Advanced Slit Lamp Skills

OR

How to adjust the lighting to see stuff!

2 types of slit lamp biomicroscope

1)Zeiss slit lamp biomicroscope

-light source is at the base

2)Haag-Streit slit lamp biomicroscope

-light source is at the top
Zeiss slit lamp biomicroscope Haag streit slit lamp biomicroscope
 Lighting controls:
• Narrow the beam of light to a narrow
slit
• Vary the length of the slit to a small
Good pinpoint of light
• Introduce color filters to provide a
Illumination green and a deep cobalt blue
• Rotate the slit
• Adjust the angle between the slit
beam and line of sight
 X15 is good for
X6 to x40
routine use

Magnification

Lower mag for Higher mag

gross exam for details
 Longer
• Examine lids, cornea,
and conjunctiva, and sclera
Slit Beam wider
Size
Fine • Examine fine details
• Produce Tyndall effect
and when looking at
short aqueous and vitreous
 Adjust Adjust interpupillary distance for binocularity

Neutralize the eyepiece to correct refractive

Neutralize error

Examination Adjust Adjust height of table for the patient

setup
Adjust chinrest to give forehead support. Use
Adjust eye mark on post

Maneuver beam to the correct position and

Maneuver adjust beam to 1-2mm

Start on Start on low mag and build to higher

 Illumination techniques
• Diffuse illumination
• Direct illumination
• Parallelepiped
• Optic section • Von Herrick Technique
• Conical(pinpoint) • Contact Lens Evaluation
• Tangential • Fluorescein techniques
• Specular reflection
• Indirect illumination • Gonioscopy
• Retro-illumination • Fundus views
• Sclerotic scatter
 DIFFUSE ILLUMINATION
SETUP:

• Angle between microscope and illumination

system should be 30-45 degree.
• Slit width should be widest.
• Filter to be used is diffusing filter.
• Magnification: low to medium
• Illumination: medium to high.
Optics of diffuse illumination Diffuse illumination with slit beam and
background illumination
 DIFFUSE ILLUMINATION
OBSERVATIONS:

• Gives a good overall picture of the eye, but no fine details. It is used
primarily for a general survey of the eye.
• corneal scar or infiltration.
• The presence of folds in Descemet's membrane.
• invading blood vessels in the cornea
• Edema of the epithelium looks hazy, gray, and somewhat granular
• Contact Lens fitting
• Observe: eyelids, lashes, conjunctiva, sclera, pattern of redness, iris,
pupil, gross pathology, and media opacities
 PARALLELEPIPED:
SETUP:

• Narrowing the beam to 1-2mm in width to illuminate a

rectangular area of cornea.
• Microscope is placed directly in front of patients
cornea.
• Light source is approximately 45 degree from straight
ahead position.
 PARALLELEPIPED
OBSERVATIONS:

• Detect and examine corneal structures and defects.

• Opaque features in the cornea such as scars, abrasions, nebulae, blood
vessels, and folds in Descemet's membrane reflect the light and thus
appear whiter than the surround. These should also be examined under
retro-illumination.
• Higher magnification than that used with wide beam illumination is
preferred to evaluate both depth and extent of corneal scarring or foreign
bodies.
• Corneal nerves appear under higher magnification as fine white silk threads
usually branching into a Y (seen mostly in middle third of stroma).
• Detect corneal striae that develop when corneal edema occurs with hydrogel
lens wear and in keratoconus.
• Used to examine the endothelium.
Cornea
SCLEROTIC SCATTER
SETUP:

• Focus a bright but narrow slit beam on the

limbus
• Use microscope on low magnification- 10X
• The slit beam placed approximately 40-60
degree from the microscope
• Microscope directed straight ahead
• When the light is properly aligned with
regard to the eye, a ring of light will appear
around the cornea.
• The light is absorbed and scattered
through the cornea highlighting pathology.
SCLEROTIC SCATTER

OBSERVATIONS:

•Central corneal epithelial edema

•Corneal abrasions
•Corneal nebulae and maculae
 OPTIC SECTION

SETUP:

