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Slit Lamp Illumination Types Associated Ocular Conditions And Slit Lamp Examination Procedures
Direct Illuminations: 1.) Diffuse: Diffuse illumination or "wide beam" illumination deserves a short separate discussion from the other types of illuminations. The term diffuse has been carried over from earlier writings when slit lamps had either diffusing filters or independent racking microscopes. This allowed each to be independently focus on different structures. Most of today's slit lamp biomicroscopes have their light sources and microscope coincident to one another and are focused on the same structure at the same time. Diffusing filters are still found in some slit lamps and are used in photographing the anterior segment of the eye. "Wide beam" illumination is the only type that has the light source set wide open. Its main purpose is to illuminate as much of the eye and its adnexa at once for general observation. A wide, un-narrowed, beam of light is directed at the cornea from an angle of approximately 45 degrees. Position the microscope directly in front of the patient's eye and focus on the anterior of the cornea. Low to medium magnification (7 - 16x) should be used which allows the observer to view as many of the structures as possible. When viewing the eye with achromatic light one should note, on gross inspection, any corneal scars, irregularities of the lids, tear debris, irregularities of Descemet's membrane or pigmentary changes found in the epithelial layer, etc. These findings are investigated more thoroughly with other types of illumination. With the aid of the cobalt blue filter and either fluorescein sodium or Fluoresoft® permit the evaluation of bearing, movement, positioning of contact lenses. Using the cobalt blue filter and fluorescein sodium this is a reasonable illumination for assessing a patient's tear break up time (TBUT), dark drying areas of the epithelium. Staining of the cornea and conjunctiva can also be assessed. Fluorescein sodium dye will stain the cornea and conjunctiva any time the epithelium is compromised. Fluorescein dye does not stain epithelial cells themselves, but pools within the intercellular defects thus highlighting the damaged area. Fluorescein staining is relatively nonspecific, occurring with any condition affecting epithelial integrity. Do not confuse "negative staining" for true TBUT. Negative staining is often seen when checking TBUT or evaluating an area that has stained in the past. "Negative staining" results because of irregularities in the corneal epithelium. These dark areas are where the tears separate quickly rather than stain tissue. Examples: Map and dot dystrophies, micro-cystic edema, healing but still rough and not smoothly healed abrasions, etc. The cobalt blue filter is also helpful in detecting Fleischer's Ring or Line in keratoconus and Hudson Stahli's Line in older patients.
Using Rose Bengal and no filters will show a pink staining of epithelial cell damaged tissue as in cases of keratoconjunctivitis Sicca, herpatic lesions of the lids and cornea and other ulcer margins. Other types of illumination are better for evaluating the degree and depth of any staining. See color plates in Dr. Casser's book. Diffuse, wide-beam, illumination together with the red free (green) filter is helpful when viewing the bulbar conjunctiva, and episcleral blood vessels. With the aid of the red free filter small hemorrhages, aneurysms and engorged vessels stand out. It is not difficult to differentiate between conjunctival,
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try scanning the cornea from temporal limbus to nasal limbus. the angular separation of the illumination source is reduced until the light beam just grazes the edge of the pupil and the vertical height can be reduced to approximate the pupil size. This alignment can easily be accomplished from outside the biomicroscope. M. whereas less superficial and deep vessels show minimal to no movement with the overlying conjunctiva. the crystalline lens will appear sectioned. The slit width is almost closed. it is possible to detect changes in corneal and conjunctival thicknesses.10 X) and focused on the patient's closed lid. By focusing the biomicroscopes with one hand and controlling the direction or 2 of 8 3/08/2011 9:35 p. conjunctiva or locating the depth of an opacity within the lens of the eye. which means focusing on the cornea is accomplished by only slightly moving the joystick forward. 