SLIT-LAMP BIOMICROSCOPY

Module 1.4

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Published in Australia by
The International Association of Contact Lens Educators
First Edition 1997
!The International Association of Contact Lens Educators 1996
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CONTRIBUTORS
Slit-lamp Biomicroscopy
Procedures:
Sylvie Sulaiman, BOptom, Mcom

Deborah Sweeney, BOptom, PhD
THE SLIT-LAMP
BIOMICROSCOPE
PARTS OF A
SLIT-LAMP
1. Mechanical support
2. Observation system
3. Illumination system
EXAMINING A PATIENT USING A
SLIT-LAMP
SLIT-LAMP
MICROSCOPE SYSTEM
Variable magnification
Binocular system
FEATURES
SLIT-LAMP MICROSCOPE
SLIT-LAMP MICROSCOPE
Low 7X - 10X General eye
Medium 20X - 25X Structure layers
High 30X - 40X Detail
General eye:
Lids
Bulbar conjunctiva/sclera
Cornea/limbus
Tears
Anterior chamber/iris/crystalline lens
LOW MAGNIFICATION (7x - 10x)
SLIT-LAMP BIOMICROSCOPY
SLIT-LAMP BIOMICROSCOPY
SLIT-LAMP BIOMICROSCOPY
Structures:
Epithelium
Stroma
Endothelium
Lens fit/surface
MEDIUM MAGNIFICATION (20x - 25x)

SLIT-LAMP BIOMICROSCOPY
SLIT-LAMP BIOMICROSCOPY
Details:
Epithelial changes
Stromal striae, folds
Endothelial folds, polymegethism
HIGH MAGNIFICATION (30x - 40x)

SLIT-LAMP BIOMICROSCOPY
SLIT-LAMP BIOMICROSCOPY
Epithelium
Vacuoles
Microcysts
Dystrophies
HIGH MAGNIFICATION (30x - 40x)

SLIT-LAMP BIOMICROSCOPY
SLIT-LAMP BIOMICROSCOPY
Stroma
Striae
Folds
HIGH MAGNIFICATION (30x - 40x)

SLIT-LAMP BIOMICROSCOPY
SLIT-LAMP BIOMICROSCOPY
Endothelium
Polymegethism
Guttata
Blebs
Dystrophies
Cell Density
HIGH MAGNIFICATION (30x - 40x)

SLIT-LAMP BIOMICROSCOPY
SPECULAR REFLECTION: ENDOTHELIUM
STRUCTURES OBSERVED
WITH
DIFFERENT ILLUMINATIONS
SLIT-LAMP BIOMICROSCOPY
Method of illumination is
IMPORTANT
SLIT-LAMP
ILLUMINATION SYSTEM
Variable light intensity
Filters
Width
Height
Angle
FEATURES

SLIT-LAMP
ILLUMINATION SYSTEM
ILLUMINATION
TECHNIQUES
Diffuse
Direct
Indirect
Retro-illumination
Specular reflection
Sclerotic scatter
Tangential
ILLUMINATION
TECHNIQUES
DIFFUSE ILLUMINATION
45 degree angle between light &
microscope
Slit open fully
Diffusing filter
Variable magnification (low to high)
BROAD BEAM
Microscope
Beam of light
Cornea
Iris
DIFFUSE ILLUMINATION
Overall view of:
Lids and lashes
Conjunctiva
Cornea
Sclera
Iris
Pupil

DIRECT ILLUMINATION
Observation and illumination systems
focused on the same point
DIRECT ILLUMINATION
Microscope
Beam of light
Iris
Cornea
DIRECT ILLUMINATION
Vary angle of illumination
Low to high magnification
Vary width and height of light source
DIRECT ILLUMINATION
Optic Section
narrow, focused light
Parallelepiped
wider, focused light
Conical Beam
small, circular light
DIRECT ILLUMINATION
OPTIC SECTION
Indicates depth
localize: - nerve fibres
- blood vessels
- infiltrates
- cataracts
Anterior chamber angle

PRINCIPLE OF OPTIC SECTION
Aerial View
Cornea
Iris
B
A
OPTIC SECTION
A B
DIRECT ILLUMINATION
Broader view
Illuminated block of the cornea
More extensive examination
PARALLELEPIPED


PRINCIPLE OF THE PARALLELEPIPED
Iris
Cornea
Aerial View
A
A'
B
B'
PARALLELEPIPED
A A'
B
B'
DIRECT ILLUMINATION
Inflammatory cells/flare in the
anterior chamber
Darkened room
CONICAL BEAM
CONICAL BEAM
Microscope
Conical beam
Cornea
Iris
Conical Beam
Beam cross-section

INDIRECT ILLUMINATION
Observation and illumination systems are
not focused at the same point
INDIRECT ILLUMINATION
Microscope
Beam of light
Cornea
Iris
INDIRECT ILLUMINATION
Vary angle of illumination
Slit beam is offset
Vary beam width
Low to high magnification
INDIRECT ILLUMINATION
Valuable for observing:
Epithelial vesicles
Epithelial erosions
Iris pathology
Iris sphincter


RETRO-ILLUMINATION
Object of regard is illuminated only
by reflected light
RETRO-ILLUMINATION
Microscope
Beam
of light
Iris
Cornea
RETRO-ILLUMINATION
Vary angle of illumination
Moderately wide beam
Slit beam is offset
Medium to high magnification
Reflected light from iris or fundus
Observer
Transparent intra-corneal
object
Background for marginal
retro-illumination
Unreserved (U) and
reversed (R) appearance
DIVERGING
REFRACTOR
CONVERGING
REFRACTOR
(AFTER Brown, 1971)
U R
RETRO-ILLUMINATION
Direct Direct and full view
Indirect Adjacent
Marginal Margin or edge
TYPE ALIGNMENT
Alignment of reflected beam with
area under observation
RETRO-ILLUMINATION
Valuable for observing:
Vascularization
Epithelial oedema
Microcysts
Vacuoles
Dystrophies
Crystalline lens opacities
Contact lens deposits



