SLIT LAMP EXAM

Authors:
Dr. Amy Fowler
Dr. Tim Platts-Mills
Dept of Ophthalmology
Department of EmergencyMedicine
University of North Carolina
Chapel Hill, NC
Medical Editors:
Dr. Amy Fowler
Dr. Tim Platts-Mills

INTRODUCTION
My name is Dr. Platts-Mills and Im an Emergency Physician. With me is Dr. Fowler from
the Department of Ophthalmology. Today we are going to teach you how to use a slit
lamp to evaluate common eye complaints.
The slit lamp biomicroscope is a tool used by ophthalmologists, but is also found in most
emergency departments. The slit lamp not only allows for three-dimensional
magnification of eye structures, but by generating a thin, bright beam of light, the
observer can actually view an optical cross section of the clear structures of the eye,
including the cornea, anterior chamber, and lens.
Lets learn how to use a slit lamp and diagnose some commonly-encountered eye
problems.
Slit lamp biomicroscopy skills are invaluable in diagnosing problems of the cornea,
anterior segment, and sclera of the eye. The slit lamp can also be used to examine the
vitreous, the retina, the optic nerve, and also measure the interocular eye pressure.
These are more advanced skills, however, and we will not be covering those in this
tutorial.
Commonly encountered problems where a slit lamp should examination should be
performed will include an acute red eye, acute eye pain, and eye and orbital trauma,
corneal ulcers, abrasions, foreign bodies, herpetic lesions, and penetrating globe
injuries. The ability to detect hyphema or hypopyon is also facilitated with a slit lamp
examination.

While cell pathology of the anterior segment can be seen without a slit lamp, a thorough
slit lamp examination is useful in finding the extent and depth of injury, and may be
present to exclude the presence of a foreign body. In cases where the pathology is not
obvious, a slit lamp is needed to confidently establish or exclude a diagnosis.
All slit lamps have three basic components: a light source, a binocular microscope, and
an assembly for stabilizing the patient and manipulating the light and microscope. While
there are several different models of slit lamps, we will be using a Haag-Streit slip lamp
for this tutorial. The basic controls are the same for every brand of tabletop slit lamp, but
you may need to consult your instruction manual to locate the controls on your particular
model.
PATIENT POSITIONING AND SLIP LAMP OPERATION
To begin, the patient should be properly positioned. Ask the patient to lean forward,
leaning their chin on the chin rest and their forehead on the bar across the top. Move the
chin rest up or down using the dial until the patients lateral canthus is lined up with the
black horizontal mark on the side of the slit lamp. If your slit lamp does not have a mark
that indicates the proper positioning of the chin rest, simply raise or lower the chin rest
until the light source is able to illuminate the entire eye.
Familiarize yourself with the table controls since these differ widely among
manufacturers. In this case the table is moved up or down while depressing this lever.
The table should be at height that allows the patient to be seated comfortably while
positioned at the slit lamp. The examiner should adjust their own chair to be seated
comfortably as well. Remember the patient should not be seated on a chair with nonlocking wheels.
To start, make sure that the light source is in the neutral, or midline, position. Find the
on/off switch and turn on the light source. Typically on the Haag-Streit slip lamp this
switch will be located on the underside of the table. This switch will also allow the
provider to vary the intensity of the beam by varying the voltage. Typically the slit lamp
should be operated at 5 volt or one-half strength so as to prolong the life of the lamp
bulb.
The joystick is used to move the lamp up or down by turning the handle. Moving or
rotating the joystick right or left causes the light source to move correspondingly. Focus
is achieved by moving the joystick forwards or backwards.
The upper control knob is used to adjust the length or height of the light beam. The
number gauge next to the upper control knob tells you the length of the beam in
millimeters and can be used to estimate the size of a lesion. The lower control knob
adjusts the width of the beam. In general, a tall wide beam is used for scanning the
eyelids, conjunctiva, and surface of the cornea, while a narrow beam is used for
examining the anterior segment structures of the eye. The upper control knob can also
be used to add a cobalt blue light filter. This is used to examine a fluorescein stained
eye.
The examiner needs to adjust the eyepieces of the microscope to accommodate their
own interpupillary distance, or PD, before beginning their exam. In general, the fine