2. Once the cornea is in sharp focus. scars and opacities. First place the magnification on low to medium (7 . the illumination source at about 45 degrees and the illumination mirror in "click" position. . give the patient a point of fixation such as the fixation light.Slit Lamp Biomicroscopy Part One http://www. Deeper episcleral injection may also appear somewhat darker and give an overall purplish hue. The biomicroscope should be directly in front of the patient's eye.opt. distortion-free view.. A) Ciliary Injection B) Episcleral Injection C) Conjunctival Injection Grade Severity 0 White and Quiet Slight. Have the patient open their eyes. To maintain a clear.. When the beam cuts just across the edge of the pupil. Conjunctival vessels are obviously fairly superficial and are movable upon friction from the eyelid.) Optic Section: Optic section is used primarily to determining the depth or elevation of a defect of the cornea. and scleral injection. about 0. With the optic section as mentioned above. episcleral. to assess depths of foreign bodies. (Abelson et al) proposed a standardized grading system for judging the different types of injection. The thickness of the eyelid is about 1 mm thick.)Direct Focal a. Usually 1/2 Normal 1 to 1+ Mild 2 to 2+ Moderate 3 to 3+ Severe Adapted and modified from Abelson. to estimate the anterior chamber depth and to identify the anatomical location of cataracts within the crystalline lens. et al. With a clearly focused optic section slightly temporal to the center of the cornea. increase the magnification to 16x then to 20x and illumination brightness and note the following: 1) The Tears 2) The 3) The 4) The 5) The Front Surface Bright Zone Is The Surface Of The Next Darker Gray Line Is The Epithelium Layer Next Brighter Thin Line Is Bowman's Membrane Gray Wider Granular Area Is The Stroma Zone Last Bright Inner Zone Is The Endothelium To attain an optic section of the crystalline lens.m. or the top of the your opposite ear.indiana. part of the biomicroscope. the illumination source is always moved to the opposite side when crossing the mid-line of the cornea about at the center of the pupil.edu/riley/HomePage/newslitlamp/1_part_one_sli.25 mm wide and 7 to 9 mm high.
. Iris to Corneal Angular Separation Equals 20 0 Anterior Chamber Depth (Shadow) is Equal to 1/4 the Corneal Thickness Anterior Chamber Depth (Shadow) is Equal to Less Than 1/4 the Corneal Thickness Anterior Chamber Depth (Shadow) is Only a Very Narrow Slit or no Anterior Chamber Angle 1 Extremely Narrow Angle. lens opacities classification system II (LOCS II)[Chylack.opt. Iris to Corneal Angular Separation Equals 0 0 Adapted from: Van Herick W. Furthermore. hence. Different magnifications may be used. but medium and high give the best detail.68:626-9. Estimation of width of angle of anterior chamber. Closure Probable. Shaffer RN. The doctor then views the arc of light through the cornea and that falling on the iris without the aid of the slit lamp. Closure is Most Emanate. The "Split Limbal Technique" allows you to make an estimation of the superior and inferior angles.m. Iris to Corneal Angular Separation Equals 10 0 0 Basically Closed Angle. which is focused on the limbal cornea junction thus. The angular separation seen at the limbus corneal junction is an estimation of the anterior chamber angle depth in degrees. Iris to (Shadow) is Between 1/4 and Corneal Angular Separation 1/2 the Corneal Thickness Equals 20-35 0 2 Moderately Narrow Angle.. the anatomical location of any opacity can be determined. This is a grade 1 or narrow angle. 3 Moderately Open Angle. Schwartz A.indiana. angle of the light source with the other hand. Closure Possible. 3 of 8 3/08/2011 9:35 p. Anterior Chamber Depth Incapable of Closure.Slit Lamp Biomicroscopy Part One http://www. The beam width is that of an optic section. 1989]. Van Herick Angle Estimation Method Angle Grades 4 Risk of Angle Closure Cornea to Angle Ratio Wide Open Angle. the degree of nuclear opalescence and color can be evaluated and graded via the. Optic section using the Van Herick Technique to grade the anterior chamber depth. This technique only allows you to judge the temporal and nasal angles. splitting the cornea and limbus.edu/riley/HomePage/newslitlamp/1_part_one_sli. Iris to Cornea (Shadow) is Equal to or Greater Angular Separation Equals Than Corneal Thickness 35-45 0 .. Van Herick's technique for grading the anterior chamber angles uses an optic section placed near the limbus with the light source always at 60 degrees. the different layers of the lens can be brought into focus. Am J Ophthalmol 1969. The slit lamp and illumination system are in click position aligned directly in front of the patient. The biomicroscope is placed directly before the patient's eye. Incapable Anterior Chamber Depth of Closure.