SPECULAR REFLECTION
Angle of incidence equals
angle of reflection
SPECULAR REFLECTION
Microscope Beam
of light
Cornea
Iris
SPECULAR REFLECTION
Valuable for observing:
Endothelial cell layer
Tear film debris
Tear film lipid layer thickness




SCLEROTIC SCATTER
Valuable for observing:
localised epithelial oedema (CCC)
corneal scars
foreign bodies in the cornea
SCLEROTIC SCATTER
Corneal feature disclosed

SCLEROTIC SCATTER
TANGENTIAL ILLUMINATION
Large angle of 70
o
- 80
o
between
illumination and observation system

TANGENTIAL ILLUMINATION
Microscope
Beam of light
Cornea
Iris
TANGENTIAL ILLUMINATION
Valuable for observing:
Iris freckles
Tumours
General integrity of cornea and iris
FILTERED ILLUMINATION
Cobalt blue
Green (red-free)
Neutral density
FILTERED ILLUMINATION
Most valuable:
Cobalt blue
+
Wratten # 12

FILTERED ILLUMINATION
Valuable for observing:
Tear layer
Ocular staining
RGP lens fitting patterns






GRATICULE
Useful for lens fitting assessment

ROUTINE EXAMINATION OF
THE EYE USING THE
SLIT-LAMP
BASELINE EXAM FLOWCHART
Lids
Conjunctiva
Limbus
Cornea
Tears
Anterior Chamber
Iris
Lens
Bulbar
Palpebral
SLIT-LAMP OBSERVATIONS OF
CONTACT LENS
COMPLICATIONS
LID EXAMINATION
Lids
redness, swelling, defects, growths,
discolouration
Puncta
clear, functioning
Caruncle
swollen, inflamed

CONJUNCTIVA
Redness
Inflammation

LIMBUS
Redness
Neovascularization
Staining

CORNEA
Transparency
Tissue damage/insult
DETECTION OF OEDEMA
Corneal clarity
Striae/folds
Corneal thickness measurement
STRIAE
Refractile effect
Fluid separation of collagen fibrils
Minimum 5% corneal swelling
Refit with higher Dk/t lenses

CORNEAL OEDEMA vs STRIAE
0 5 10 15 20 25
25

20

15

10

5

0
Striae (number)
striae = 1.45 x oedema - 6.5
n = 192
r = 0.88
p < 0.001
(La Hood & Grant, 1990)
Oedema (%)
FOLDS
Physical buckling of Descemet's
membrane and the endothelium
Minimum 8% corneal swelling
Severely compromised cornea
Immediate refit with higher Dk/t

FOLDS
CORNEAL OEDEMA vs STRIAE
1 Striae = 5.2% Oedema


Each
= 1% Oedema additional
striae
CORNEAL OEDEMA vs STRAIE
1 Fold = 7.7% Oedema


Each
= 1% Oedema additional
striae
CORNEAL OEDEMA vs FOLDS
0 5 10 15 20 25
25

20

15

10

5

0
Folds (number)
folds = 1.33 x oedema - 9
n = 166
r = 0.87
p < 0.001
(La Hood & Grant, 1990)
Oedema (%)
DAYTIME STRIAE RESPONSE
0
0
0
0.6
0.1
1.0
0.3
1.1
0
0.5
1
1.5
0 2 4 6
High Water
Low Water
HIGH WATER 74% vs LOW WATER 43%
Striae (Grade 0-4)
(La Hood, 1991)
+5.00 D n=11
Time after lens insertion (hours)

MICROCYSTS
Small, irregular shape (15-50 m)
Reversed illumination
Slow onset
Cyclic phenomenon
Asymptomatic

MICROCYSTS
DISPOSABLE HFDROGELS
0 4 8 12 16 20 24 28 32 36
50

40

30

20

10

0
Microcysts (number)
(Grant et al., 1990)
Time (months)
6-13N
DW
MICROCYSTS
Basal epithelial cells secrete intra-
epithelial sheets
Disorganised cell growth
Pockets of dead cells
Slowly pushed to surface
PATHOLOGY
MICROCYSTS
ONSET AND RECOVERY
35
30

20

10

0
Microcysts (number)
0 2 4 6 8 10 12 0 2 4 6
Time (months)
HWC
n=51
CCLRU
HWC
n=29
GOTEBORG
MICROCYSTS
. . . Break through the anterior
corneal surface and manifest as
corneal dry spots
(Zantos, 1981)

ENDOTHELIUM
Detection with slit-lamp:
High magnification (30x - 40x)
High illumination
Specular reflection
POLYMEGETHISM
SIGNS
Increasing variation in endothelial cell size
Increased ratio of large/small cells
CCLRU POLYMEGETHISM SCALE
GRADE
1 2 3 4
CLINICAL SIGNIFICANCE
OF POLYMEGETHISM
POLYMEGETHISM
Age
Diseases (diabetes, etc)
Trauma
Contact lenses
CAUSES
TEAR EXAMINATION
Quality
Lipid layer
Debris

TEAR EXAMINATION
Quality
BUT (fluorescein)
Tear prism height
Movement of debris
Rose Bengal staining

ANTERIOR CHAMBER
Transparency
Cells and flare
Persistent pupillary membrane
IRIS EXAMINATION
Architecture
Inflammation
Pigmentation
Naevi
Iridectomy
Colobomas

CRYSTALLINE LENS EXAMINATION
Orange Peel
Opacities
Pigment on capsule
Centration
Iris attachments

THANK YOU
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