• Optic section is a very thin parallelepiped and optically cuts a very thin slice
of the cornea.
• Magnification: maximum.
• Slit length should be kept small
• Examination of AC depth is performed by wider slit width .1-.3mm
• Angle between illuminating and viewing path is 45 degree. intersect in the
area of anterior eye media to be examined e.g. the individual corneal layers.
 OPTIC SECTION
OBSERVATIONS:

• Used to localize: Nerve fibers, Blood vessels, Infiltrates, Cataracts, AC

depth.
• To discover thickening, thinning, and distortions in the corneal contour.
• To determine the depth of foreign bodies or opacities in the corneal
substance. (a percentage of the total corneal thickness)
• To see a wide slice of stroma. (The angle between the microscope and
illuminating arm can be increased.)
• To perceive the flare in normal aqueous. The luminous beam is directed so
that the upper portion of the beam enters the lower part of the pupil. This
permits dark areas immediately above to serve as a dark contrasting
background.
Cornea
 VAN HERRICK TECHNIQUE
• To evaluate anterior chamber angle without gonioscopy
• Medium magnification
• Angle 60 degrees
• Narrow beam close to limbus

• Depth of anterior chamber is evaluated to the thickness of cornea:

4. grade – open anterior chamber angle 1:1 ratio

3. grade – open anterior chamber angle 1:2 ratio
2. grade – narrow anterior chamber angle1:4 ratio
1. grade – risky narrow anterior chamber angle less than 1:4 ratio
0. grade – closed anterior chamber , cornea “sits” on iris
 CONICAL BEAM(pinpoint)

SETUP:

• Produced by narrowing the vertical height

of a parallelepiped to produce a small
circular or square spot of light.
• Source is 45-60 degree temporally and
directed into pupil.
• Biomicroscope: directly in front of eye.
• Magnification: high(16-25x)
• Intensity of light source to highest setting.
 CONICAL BEAM
OBSERVATIONS:

• Beam is focused between

cornea and anterior lens
surface and dark zone between
cornea and anterior lens
observed.
• Most useful when examining
the transparency of anterior
chamber for evidence of
floating cells and flare seen in
anterior uveitis.
 Tyndall phenomenon
• Principle is same as that of beam of
sun light streaming through a room
illuminating airborne dust particles.
• Cells, pigment or proteins in the
aqueous humour reflect the light like a
faint fog.
• To visualize this the slit illuminator is
adjusted to the smallest circular beam
and is projected through the anterior
chamber from a 42° to 90° angle.
• The strongest reflection is possible at
90°.
 SPECULAR REFELCTION

SETUP:

• Established by separating the microscope and slit beam by equal angles

from normal to cornea.
• Position of light source: 30 degree to one side position of microscope: 30
degree to other side.
• Angle of illuminator to microscope must be equal and opposite.
• Angle of light should be moved until a very bright reflex obtained from
corneal surface which is called zone of specular reflection.
SPECULAR REFLECTION
 SPECULAR REFLECTION
OBSERVATIONS:

• Specular reflection is used to visualize the integrity of the corneal and lens
surfaces.
• If the surface is smooth, the reflection will be smooth and regular;
• if the surface is broken or rough, Irregularities ,deposits will fail to reflect light and these
appears darker than surrounding
• To visualize the endothelium, start with lower magnification (10X to 16X). Direct a
relatively narrow beam onto the cornea
• Switch to the highest magnification available
• Endothelium is best viewed using only one ocular.
• Under specular reflection anterior corneal surface appears as white uniform surface
and corneal endothelium takes on a mosaic pattern.
 RETRO-ILLUMINATION
SETUP:

• Formed by reflecting light of slit beam from a

structure more posterior than the structure
under observation.
• A vertical slit beam 1-4mm wide can be used.
 RETROILLUMINATION
OBSERVATIONS:

• Used most often in searching

for keratic precipitates and
other debris on corneal
endothelium.
• The crystalline lens can also be
retroilluminated for viewing of
water clefts and vacuoles of
anterior lens and posterior
subcapsular cataract
 Direct retro-illumination from iris:

SETUP and OBSERVATION

• Use magnification of 16x to 25x and direct the light from 45

degree.
• Microscope is directed straight ahead .
• View corneal pathology.
• A moderately wide slit beam is aimed towards the iris directly
behind the corneal anomaly.
 Schematic of
direct retroillumination from
the iris.

direct retroillumination from the iris.