More Than You Can Count READ VOL..) Conical Beam: Examination of the anterior chamber for cells or flare must be performed before either dilation or applanation tonometry. Use a parallelepiped approximately 2 mm wide and 4 mm high. The conical beam is focused between the cornea and the anterior lens surface and observation is concentrated on the dark zone between the out of focus cornea and lens.m.opt. 1982].35 ) ( 35 . Dilation often results in an increase in the number of cells and fluorescein used in applanation tonometry causes an increase in flare [Schlaegel. You watch and count the number of cells seen during a minute period.20 ) < 20 BUT > 10 ) ( 10 OR LESS ) 0 0 0 0 b.20x and illumination (high) or what the patient will tolerate. 4 . The traditional method of locating and grading cells and flare is to reduce the beam to a small circular pattern with the light source 45 to 60 degrees temporally and directed into the pupil.indiana. This type of illumination is used to detect floating aqueous cells and flare by the. "Split Limbal Technique" Which Is Observed With The Naked Eye Grade Angle + 4 TO 4 + 3 TO 3 + 2 TO 2 1-0 ( 45 . The convection currents of the aqueous will move any protein or cells up and through this zone. Position the biomicroscope directly in front of the patient's eye with as bright illumination as the patient will permit and high magnification.. The examiner always allows themselves a period of time to dark adapt. Flare (protein escaping from dilated vessels) makes the normally optic empty zone appear gray or milky when compared to the uninvolved eye.CHAPTER 32 IN "DUANES' CLINICAL OPHTHALMOLOGY" Cells and flare in the anterior chamber represent a condition 4 of 8 3/08/2011 9:35 p. Grading Cells and Flare Grade Aqueous Cells Grade Flare 0 1 2 3 4 None 0 1 2 3 4 Optically Empty Compared Bilaterally Faint: Haze or Not Equal Bilaterally Moderate: But Iris Detail Still Clear Marked: Iris Details Becoming Hazy Dense Haze: With Obvious Fibrin Collecting on Iris 2-5 Cells Seen in 45 Seconds or One Minute 5-10 Cell Seen at Once Cells Scattered Through Out Beam 20 or More Dense Cells in Beam. Tyndall effect. The examiner waits and watches the dark zone between the out-of-focus cornea and the light passing through the pupil and lens. Magnification 16 . Focus on the iris near he pupil then pulled back the focus into the anterior chamber so light is seen passing through the out-of-focus cornea and lens. This zone is normally optically empty and appears totally black. . much like seeing dust floating in the air of a sun filled window.Slit Lamp Biomicroscopy Part One http://www. The following techniques have been suggested: either to oscillate the light source with the joy stick from left to right while focused in the anterior chamber or to focus from the posterior cornea to the anterior lens while oscillating the light source.edu/riley/HomePage/newslitlamp/1_part_one_sli. These techniques are not typically used clinically The following is a more traditional technique and one that works well clinically and is superior when grading the severity of inflammation. Cells (white blood cells escaping from dilated vessels) will reflect the light and be seen as white dots.
