Pseudo-gonio synechia: An artifact on two-mirror gonioscopy

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-goniosynechia that disappeared on indentation gonioscopy with Sussman lens but persisted with manipulation gonioscopy with a Goldmann lens is reported.

Gonioscopy is an essential part of the work up for proper diagnosis and classifi cation 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 diff erentiate between appositional and synechial closure of the angle. [1] Variations in gonioscopic techniques are evident from the published epidemiological studies of glaucoma. [2][3][4][5][6][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 fourmirror 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 fourmirror lens." [8] In this report we present an additional benefi t 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 fi nding 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 fl att ens the peripheral iris and the bulge making the "synechia" disappear.

Discussion
The WGA consensus statement reiterates the diff erence 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][6][7] It is possible that the diff erences in the prevalence of angle closure [5][6][7] may in part be due to the diff erences 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 diff erentiation 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 diff erentiate between pseudo and true goniosynechia.

Nita Umesh Shanbhag, Sumita Karandikar, Pooja Anil Deshmukkh
Mycetoma is a chronic granulomatous infection. Lower extremities are commonly involved. A 20-year-old male came with complaints of multiple sinuses on scalp, left eyelid swelling with a sinus and dystopia, since one year. On examination there was relative proptosis in left eye of 2 mm. Computed tomography scan showed soft tissue swelling of the pre-septal area of the left upper eyelid with orbital involvement. Magnetic resonance imaging showed increased left orbital volume and evident dystopia. Microbiology testing of the erosive scalp and lid lesions showed genus Nocardia, suggestive of actinomycetoma. This case is presented as it shows an unusual involvement of the orbit. Mycetoma is a chronic granulomatous infection aff ecting the skin, subcutaneous tissues, and bone. The causative agents include bacteria (actinomycetoma), fungi (eumycetoma), which gain entry to the skin by traumatic inoculation. [1] Foot is the commonest site followed by the upper extremity. [2] Involvement of the perineum being third in the order of frequency and the fourth commonest site is the scalp. [3] We are reporting this case because orbital involvement of actinomycetoma is very unusual. In our review of the literature, we did not come across any such case.

Case Report
A 20-year-old male came with complaints of multiple sinuses over the region of the scalp for a period of one year. He gave a similar history of sinus over the left eyelid since a year, with dystopia for the last six months. The dystopia was gradually progressive, painless, with no diminution of vision or diplopia [ Fig. 1]. He further gave history of lacerated wound being sutured over the left eyebrow fi ve years back, following fall on the left forehead.
On examination of the eyes, vision was 20/20 in both eyes. All fi ndings in right eye were within normal limits. The left eye showed dystopia of 20 prism diopters (∆) downwards and 10 ∆ outwards on prism bar test. On exophthalmometry there was relative proptosis in left eye of 2 mm. The extraocular movements were within normal limits except for restriction in left gaze [ Fig. 2]. The left eyelid showed a diff use swelling 337_08