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Pseudo-gonio synechia: an artifact on two-mirror gonioscopy.
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MedLine Citation:
PMID:  20029147     Owner:  NLM     Status:  MEDLINE    
Gonioscopy is an important component of evaluation of any glaucoma patient. Goldmann two-mirror and Sussman or Zeiss four-mirror are the commonly used gonioscopes. Presence of synechia in the angle is diagnostic of angle closure disease in an occludable angle. A patient with pseudo-gonio synechia that disappeared on indentation gonioscopy with Sussman lens but persisted with manipulation gonioscopy with a Goldmann lens is reported.
Chandra Sekhar Garudadri
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Publication Detail:
Type:  Case Reports; Journal Article    
Journal Detail:
Title:  Indian journal of ophthalmology     Volume:  58     ISSN:  1998-3689     ISO Abbreviation:  Indian J Ophthalmol     Publication Date:    2010 Jan-Feb
Date Detail:
Created Date:  2009-12-23     Completed Date:  2010-03-18     Revised Date:  2013-05-31    
Medline Journal Info:
Nlm Unique ID:  0405376     Medline TA:  Indian J Ophthalmol     Country:  India    
Other Details:
Languages:  eng     Pagination:  59-60     Citation Subset:  IM    
LV Prasad Eye Institute, Kallam Anji Reddy Campus, LV Prasad Marg, Hyderabad, India.
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MeSH Terms
Cornea / pathology*
Diagnostic Errors*
Glaucoma, Angle-Closure / diagnosis*
Gonioscopy / instrumentation*
Middle Aged
Reference Values

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

Full Text
Journal Information
Journal ID (nlm-ta): Indian J Ophthalmol
Journal ID (publisher-id): IJO
ISSN: 0301-4738
ISSN: 1998-3689
Publisher: Medknow Publications, India
Article Information
? Indian Journal of Ophthalmology
Received Day: 28 Month: 8 Year: 2008
Accepted Day: 30 Month: 12 Year: 2008
Print publication date: Season: Jan?Feb Year: 2010
Volume: 58 Issue: 1
First Page: 59 Last Page: 60
Publisher Id: IJO-58-59
PubMed Id: 20029147
DOI: 10.4103/0301-4738.58473

Pseudo-gonio synechia: An artifact on two-mirror gonioscopy
Chandra Sekhar GarudadriAF0001
LV Prasad Eye Institute, Kallam Anji Reddy Campus, LV Prasad Marg, Banjara Hills, Hyderabad ? 500 034, India
Correspondence: Correspondence to: Chandra Sekhar Garudadri, LV Prasad Eye Institute, Kallam Anji Reddy Campus, LV Prasad Marg, Banjara Hills, Hyderabad ? 500 034, India. E-mail:

Gonioscopy is an essential part of the work up for proper diagnosis and classification of glaucoma. The visualization of the angle would vary depending on the optics and the mechanics of lens used. Indentation gonioscopy has been advocated to differentiate between appositional and synechial closure of the angle.[1] Variations in gonioscopic techniques are evident from the published epidemiological studies of glaucoma.[2?7] As per the World Glaucoma Association's (WGA) consensus statement ?The best lens to use remains controversial. Many specialists say that the use of a four-mirror lens is mandatory. Many others disagree. Many closed angles can be ?manipulated? open using a Goldmann lens. However, a small proportion of appositionally closed angles cannot. In these cases, the use of a four-mirror lens is mandatory. For this reason, the minimum standard is a four-mirror lens.?[8] In this report we present an additional benefit of indentation gonioscopy.

Case Report

A 45-year-old female patient presented for a routine ophthalmic evaluation. Her visual acuity was 20/20 in each eye without correction, the intraocular pressure was 15 mm Hg in both eyes. The anterior segment examination was unremarkable, with a deep anterior chamber. She underwent gonioscopy as a part of routine complete evaluation. Fig. 1 A, B show the gonioscopic appearance of the angle with what looks like a typical goniosynechia in a wide open angle both with Goldmann (two-mirror) and Sussman (four-mirror) gonioscope. Indentation with the Sussman lens results in the disappearance of the synechia [Fig. 2A] as opposed to the Goldmann lens where in spite of the patient looking towards the mirror, with increased illumination and height of slit beam as well as ?manipulation?, the ?synechia? persists [Fig. 2B]. This finding we believe is due to a bulge in the periphery of the iris close to the iris insertion, which viewed end-on in gonioscopy looks like a synechia. Indentation flattens the peripheral iris and the bulge making the ?synechia? disappear.