.0 mm) and the height may vary.edu/riley/HomePage/newslitlamp/1_part_one_sli. They are diagnostic of poor soft contact lens fitting. to help confirming an inflammatory diagnosis. but may correlate with bacterial infections. if cells or flare are not seen.. The patient completely covers the eye in question so no light can enter. Corneal scars are white in color and diagnostic of some past corneal damage. Corneal striae are white usually vertical thread-like twisting lines found in Descemet's membrane and posterior stroma. They are to report any discomfort when the slit lamp is turned on in front of the "good eye" and the brightness is turned up. A parallelepiped is essentially an optic section. Ghost vessels extend from the limbus onto or into the cornea. a clear undistorted view must be maintained by positioning the light source to the opposite side when crossing the mid-line of the cornea. Grading the Consensual Pain Reflex Grade Patient Response Definite Pain Without Acute 1 To 1+ Distress Causes Wincing or Complaint 2 To 2+ of Pain Causes Withdrawal From the 3 To 3+ Light Severe Allows No Light in the 4 To 4+ Eye C. It is used in combination with a number of different types of illuminations.) Parallelepiped: A parallelepiped is one of most common types of illumination used. Both normal and abnormal findings can be seen when scanning the cornea with varied levels of magnifications and brightness. and are diagnostic of chronic or acute insult or inflammation.indiana. but an inflammation is suspected.opt. The three-dimensional view permits observation of distinguishable details within the crystalline lenses "zones of discontinuity". abrasion or foreign body. 1981]. The whole cornea should be scanned using a parallelepiped. When scanning the cornea. Look for any of the following: Tear debris is usually benign and related to allergies or sinus conditions. cells and flare may not be present. As with the optic section. However. . providing a more three dimensional view of the cornea or crystalline lens. the illumination source at about 45 degrees and the illumination mirror in "click.m. ulcer. Blood filled vessels extend from the limbus onto or into the cornea. Grades of Cornea Striae Grade Observed Number 0 None 1 Less Than Five 2 Five To Ten 3 Ten To Twenty 4 More Than Twenty Endothelial pigmentation when heavy and located vertically on the endothelium is known as "Krukenberg's 5 of 8 3/08/2011 9:35 p. The biomicroscope should be directly in front of the patient's eye.Slit Lamp Biomicroscopy Part One http://www." position. stroma and endothelium. use the "Consensual Pupillary Reflex" test "Henkind" test or "Consensual Pain Reflex" test. except the slit width is greater (2. but there most likely is a smoldering inflammation that has not resolved or is about to develop [Au. the angle between the illumination source and biomicroscope may be varied to expose more corneal epithelium. Corneal nerves are white thread-like structures that bifurcate and trifurcate and are located anywhere within the cornea. They are empty of blood and diagnostic of some type of past corneal insult or inflammation. If he/she reports discomfort. of great concern and are usually diagnostic of an inflammation. They are the result of overall thickening of the entire cornea and buckling of the back surface. diabetes or metabolic changes as with the reduced number of endothelial cells of the elderly.0 . all one and the same.4.
Because it utilizes direct. Make sure the illumination mirror is in "click" position. Keratic precipitates (accumulation of white blood cells and fibrin) will appear white in direct illumination but dark by retro-illumination.m. The alignment and angular separation of the biomicroscope to the illumination source will vary. Casser's book. Most helpful in detection of mycrocystic edema.. Use low 6 . it may be diagnostic of iris atrophy and pigmentary glaucoma.Slit Lamp Biomicroscopy Part One http://www. This technique is valuable for observation of deposits on the corneal endothelium and invading blood vessels. .opt. 3. In the case of central corneal clouding (CCC) the biomicroscope is not used. indirect and retroillumination simultaneously. Retro-illumination is regarded by most optometrist to be second in importance only to direct illumination. very fine deposits are commonly seen and not pathological. faint corneal infiltrates and other types of irregularities of the epithelium and tears.indiana. warning the so-called "quiet iritis" is still active. The dark area just lateral or proximal to the parallelepiped is the indirect or proximal zone of illumination.10x). According to some authors this is the only way by which tiny rod-like fibrin flecks may be seen on the back of the cornea. 5. Spindle".) Retro-Illumination: Usually uses a parallelepiped that bounces unfocused light off one structure while observing the back lighting of another.2 mm wide and 4 .10x magnification. The light passes through the cornea and falls out of focus on the iris. Furthermore. Scant. Use a parallelepiped beam sharply focused on a given structure like the cornea. The light source beam is reflected off another structure like the iris. This is the area of the cornea which one surveys through the biomicroscope. one should consider it to be as important as any other type of illumination.5 mm high with the biomicroscope and light source placed in direct alignment with each other. 6 of 8 3/08/2011 9:35 p. Focus the slit just off the edge of the iris and on the front of the lens.edu/riley/HomePage/newslitlamp/1_part_one_sli. Retroillumination or transillumination the iris or crystalline lens uses low to medium magnification (7 . crystalline lens or retina while the biomicroscope is focused on a more anterior structure. retroillumination of the crystalline lens is required to classify and grade both cortical and posterior subcapsular cataracts using LOCS II. If there are defects or atrophy of the iris they will be seen as a retinal "orange" glow coming back through each defect or hole. The slit width 1 . 4. See color plates in Dr.) Sclerotic Scatter: This illumination uses a parallelepiped at the limbus to scatter light internally throughout the cornea. This type of illumination is widely used for observation of the corneal epithelium and tears. holes in the iris. They are both positioned directly in front of the eye to be examined. Remember the term transillumination iris defects or (TID's).) Indirect-Lateral-Proximal: Place the biomicroscope directly in front of the patient's eye and the illumination light source at about 45 degrees. The pupil is observed with the naked eye from an angle directly opposite from the light source. noted. The cornea is probably the most common structure viewed in retro-illumination. Patients who have numerous endothelial pigment deposits you must transilluminate their iris.. Transillumination of the iris should be performed and any transillumination iris defects (TID's).