focus dials on the oculars should be set at zero. Magnification can be changed from 10x
to 16x by moving the lever between the eye pieces. You should start your exam at the
10x magnification level and increase to 16x to better visualize subtle findings.
For most examinations, you will want to keep the microscope arm in the midline position
and rotate the light source to maximally illuminate the eye. However, there will be times
when you will need to set the microscope arm at an angle to better view certain
pathology or to better access the eye during foreign body removal.
EYE EXAM
Once you and your patient are comfortably and properly positioned at the slit lamp and
the overhead lights are dimmed, you are ready to begin. Start by examining the lids and
lashes by using a tall, broad beam of light under low magnification with light arm and
microscope arm in midline position. Next, using the same settings, evaluate the surfaces
of the conjunctiva, cornea, and sclera. Remember, small adjustments in focus and
lateral movement are made by moving or rotating the joystick. In patients with traumatic
eye injuries, be sure to examine the entire sclera, conjunctiva, eyelid margins, and
canalicular system for signs of lacerations.
If a corneal abrasion or herpetic lesion is suspected, you should perform a fluorescein
examination using the cobalt blue filter. You will need a fluorescein strip, topical
anesthetic, and gloves. To apply foreskin, place a drop of topic anesthetic on the
fluorescein paper strip. Then touch this wet paper to the posterior surface of the lower
eyelid. Make sure you use a fresh, unexpired bottle of anesthetic for each patient. If the
patient is having severe pain, a drop of topic anesthetic should be instilled in the lower
fornix prior to fluorescein instillation. Of note: if pain is completely relieved with the
topical anesthetic, a problem with the cornea is probably is likely.
After applying fluorescein, turn the upper knob until the cobalt blue light is on. Corneal
epithelial defects will stain green with fluorescein when viewed with the blue filter. If you
see fluorescein uptake on the surface of the cornea, ask the patient to blink to make
sure this is truly a lesion and not just a mucous strand or chance collection of dye known
as pooling of dye.
SLIT BEAM EVALUATION
Once the surface of the eye is examined, you are ready to perform the slit beam
evaluation. Using the lower knob, decrease the width of the light source to create a thin
beam, then move the light source to approximately 45 degree angle.
By generating a very thin beam of light directed at an angle, you are able to view an
optical cross section of the clear structures of the eye. The first structure the light passes
through is the cornea, which under normal conditions is clear. The first curve is the precorneal tear film and corneal epithelium. The broad part of the beam is a cross-section of
the corneal stroma. The posterior curve is the corneal endothelium. Next, light passes
through the optically empty antierior chamber which is filled with a clear, aqueous fluid. If
light is scattered or visible in this region, this usually represents the presence of cells
and/or proteinaceous material. The light beam is then reflected off the surface of the iris.
To clearly focus the details of the iris, you may need to gently push the joystick forward.
The light beam then passes through the lens of the eye. The lens has a lamellar, or

layered, structure; if a patients structure is naturally large or dilated, you can see all of
these layers. The beam passes through the lens in this order: anterior lens capsule,
anterior lamellae, lens nucleus, posterior lamellae, and posterior lens capsule. Notice,
when focused on the posterior parts of the lens, the cornea is out of focus. When the
patient has cataracts, which is defined as any opacification of the lens, you will be able
to see that. This is an example of a very dense, mature cataract.
ABNORMAL FINDINGS
This is a corneal abrasion. The defect stains green with fluorescein when viewed with
the cobalt blue filter. Be sure to avert the upper eyelid to exclude the presence of a
foreign body. Corneal abrasions are painful; apply anesthetic to the surface of the
cornea before applying fluorescein dye. Complete relief of symptoms with topical
anesthetic support the diagnosis.
This is a corneal ulcer. Fluorescein will stain any associated epithelial defect. A whitish
outer ring or focal white spot is known as an infiltrate, which represents reactive white
blood cells. Using the slit beam, you can estimate the depth of ulceration or thinning of
the cornea. Notice how the slit beam is thinner between the two arrows. You can also
estimate the depth of infiltration with the slit beam. This infiltrate involves only the
superficial layers of the cornea.
This infiltrate, seen here with a broad beam of light, involves the full thickness of the
cornea, as seen with a very thin slit beam.
This is a hypopyon, which is a collection of white blood cells in the anterior chamber. In
this case this is a layered hypopyon which is easily seen in the bottom of the anterior
chamber of the eye. A hypopyon may be a reaction to a corneal ulcer or may be caused
by an infection inside the eye turned endophthalmitis. A hypopyon resulting from
endopthalmitis may occur after a delay of treatment from open globe injury or after
recent cataract surgery represents a true eye emergency.
A hypopyon can also be microscopic. In this case white blood cells freely float in the
anterior chamber along with proteinaceous material. This combined finding, known as
cell enflare, is seen with iritis, but can be difficult to detect. Keep your slit beam at an
angle, shorten your beam to 1 mm, narrow it to approximately 1 mm, and turn up the
lamp voltage. Focus on the anterior space. This finding should looking something like a
movie projector shining in a dusty room.
This is a dendritic ulcer in a patient with herpes keratitis. The detection of this finding is
aided by the use of fluorescein staining. Often patients will not present with the servere
pain found with corneal abrasions despite the often large areas of fluorescein uptake. If
the patient presents with irritation or foreign body sensation, but has extensive stain
uptake, expect a herpes infection.
This patient has iritis. Note the perilimbal injection of the conjunctiva, the mid-dilated
pupil, and the cell enflare in the anterior chamber. These patients tend to have photophobia, or light sensitivity. Tramatic iritis is common after blunt injury to the eye.
This is a hyphema, caused by red blood cells in the anterior chamber. Traumatic injuries
to the eye often cause hyphemas, and are typically known as a layering of blood cells in

