The skill of gonioscopy took the spotlight with the explosion of MIGS. Beyond using gonioscopy to perform various MIGS procedures, I have found my trusty single-mirror gonio lens helps enhance quality of care in several scenarios.
I was recently guiding a resident through the implantation of a Hydrus Microstent (Alcon). The stent advanced almost too quickly after some initial resistance during insertion was overcome. The proximal end of the device appeared to be well seated in the angle, but something did not seem right. After the patient and microscope were rotated back into position, I used a single-mirror gonio lens to view the full stent. I saw that the distal end was poking out of the angle into the anterior chamber. With the problem in view, we were immediately able to remove the device and spare the patient a future trip to the OR.
Access to a gonio lens also helped recently when I was working with a resident to visualize and remove a pesky lens fragment after phacoemulsification. Even with irrigation, the lens fragment could not be easily identified. Using the gonio lens, we were able to locate and remove the fragment, which had firmly adhered to the iris in the angle. The gonio lens saved the day.
When I am conducting an exam under anesthesia, I use a single-mirror gonio lens not only to perform gonioscopy with the operating microscope but also to help obtain clear and detailed optic nerve photos. This approach has been a game changer because I do not have a fundus camera available in the OR. Focusing through the central part of the gonio lens after pupillary dilation provides a detailed view of the optic nerve on-screen. Photos of the screen can then be captured, placed in the patient’s chart, and used to monitor disease progression.
The trusty single-mirror gonio lens in my surgical toolkit has been invaluable—it truly is all about the view. This lens has provided me with the clarity needed to resolve several scenarios, and it can be a small but mighty tool in the glaucoma surgeon’s armamentarium.
