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Slit Lamp Biomicroscopy

Basic Course in Ophthalmology

September 28, 2017

Ivo John Dualan, MD

Clinical Associate Professor
Department of Ophthalmology and
Visual Sciences
University of the Philippines
Philippine General Hospital
Why slit lamps are essential
The slit lamp exam is considered to be the gold
standard for the assessment of the anterior segment
of the eye in clinical practice

Excellent image quality
Stereoscopic image
Flexible illumination
Flexible magnification
What can we use them for?
On their own With accessories
Routine examination of Gonioscopy
anterior segment Fundoscopy
From the ocular adnexa
Ocular photography
through the anterior vitreous
Problem-based examination Applanation tonometry
of anterior segment (Goldmann)
Contact lens evaluation Pachymetry
Assessment of anterior Laser photocoagulation
chamber depth and angle Dry Eye evaluation
Basic Design
Viewing arm
Adjustable focus eyepieces
Magnification dial

Illumination arm
The slit lamp
Slit size, shape and filter controls
Variable size, shape, colour and brightness

Biomicroscope and illumination are mechanically

coupled around central pivot point (copivotal)
Both focus at the same point (parfocal)
Both arms can swing independently 180 along
horizontal there is a scale in degrees
Both always central regardless of angle (isocentric)

Moveable base plate and joystick control

Haag-Streit type Zeiss type
A good Slit Lamp has
Adequate working distance between the microscope
and the eye to allow the practitioner to access the
Adaptable to suit different practitioners
Good resolution
Good depth of focus
A wide range of magnifications
Slit lamps provide variable magnification
Lower magnifications are used for general
assessment and orientation
Higher magnifications are used for detailed
inspections of areas of interest
There are several ways to do this
Common methods: Littmann-Galilean telescope and
zoom systems
Less common methods: Change the eyepieces and/or
change the objective lens (old style)
Littmann-Galilean telescope method
A separate optical system is placed in between the
eyepiece and the objective
It consists of a rotating drum that house 2 Galilean
telescopes plus a pair of empty slots
Optics refresher: Galilean telescopes consist of a
positive and negative lens that provide magnification
based on the lens powers and their separation
The magnification dial will click into place as you turn
it, and there will be numbers on the dial that
correspond to the magnification in each position
A Galilean telescope
Parallel light enters and exits.
Magnification is typically the intended
However, if you look from the other
side, the image will be minified.
Two telescopes produce two
Mag highest when the
convex lens is near
Reversal of these two
telescopes produces two
further minifications
No telescope provides 5th
Zoom systems
This tends to be found on high-end models.

Magnification can vary between 7x to ~ 40X

Change eyepieces or objective
Eyepieces Objective
Often two sets provided with Flip arrangement for rapid
slit lamp change
Typical values 10x, 12.5x, 15x or
20x Usually only two options due
Inconvenient so rarely used to space confinements
Generally unnecessary on Typical values are 1x and 2x
modern slit lamps

The slit lamp
Slit width
Continuously variable (0 to 8-
May be graduated to allow
Narrow slits are used to
slice through the cornea to
determine depth or thickness
Wide slits are used to inspect
Slit height
May be continuous or set to fixed
Usually a combination of the two
May be graduated to allow for
measurement (caliper function)
Long slits are used to view most
structures in front of the pupil,
while short slits pass through the
pupil much better
Short slit also used to assess the
clarity of the anterior chamber
(cells & flare)
Achieved by rotating
Slit orientation lamp housing
Slit lamps may have some/all of the following filters

Red free
Cobalt blue
Wratten (in observation system)
Types of illumination
Methods of illumination
Sclerotic Scatter
Specular View
A combination of these methods is used to view
the anterior eye structures
Direct illumination

