History of Gonioscopy

As a member of the board of Ophthalmology at the University Eye Clinic Graz since 1978. I – by chance – served at the same University where Maximilian Salzmann (Fig. 1.1; born 1862 in Vienna, Austria and died 1954 in Graz, Austria) was professor and chairman from 1911 to 1932. Salzmann was the first to use a contact lens (originally designed for correction of irregular astigmatism) and indirect gonioscopy for examination of the chamber angle besides direct observations. He produced wonderful detailed paintings of the chamber angle and the observed pathologies (Figs. 1.2 and 1.3).

Independently, and some years before, Alexios Trantas (born 1867 in Konitsa, Greece, and died 1961 in Istanbul, Turkey) coined the word “gonioscopy”. Gonia means “angle” and skopein means to “observe” in Greek. He described the chamber angle using a direct ophthalmoscope and simultaneous digital pressure on the limbal region. Therefore both scientists are called “fathers of gonioscopy”.

Further pioneers were M. U. Troncoso (anatomical structures), T. Thornburn (peripheral anterior synechiae, photography of the angle), O. Barkan (differentiation between open-angle glaucoma (OAG), narrow-angle glaucoma and the first description of goniotomy).

An important step forward was the invention of a practicable slit lamp with magnification, powerful illumination and stereoscopic view. In a study reported in 1956, Shaffer and Tour compared the formerly used gonioscopic methods, and drew the following conclusion: “the easiest

and least confusing gonioscopic method for beginners, and perhaps for the average ophthalmologist, is the use of a 16-mm glass Koeppe contact lens, the Barkan hand illuminator, and the hand-held Haag-Streit gonioscopic microscope.”

In particular, Goldmann’s gonioscopes (a one mirror and later a three-mirror lens) made the

Fig. 1.1 Portrait of Maximilian Salzmann

Fig. 1.3 Drawings of the disc (with collaterals), the iris (the sphincter pupillae is colored red) with the chamber angle (peripheral synechiae are in gray) and Salzmann’s hand-written description of the histological findings in an eye with

neovascular glaucoma after central venous thrombosis. Original text: “The chamber angle is not free, there are fine arbors crossing … it is difficult to say, if these are iris processes or pathological bridges …”

examination much easier. We still perform the examination in the same way as he described with the patient sitting at the slit lamp and a lens on the eye rotated 360° by the examiner.

Grading systems, especially that of Spaeth, and the introduction of dynamic gonioscopy (Forbes) made the classification of different glaucomas comprehensible and reproducible. Findings from sophisticated machines such as anterior segment optical coherence tomography (AS-OCT) and ultrasound biomicroscopy (UBM) offered important insights into specific mechanisms.

Detailed histories of gonioscopy by Dellaporta and Alward are available, and are worth reading.

Bibliography

Alward WLM (2011) A history of gonioscopy. Optom Vis Sci 88:29–35

Dellaporta A (1975) Historical notes on gonioscopy. Surv Ophthalmol 20:137–149

Forbes M (1966) Gonioscopy with corneal indentation. Arch Ophthalmol 76:488–492

Goldmann H (1938) Zur Technik der Spaltlampenmikroskopie. Ophthalmologica 96:90–97

Salzmann M (1914) Die Ophthalmoskopie der Kammerbucht. Z Augenheilk 31:1–19

Shaffer RN, Tour RL (1956) A comparative study of gonioscopic methods. Am J Ophthalmol 41:256–265 Spaeth GL (1971) The normal development of the human anterior chamber angle: a new system of descriptive

grading. Trans Ophthalmol Soc U K 91:709–739 Sugar HS, Foster CC (1981) Maximilian Salzmann.

Ophthalmic pioneer and artist. Surv Ophthalmol 26:28–30