SLIT LAMP EXAMINATION

By Dr.Pragnya Rao

Contents

Introduction Parts of slit lamp Slit lamp examination Illumination techniques 1)diffuse 2)direct: -beam - tangential -pinpoint - specular 3)indirect - proximal - sclerotic scatter - retroillumination - transillumination Special procedures

 Slit lamp is an instrument giving a binocular observer a sterioscopic observation of the eye, helping in determination of location of abnormalities with precision Biomicroscope Eye can be scanned horizontally and anteroposteriorly. Optically -homogenous media appear black. - cornea, lens and suspended particles in aqueous scatter light opalescent

Introduction

Magnification= power of oculars x power of objective lens.

Parts
Parts: - illuminating arm - observing limb - supporting apparatus

Horizontal illuminating source

vertical illuminating source

Slit lamp examination

Patient positioning: - lock the slit lamp away from head support unit. - pull the tonometer arm away . - reassure and instruct the patient to place his chin on chin rest and forehead against the bar. - teeth together and breathe through nose.

 Fixation: to keep eyes steady can use a fixation device ask to look over examiners ear or shoulder. Magnification : initially 6x or 10 x magnification can use 16x if more closer examination is warranted manipulation of light source: one hand is kept on light source to change beam width, angle, and height other hand on joystick for position change.

Suggested Power 6X or 10X: external (lids, conjunctiva), contact lenses 16X angles, cornea, lens, foreign bodies, corneal abrasions 40X corneal endothelium Beam Width narrowest : a bit wider : a bit wider yet : full width :

angles, cornea, anterior chamber cornea, lens, etc external, contact lenses external, applanation tension (with blue filter)

Beam Height full : most areas and structures short : checking anterior chamber for cells & flare

Color/Filter White:

most areas and structures

Blue (with fluorescein dye) applanation tensions, corneal staining, tear film, staining patterns of rigid contact lenses
Green (red-free) : evaluating blood vessels, iron lines

Illumination techniques
Categories of illumination 1) Diffuse 2) Direct 3) Indirect.

Diffuse illumination: provides an even light over the entire ocular surface. Direct illumination: light is shone directly onto the area or structure of interest. Indirect illumination: object of interest is illuminated by light that is reflected off of another structure.

Illumination techniques
1. Diffuse 2. Direct Beam Tangential Pinpoint Specular 3. Indirect Proximal Sclerotic Scatter Retroillumination Transillumination

Diffuse illumination
Light is spread evenly over the entire observed surface.

permits a gross survey of the eye (especially the skin).

the beam is opened all the way & light is directed onto the eye at a 450.

Least amount of magnification available (6X or 10X) is used.

Observe: eyelids, lashes, conjunctiva, sclera, pattern of redness, iris, pupil, gross pathology, and media opacities

Diffuse illumination

Beam

Direct illumination

observing the configuration and densities of opacities, lesions, and other abnormalities. Must be used in conjunction with indirect techniques Sweep the cornea or other structures with a narrow full-length beam with microscope directed straight (may also be moved to an angle opposite the illuminator) The greater the angle between the illuminator and the microscope, the greater the width of the illuminated section. very narrow beam (optical section) directed onto the cornea corneal shape, elevation, and thickness.

Observe: cornea, iris, lens, vitreous

Focal broadbeam illumination

Focal slit beam

Tangential illumination:
useful in observing surface texture. light projected from an oblique angle(Tangential)creates shadows highlight surface irregularities medium-wide beam of moderate height is swung to the side at an oblique angle (almost parallel to viewed structure) with microscope pointing straight ahead. Magnifications of 10X, 16X, or 25X are used.

Iris without dilation Cornea and lens with dilation

Observe: anterior and posterior cornea, iris, anterior lens.

Tangential illumination

Pinpoint (Conical Section)

to detect suspended particles in AC in liquid media (Tyndalls phenomenon) Direct the beam so that it enters the cornea temporal to the pupil to strike iris nasal to the pupil .

Increase magnification to 16X or 25X. Focus in the anterior chamber between the lens and corneal endothelium.
Cells (immune cells) and flare (clumps of protein) may be present in the aqueous. is easier if pupil is not dilated. Observe: cells, flare

grade

Aqueous flare
absent Faint,barely detectable

Flare (2mm height, 1mm width)

Cells per field (2mm height, 1mm width) 0 5-10

0 1+ 2+ 3+ 4+

Moderate, 10-20 iris and lens details clear Marked, 20-50 Iris and lens details hazy Intnse flare, Fibrinous exudates >50

Specular Reflection
used to visualize the integrity of the corneal and lens surfaces.
If the surface is smooth reflection is smooth and regular; surface is broken or rough reflection is irregular/appears textured. Position: illuminator & microscope are about 30 degrees on either side of central perpendicular.

The angle of the illuminator to the microscope must be equal and opposite
Direct relatively narrow beam onto cornea and reduce height of beam(to reduce glare. Best viewed uniocularly. Observe: corneal epithelium & endothelium, lens surface

Indirect illumination
Structure to be viewed is lit up by light reflected off uninvolved area

Proximal indirect illumination:

used to observe internal detail, depth, and density. short,fairly narrow slit beam is placed at the border of the structure or pathology (The light will be scattered into the surrounding tissue, creating a light background that highlights the edges of the abnormality. Observe: corneal opacities (edema, infiltrates, vessels, foreign bodies), lens, iris

Proximal indirect illumination

Sclerotic Scatter
Indirect form of illumination created by decentering the beam after releasing the central locking screw Broad beam is directed to temporal limbus

Light is reflected through thickness of cornea to reflect onto opposite limbus,highlighting opacities in central cornea. . 10X magnification, with the microscope directed straight ahead.
iris provides a contrasting dark background.

Observe: general pattern of corneal opacities

Retroiilumination
The light strikes the object of interest from a point behind the object and is then reflected back to the observer Direct Retroillumination From the Iris Used to view corneal pathology. moderately wide slit beam is aimed toward the iris directly behind the corneal abnormality. Indirect Retroillumination From the Iris the beam is directed to an area of the iris bordering the portion of the iris behind the pathology This provides a dark background, allowing corneal opacities to be viewed with more contrast. The angles are also evaluated with this technique

 Retroillumination from the Fundus (Red Reflex) The light is directed so that it strikes the fundus and creates a glow behind the abnormality Highlights media opacities( cataracts, corneal scars) The slit beam and microscope must be nearly coaxial; Shorten the beam to the height of the pupil to avoid reflecting the bright light off of the iris. This view is with pupil dilated. Observe: cornea, lens, vitreous

Transillumination
a structure is evaluated by how light passes through it.

Iris Transillumination The pupil must be at mid mydriasis (3 to 4 mm when light stimulated) and light source coaxial with the microscope. Use a full circle beam of light equal to the size of the pupil with microscope focussed on iris. Observe: iris defects (they will glow with the orange light reflected from the fundus)

Applanation tonometry
Principle: Imbert- Fick principle amount of force needed to flaten/applanate a known area of cornea. IOP is - directly proportional to pressure applied - inversely proportional to area flattened

7mm of flat plexiglass plate flattens an area of 3.06mm in diameter at posterior corneal surface.
Most accurate reading is obtained when the inner surface 2 mires coincide

Gonioscopy

Observation of angle of anterior chamber by diverting the light beams using gonioscopes

 Slit lamp enables stereoscopic observation of the eye

Parts: biomicroscope illuminating arm supporting apparatus Illumination techniques: diffuse,direct, and indirect

References
The slit lamp primer Parsons diseases of the eye