The light and the microscope

are both pointed at the object
of interest

Direct illumination
There are several different forms, named simply by how
wide the slit is
Diffuse (usually not a slit at all)
Wide beam
Optical section
The slit width will change what you can see
Diffuse/wide beam for an overall view
Wide parallelepiped for broad views of one plane (e.g.
Surface of a structure) and narrow parallelepiped for a
balanced view
Optical section to cut through a tissue, for thickness and
Effect of slit width (cornea)

Wide beam: mostly surface Parallelepiped: balance of

Optical section:
surface and depth
mostly depth
Why is the angle important?
Angle between the microscope (optical arm) and the
illumination arms matters.
Wider angles
Allow visualization of deeper layers without interference
from reflections from anterior layers
Estimate depth
The wider the beam, the greater the angle needed to view
the posterior surface layer
Allows better perception of texture
Graduated scale located at the pivot point of the two slit
lamp arms (illumination & optical arms)
It will give you the total separation between the two arms in
Effect of angle (cornea)

45: balance of 5: surface only 85: depth only

surface and depth
Wide beam/Diffuse
Used for general inspection
of eye and adnexa
Good for colour
Contact lens fit
Wide slit, diffusing inserted,
microscope in front,
illumination angle 3050,
magnification of 6-10x
Patients are generally This eye has iris naevi (freckles)
unable to tolerate the
brightness of a wide beam
Default method for
corneal inspection
Shows a block of tissue
in 3-D, so good balance
between surface and
depth inspection
Beam about 2 mm,
variable angle, medium
to high mag (10-25x)
Optical section
Allows judgement of
thickness or depth

Use the narrowest slit

possible (0.1 0.2 mm),
angled beam (largest
angle possible), high
illumination, and a dark
Indirect illumination

An object being viewed is illuminated

indirectly when it lit by
reflections/scatter of light that occur
when the light is shone other than
onto the object itself.

Indirect illumination
Good for subtle detail, which would be obscured or
washed out by large amounts of illumination

Light internally reflected within the cornea, or reflected by

other surrounding tissue

Opacities scatter light so they will appear light in colour

best viewed against the dark pupil or dark iris

Keep the slit width narrow to medium (2-4 mm), and view
with a medium to wide angle. Magnification will vary
depending on the size and extent of the object, but its
typically medium to high for subtle defects

Indirectly illuminated

This picture shows a contact-lens related condition called neovascularisation. These are
blood vessels in the cornea. In this example, we dont move anything but our attention
the light and focus stays where it is. We can do this because the slit doesnt light up our
whole field of view

An object of interest is lit by retro-illumination

when the light source is directed onto another
structure so that the reflected light must pass
through that object.

Light may be reflected from 2 main structures:
Iris: this back-lights the cornea
Fundus: this back-lights the lens and the cornea

Opacities will appear dark against a bright background

For iris retro-illumination, use a narrow-moderate width
slit, a wide angle of illumination, and magnification
appropriate to the object size/extent
Decoupling may be necessary when the magnification high

For fundus retro-illumination, use a short slit with narrow-

moderate width, narrow angle of illumination (0-10), and
moderate magnification

Indirectly illuminated

This is the same example from earlier. The blood vessels in the indicated section are
retro-illuminated because they are being lit from behind (the light has reflected off the
This is an example of retro-illumination of the lens (the light has
reflected from the retina). This patient has cortical spokes,
which are indicative of early cortical cataract.
keratic precipitates (direct & retro-illumination )
Sclerotic Scatter
Decoupling is done.
Intense light is illuminated at limbus at 45 but
optical view is at center of cornea.
Total internal reflection of light through cornea.
Lesions in stroma will manifest to observer
Specular Reflection
Technique to view the
endothelial surface

Done at high

Optical arm may be

brought to extreme
angle to view
Anterior Chamber reaction
Beam can be narrowed and shortened to examine
cells and flare in AC.
Take good care of your Slit Lamp!
Keep it clean

Dont leave the switch on when not in use

Learn to trouble shoot minor issues (bulb, power

supply, alignment and focusing problems.)

Lock the base and arms when transporting

Thank You!