed in a few hours by a rash on the face. Upon admission she was in acute distress with high fever and massive edema of the face. Both eyes were closed by the edema. There were numerous small vesicles over the entire body. The diag nosis was herpes zoster generalitivus. The next morning the patient was seen by the eye service. The vesicles were noted to be chiefly on the right side of the face along the course of the ophthalmic di vision of the fifth nerve. Vesicles extended to the tip of the nose. The cornea and the conjunctiva were grossly edematous, and the globe deeply injected. The pupil was static and very small. The fundus could not be
seen, due to the corneal edema and the con stricted pupil. To the medical diagnosis was added : herpes zoster ophthalmicus ( 1 ) keratitis, (2) iridocyclitis. Local treatment was started and consisted of cortisone solution (O.S-percent every two hours), aureomycin ointment (three times daily), and atropine solution (one percent, twice daily). On this therapy the pupil dilated to five mm. and the patient was more comfortable. By June 2nd, 12 days after ad mission, the cornea had cleared somewhat, although it was still thickened and had folds in Descemet's membrane. Slitlamp examina tion of the anterior chamber showed consid erable precipitation of pigment on the cornea and lens, indicative of the severity of the iridocyclitis which by now had been largely suppressed by steroid therapy. The patient was observed daily, and the skin and anterior segment were noted to improve steadily. No attempt was made to examine the fundus until the patient re ported that she had no vision in the right eye. Testing confirmed this ; there was not even light perception. Examination with a five-volt ophthalmo scope revealed a funnel-shaped detachment with the retina lying against the lens. To the previous diagnosis was added massive detachment of the retina, secondary to an exudative choroiditis. Direct treatment of the detachment was not considered feasible at this time. Atropine and topical cortisone were continued, in an attempt to quiet further the diseased eye and to reduce the photo phobia in the uninvolved eye of which the patient complained. At one point subconjunctival cortisone was started, but this was abandoned because of difficulty in adminis tering the injection. When the patient was discharged to the out-patient service, after 27 hospital days, the right eye was still moderately injected and without light perception, and photo phobia was still present. During the next six months, the patient was seen regularly and frequently and
RETINAL DETACHMENT IN HERPES ZOSTER
showed a gradual lessening of the ciliary in jection. Treatment with cortisone, four times daily, and atropine (one percent, three times daily) was continued. In May, 1953, the pa tient stated that she could see shadows. Visual testing confirmed that light perception had returned in the right eye. Ophthalmoscopic examination revealed that the retina was no longer against the lens, but a very cloudy media prevented any visualization of the retina itself. In October, 1953, the media, although still hazy, had cleared sufficiently so that the retina could be seen. It seemed to be flatly detached above, but largely in place inferiorly. In February, 1954, this opinion was confirmed through a greatly cleared media and the patient counted fingers at one foot. A field examination with a bright light at this time showed an irregular 15-degree field with poor fixation. Through the remainder of the year the vitreous continued to clear, until, with the exception of a few small floaters, it was en tirely transparent. Vision improved to finger counting at five feet, and the field steadily enlarged, until a nearly full peripheral field for light was obtained in February, 1955, (fig. 1). Central fields showed an absolute central scotoma of four degrees. On ophthalmoscopic examination the retina was now seen to be completely at tached. The areas of relative scotoma me dially and laterally were due to areas of retinal degeneration that were clearly defined by pigment deposits. The macular area also showed degeneration. It had evidently been out of contact with the choroid too long to survive. CASE 2
The case of G. W. was that of 58-year-old Negro, who had suffered a severe attack of herpes zoster ophthalmicus on the right side in September, 1950. There was an associated paresis of the third and fourth cranial nerves, punctate keratitis, iridocyclitis, and secondary glaucoma. In October an iriden-
255
Fig. 1 (Lincoff, Wise, and Romaine). Case 1. Visual fields in February, 1955, almost three years after the attack of herpes zoster ophthalmicus.'