the anterior chamber. These blood cells can block the outflow of aqueous humor leading
to increased intraocular pressure. Patients with large hyphemas must be closely
monitored for this development. If a diffuse subconjunctival hemorrhage is present in
addition to the hyphema, suspect a ruptured globe and proceed appropriately.
This is a subconjuctival hemorrhage, which represents blood layering beneath the
conjunctiva. Note how the redness is solid, unlike the redness seen with the
conjunctivitis. Subconjuctival hemorrhages usually resolve without problems or
intervention.
This patient has an open globe injury. In this case, the iris protrudes through the
laceration of the cornea. A loss of the roundness of the globe, a defect in the pupil, or
steaming of fluorescein from the base of the foreign body are all signs of an open globe
injury, which is a surgical emergency.
This patient has a foreign body embedded in the cornea. Foreign bodies that do not
enter the anterior chamber may be removed with a needle or metal or plastic spatula.
After the foreign body is removed, a corneal burr may be used to removed any
associated rustering.
THE CLOWN EXAM: COMMON SLIT LAMP PROBLEMS
Now that we have learned how to use the slit lamp, lets do an exam.
[Knocking on door.]
Isabelle the Clown:
Come in.
Dr. Platts-Mills:
Hi, my name is Dr. Platts-Mills.
Isabelle:
My name is Isabelle the Clown.
Platts-Mills:
Isabelle, whats bothering you?
Isabelle:
Me and the other clowns were getting out of the clown car and I accidently got kicked in
my left and now all I can see are clowns and tiny elephants. It hurts.
Platts-Mills:
I see. Well, lets take a close look and see if you have injured your eye. Isabelle, lets
take a look.
One of the most commonly encountered problems with the slit lamp is not being able to
turn on the light. This leaves the patient in the dark and leaves you feeling like a clown.
First, make sure the slit lamp is plugged into the wall. Then, make sure that the plug
along that arm of the slit lamp is connected. If the slit lamp console has an on/off switch,
that needs to be turned on. Then, the switch for the slit lamp needs to be turned on. The

dial for the slit lamp should be turned to half strength, or 5 volts. The upper control knob
should be turned from the cobalt blue setting to the white light. Finally, if you are still not
able to get a light source, you need to check the light bulb, which is housed in the upper
chamber.
Isabelle:
Well, is there anything else to check?
Voiceover:
Another common problem is focusing on the patients eye. Remember, with the HaagStreit slit lamp, you focus by moving the entire slit lamp towards or away from the eye.
The light needs to shine on the patients eye. Check to be sure the patients forehead is
against the forehead strap. Then, move the light source and microscope all the way to
the back of the table. As you move forward, the eye should come into view. If the slit
lamp is locked, you will need to loosen the screw on the right slide of the table to move
it. When you are finished, lock the apparatus to prevent damage to the microscope.
CONCLUSION
We hope this tutorial has been helpful. With these skills you will be able to perform a slit
lamp examination with confidence.
Slit lamp examination is an important component of the evaluation of acute eye
pathology, and knowledge of this tool will allow you, as an emergency care provider, to
deliver the best care for your patient.