 Indirect retroillumination from iris:

SETUP and OBSERVATION

• Performed as with direct retroillumination but the beam is

directed to an area of the iris bordering the portion of iris
behind pathology.
• It provides dark background allowing corneal opacities to
be viewed with more contrast.
• Observe: Cornea, angles.
Retroillumination from fundus(red reflex photography)

SETUP and OBSERVATIONS:

• The slit illuminator is positioned in an almost coaxial position with

the biomicroscope. The slit beam at 2 to 4 degrees
• Shorten the beam to the height of the pupil to avoid reflecting the
bright light off of the iris.
• The decentered slit beam is projected near the pupil margin
through a dilated pupil.
• Focus the microscope directly on the pathology using 10X to 16X
magnification. Opacities will appear in silhouette.
Schematic of Example of retroillumination from the retina.
retroillumination from the
retina.
 TRANSILLUMINATIION
SETUP:

• The pupil must be at mid- mydriasis (3to 4 mm when light

stimulated).
• Place the light source coaxial (directly in line) with the
microscope.
• Use a full circle beam of light equal to the size of the pupil.
• Project the light through the pupil and into the eye .
• Focus the microscope on the iris.
• Magnification of 10X to 16X is adequate
 TRANSILLUMINATION
OBSERVATIONS:

• The iris is evaluated by how light

passes through it.
• This technique takes advantage of
the red reflex.
• Normally the iris pigment absorbs
the light, but pigmentation defects
let the red fundus light pass through.
 TANGENTIAL ILLUMINATION
SETUP:

• Medium-wide beam of moderate height

• Swing the slit lamp arm to the side at an oblique
angle
• Requires that the illumination arm and the viewing
arm be separated by 90 degree.
• Magnifications of 10X, 16X, or 25X are used
 TANGENTIAL ILLUMINATION

OBSERVATIONS:

• Anterior and posterior cornea

• Iris is best viewed without dilation by this method.
• Anterior lens (especially useful for viewing
pseudoexfolation).
 Cornea

• Wide slit beam

 Cobalt blue filter
• Used in conjunction with fluorescein stain
• The dye absorbs blue light and emits green.
• Ocular staining
• RGP lens fitting
• Tear layer
• IOP
• Wratten yellow filter #15 to enhance contrast visibility of
fluorescein staining with cobalt blue
Red free(green)filter:

Obscure any thing that

is red so blood vessels
or hemorrhages
appears black.
This increases contrast
revealing the path and
pattern of inflamed
blood vessels.
Fleischer ring can also
be viewed satisfactorily
with the red green
filter.
 Contact lens evaluation

• Diffuse setting used to determine

gross fitting around limbus.
• Parallelepiped used to determine
the fit of a contact lens
• Adjust width of beam to CL
beyond limbus on one side.
Keeping same width, move
to opposite limbus to
compare.
• After fluorescein has been
instilled in the eye with RGPs
to determine air spacing
between CL and Cornea.
 Using Lenses as an extension of the Microscope
• Gonioscopy
• 3- or 4-mirror lens
• Observe AC zones:
• Iris surface- iris processes
• Ciliary body- angle recess
• Trabecular zone-Scleral spur, Schwalbe’s line
• Transition zone from white sclera to bluish cornea

• Hruby, Goldmann or 90-D

• Vitreous- degeneration, floaters, cells, pigment, infiltrates

• Retina- macular cyst or hole, hemorrhage, tears, tumors

 Let’s Play!

• Share what you have seen.

• Practice, Practice, Practice
• Thank-you!
Nic Jacobs, MA, COA, CCRC, OSA
Chu Vision Institute
[email protected]
952-835-1235