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
All rights reserved. No part of this publication may be reproduced, stored in a
retrieval system, or transmitted, in any form or by any means, without the prior
permission, in writing, of:
The International Association of Contact Lens Educators
IACLE Secretariat,
PO Box 656
Kensington NSW 1465
Australia
Email: [email protected]
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
FEATURES
• Variable magnification
• Binocular system
SLIT-LAMP MICROSCOPE
SLIT-LAMP MICROSCOPE
Low 7X - 10X General eye
Medium 20X - 25X Structure layers
High 30X - 40X Detail
SLIT-LAMP BIOMICROSCOPY
LOW MAGNIFICATION (7x - 10x)
General eye:
• Lids
• Bulbar conjunctiva/sclera
• Cornea/limbus
• Tears
• Anterior chamber/iris/crystalline lens
SLIT-LAMP BIOMICROSCOPY
SLIT-LAMP BIOMICROSCOPY
MEDIUM MAGNIFICATION (20x - 25x)
Structures:
• Epithelium
• Stroma
• Endothelium
• Lens fit/surface
SLIT-LAMP BIOMICROSCOPY
SLIT-LAMP BIOMICROSCOPY
HIGH MAGNIFICATION (30x - 40x)
Details:
• Epithelial changes
• Stromal striae, folds
• Endothelial folds, polymegethism
SLIT-LAMP BIOMICROSCOPY
SLIT-LAMP BIOMICROSCOPY
HIGH MAGNIFICATION (30x - 40x)
Epithelium
• Vacuoles
• Microcysts
• Dystrophies
SLIT-LAMP BIOMICROSCOPY
SLIT-LAMP BIOMICROSCOPY
HIGH MAGNIFICATION (30x - 40x)
Stroma
• Striae
• Folds
SLIT-LAMP BIOMICROSCOPY
SLIT-LAMP BIOMICROSCOPY
HIGH MAGNIFICATION (30x - 40x)
Endothelium
• Polymegethism
• Guttata
• Blebs
• Dystrophies
• Cell Density
SLIT-LAMP BIOMICROSCOPY
SPECULAR REFLECTION: ENDOTHELIUM
STRUCTURES OBSERVED
WITH
DIFFERENT ILLUMINATIONS
SLIT-LAMP BIOMICROSCOPY
Method of illumination is
IMPORTANT
SLIT-LAMP
ILLUMINATION SYSTEM
FEATURES
• Variable light intensity
• Filters
• Width
• Height
• Angle
SLIT-LAMP
ILLUMINATION SYSTEM
ILLUMINATION
TECHNIQUES
• Diffuse
• Direct
• Indirect
ILLUMINATION
TECHNIQUES
• Retro-illumination
• Specular reflection
• Sclerotic scatter
• Tangential
DIFFUSE ILLUMINATION
• 45 degree angle between light &
microscope
• Slit open fully
• Diffusing filter
• Variable magnification (low to high)
BROAD BEAM
Iris
Cornea
Beam of light
Microscope
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
Iris
C ornea
B eam of light
M icroscope
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
Iris
B
Cornea
A
Aerial View
OPTIC SECTION
A B
DIRECT ILLUMINATION
PARALLELEPIPED
• Broader view
• Illuminated block of the cornea
• More extensive examination
PRINCIPLE OF THE PARALLELEPIPED
Iris
B B'
A A' Cornea
Aerial View
PARALLELEPIPED
B B'
A A'
DIRECT ILLUMINATION
CONICAL BEAM
• Inflammatory cells/flare in the
anterior chamber
• Darkened room
CONICAL BEAM
Beam cross-section
Iris
Cornea
Conical Beam
Conical beam Microscope
INDIRECT ILLUMINATION
Observation and illumination systems are
not focused at the same point
INDIRECT ILLUMINATION
Iris
Cornea
Beam of light
Microscope
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
Iris
Cornea
Beam
of light
Microscope
RETRO-ILLUMINATION
• Vary angle of illumination
• Moderately wide beam
• Slit beam is offset
• Medium to high magnification
• Reflected light from iris or fundus
DIVERGING CONVERGING
REFRACTOR REFRACTOR (AFTER Brown, 1971)
• Observer
• Transparent intra-corneal
object
• Background for marginal
retro-illumination
• Unreserved (U) and
reversed (R) appearance
U R
RETRO-ILLUMINATION
Alignment of reflected beam with
area under observation
TYPE ALIGNMENT
Direct Direct and full view
Indirect Adjacent
Marginal Margin or edge
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
Iris
Cornea
Beam Microscope
of light
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 70o - 80o between
illumination and observation system
TANGENTIAL ILLUMINATION
Iris
Cornea
Beam of light
Microscope
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
Bulbar
Conjunctiva
Limbus Palpebral
Cornea
Tears
Anterior Chamber
Iris
Lens
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
(La Hood & Grant, 1990)
Striae (number)
25
striae = 1.45 x oedema - 6.5
n = 192
20 r = 0.88
p < 0.001
15
10
0 5 10 15 20 25
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
(La Hood & Grant, 1990)
Folds (number)
25
folds = 1.33 x oedema - 9
n = 166
20 r = 0.87
p < 0.001
15
10
0 5 10 15 20 25
Oedema (%)
DAYTIME STRIAE RESPONSE
HIGH WATER 74% vs LOW WATER 43%
(La Hood, 1991)
Striae (Grade 0-4)
1.5
+5.00 D n=11
High Water
Low Water
1.1
1.0
1
0.6
0.5
0.3
0.1
0 0 0
0
0 2 4 6
Time after lens insertion (hours)
MICROCYSTS
• Small, irregular shape (15-50 m)
• Reversed illumination
• Slow onset
• Cyclic phenomenon
• Asymptomatic
MICROCYSTS
DISPOSABLE HFDROGELS (Grant et al., 1990)
Microcysts (number)
50
40
30 6-13N
20
10 DW
0 4 8 12 16 20 24 28 32 36
Time (months)
MICROCYSTS
PATHOLOGY
• Basal epithelial cells secrete intra-
epithelial sheets
• Disorganised cell growth
• Pockets of dead cells
• Slowly pushed to surface
MICROCYSTS
ONSET AND RECOVERY
Microcysts (number)
35
HWC HWC
n=51 n=29
30
CCLRU GOTEBORG
20
10
0
0 2 4 6 8 10 12 0 2 4 6
Time (months)
MICROCYSTS (Zantos, 1981)
. . . Break through the anterior
corneal surface and manifest as
corneal ‘dry spots’
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
CAUSES
• Age
• Diseases (diabetes, etc)
• Trauma
• Contact lenses
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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SYMBOLS
ABBREVIATIONS
ACRONYMS
ACRONYMS