The WGA consensus statement reiterates the difference of opinion among specialists about the ideal gonioscope.[8] The published epidemiological studies on angle closure glaucoma have used varying gonioscopic techniques. There have been two population-based studies in Singapore and Mongolia.[2, 3] In a report looking at the relationship between peripheral anterior synechia (PAS) and angle width the authors found the prevalence of synechiae in wide open angles to vary from 1.88% (Mongolia) to 3.68% (Singapore).[4] In the three epidemiological studies from South India, the prevalence of primary angle closure (PAC) varied from 0.71 to 4.32%.[5?7] It is possible that the differences in the prevalence of angle closure[5?7] may in part be due to the differences in methodology of gonioscopy. While manipulative gonioscopy can open the angle in 90-95% of cases, indentation is necessary in the rest.[1] In this case documenting the differentiation of true from pseudo-synechia was possible by indentation gonioscopy with a four-mirror and not by manipulative gonioscopy by a Goldmann gonioscope. We believe that this is an additional advantage of indentation gonioscopy, and indentation gonioscopy is essential to differentiate between pseudo and true goniosynechia.

1. Thomas R,Thomas S,Chandrashekar G. GonioscopyIndian J OphthalmologyYear: 19984625561
2. Foster PJ,Baasanhu J,Alsbirk PH,Munkhbayar D,Uranchimeg D,Johnson GJ. Glaucoma in Mongolia - A population-based survey in Hovsgol province, northern MongoliaArch OphthalmolYear: 19961141235418859083
3. Foster PJ,Francis TS,Machin OD,Tze-Pin Ng,Joe G,Devereux,et al. The Prevalence of Glaucoma in Chinese Residents of Singapore: A Cross-Sectional Population Survey of the Tanjong Pagar DistrictArch OphthalmologyYear: 2000118110511
4. Foster PJ,Aung T,Nolan WP,Machin D,Baasanhu J,Khaw PT,et al. Defining ?occludable? angles in population surveys: drainage angle width, peripheral anterior synechiae, and glaucomatous optic neuropathy in east Asian peopleBritish J OphthalmologyYear: 20048848690
5. Jacob A,Thomas R,Koshi SP,Braganza A,Muliyil J. Prevalence of primary glaucoma in an urban South Indian populationIndian J OphthalmologyYear: 199846816
6. Dandona L,Dandona R,Mandal P,Srinivas M,John RK,McCarty CA,et al. Angle-closure glaucoma in an urban population in southern indiaThe andhra pradesh eye disease study OphthalmologyYear: 200010717106
7. Vijaya L,George R,Arvind H,Baskaran M,Ramesh VS,Raju P,et al. Prevalence of primary angle-closure disease in an urban south Indian population and comparison with a rural population. The Chennai Glaucoma StudyOphthalmologyYear: 20081156556017869343
8. Foster PJ,He M,Liebmann JF. Epidemiology, classification and mechanismAngle closure and angle closure glaucomaYear: 2006The Hague, NetherlandsKugler Publications15


[Figure ID: F0001]
Figure 1 

Gonioscopic appearance of the angle showing what looks like a goniosynechia in a wide-open angle a) with Goldmann lens and b) with Sussman lens

[Figure ID: F0002]
Figure 2 

Gonioscopic appearance of the angle shown in Figure 1 on indentaion, showing the a) disappearance of the synechia with Sussman lens and b) persistence of the synechia despite manipulative gonioscopy with Goldmann lens

Article Categories:
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Keywords: Goldmann gonio lens, indentation gonioscopy, pseudo-synechia, Sussman gonio lens.

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