cleisis was done and the intraocular pressure reduced. G. W. first saw the case in December, 1950. At that time vision was 20/200 in the involved eye. In addition to the complications already noted, a large inferior bullous de tachment was observed. No hole could be found. Intraocular pressure measured 37 mm. Hg in the right eye and 19 mm. Hg in the left. Pilocarpine (two percent, three times daily) controlled the elevated pressure in the right eye, and was continued through out the following year. This was the only medication used. No treatment of the de tachment was attempted. By February, 1952, 14 months after the detachment was first noted, and 18 months after the onset of the herpes zoster ophthal micus, the retina had spontaneously reattached and vision of the right eye was 20/30. When last seen in February 1953, the retina was noted still to be completely attached, and vision in the right eye was 20/20. CASE 3
The case of H. R. was that of a 58-yearold man who developed herpes zoster oph thalmicus in the right eye in July, 1950, with typical skin lesions along the course of the first division of the trigeminal nerve. During the first two weeks the nasociliary branch was considered not to be affected. Vision was unimpaired, and examination of the anterior and posterior segments of the globe was negative, as was a field examination. Due to the severe pain, X-ray radiation of
256
ROBERT N. SHAFFER AND ROBERT L. TOUR
the gasserian ganglion on the right side was carried out. At the beginning of the third week the eye became inflamed and cells and a flare were noted in the anterior chamber. The diagnosis of anterior uveitis secondary to herpes zoster ophthalmicus was made. Ex amination of the fundus at that time was negative. One week later the patient complained of a flashing light and a curtain in the lower nasal field. Ophthalmoscopic examination now showed a large bullous detachment in the superotemporal area, with a hole in the far periphery. A surgical procedure was car ried out to seal the hole ; however, the retina
did not reattach immediately after this pro cedure but reattached very gradually over several months, after which normal visual acuity was restored. SUMMARY
Three cases of retinal detachment as a complication of herpes zoster ophthalmicus are presented. All were characterized by the presence of iridocyclitis, bullous detachment, and the tendency for spontaneous reattachment. In only one case was a hole found and treated. The mechanism of detachment is thought to be an exudative choroiditis. 2 Fifth Avenue (11).
REFERENCES
1. Allen, J. H. : Lids, lacrimai apparatus, and conjunctiva : Review of the recent literature. Arch. Ophth., 57:87 (Jan.) 1952. 2. Edgerton, A. E. : Herpes zoster ophthalmicus : Report of cases and review of the literature. Arch. Ophth., 34:40 (July) 1945; 34:114 (Aug.) 1945. 3. Scott, A. A. B. : Retinal detachment occurring probably after herpes zoster ophthalmicus in a case of simple glaucoma. Brit. J. Ophth., 16 :358 (June) 1932. 4. Duggan, W. F.: Vascular basis of allergy of the eye and its adnexa. Arch. Ophth., 36:55 (Nov.) 1946.
A COMPARATIVE STUDY O F GONIOSCOPIC METHODS* ROBERT N. SHAFFER, M.D.,
AND ROBERT L. TOUR,
M.D.
San Francisco, California I. INTRODUCTION
Opinions vary as to the best method of gonioscopy. Each variety of equipment has its own particular merit, its specific disad vantages, and, needless to say, its own ardent proponents. The purpose of this paper is to discuss the methods for gonioscopy which are now available, and briefly to describe the optical principles involved. We hope that this * From the Department of Ophthalmology, Uni versity of California Medical School. This work was supported in part by a grant from the McKee Fund. Presented at the 91st annual meeting of the Ameri can Ophthalmological Society, White Sulphur Springs, West Virginia, June, 1955. This paper will appear in the Transactions of the American Oph thalmological Society. It is printed here with the permission of the American Ophthalmological So ciety and the Columbia University Press.
may help the ophthalmologist to choose the equipment which may best fulfill his indi vidual requirements, within the limits of his resources and facilities. The essence of satisfactory gonioscopy is the obtaining of a highly magnified and bril liantly illuminated view of the anterior cham ber angle. For reasons which will be pres ently considered, the first requirement is a contact lens. This should be capable of easy insertion, and should stay properly positioned without the need of additional support. There should be no discomfort to the patient during the examination, and the lens itself should produce no mechanical injury to the globe. The lens should be of perfect optical quality to minimize distortion, should be durable, and, in addition, should be capable of being