Their forehead tight against the headrest.indiana. . Turn the biomicroscope on and focus the light source on the patient's lid. The eyelid is only about 1 mm thick. Keratic precipitates on the endothelium of the cornea as seen in direct. This is the only means by which one is able to view the endothelial cells of the cornea or the epithelial cells on the back of lens.) Specular Refection: Again a parallelepiped is used.) Head Position: A. It should be noted that even with 40x magnification the endothelial cells do not look as large as most texts show. when you instructed the patient to open their eyes you should almost be in focus on the tear film of the cornea. You should have already cleaned the head and chin rest with an alcohol swab. This not only helps keep things more antiseptic. one bright. therefore. Critically focus the biomicroscope on the latter until a mosaic of hexagonal cells are seen. Place he biomicroscope directly in front of the patient's eye and the illumination light source at 45 . 3. For professional and hygienic reasons always place a facial tissue on the slit lamp's chin rest. The basic requirements for specular reflection are as follows: 1) The angle between the illumination source and biomicroscope is approximately 60 degrees. Slowly advanced it across the cornea until a dazzling reflection of the filament is seen within the biomicroscope.opt. and the other ghostlike or copper-yellow in color. B. Keeping the reflected light within the biomicroscopes field of view. For Example: This is a slit lamp biomicroscope and I'll be examining the general health of your eye. 2. Suggested Slit Lamp Examination Procedure (1) (2) 7 of 8 3/08/2011 9:35 p. This might be the fixation light. When the slit lamp's illumination system and the biomicroscope are at equal angles of incidence and reflection the cornea's endothelium is viewable.edu/riley/HomePage/newslitlamp/1_part_one_sli.. They resemble the appearance of the dimpled surface of an orange peel or basketball.) Pre-Alignment And Focusing: Tell your patient to close their eyes and relax while you get things aligned. The cells are seen only by one eye and they appear in the ocular opposite from the direction of the illumination light source. chin firmly down on the chin rest and their outer canthus aligned with the black marker on the slit lamp post. 3) High illumination is needed. 6. Positioning The Patient In The Slit Lamp 1. where you want them to look.Slit Lamp Biomicroscopy Part One http://www. 4. and retroillumination using a parallelepiped. but also makes the slit lamp smell clean and more professional. 2) High magnification must be used.) Tell the patient what you want them to do: chin in the chin rest and forehead up against the headrest. Just off the limbus.) Make sure the patient not only looks comfortable but is comfortable. At this point it is a good idea to reach around and gently pull their head slightly forward against the headrest. obtain a sharply focused parallelepiped of the cornea. the focus is moved back toward the endothelial cells. Both front and back surfaces of the crystalline lens can also be viewed using specular refection. indirect.) Procedure: Inform the patient what you are going to do and why. part of the slit lamp or just past your ear.) Fixation Instructions: The patient must be given fixation instructions. This is always done between every patient.60 degrees..m. 4) A parallelepiped beam of light is used. There will be a point where two images of the filament are seen. This reflection is only seen by one eye the other eye is not bothered.
light source at 45 degrees and the microscope set straight ahead. To View Part Two Return To Home Page 8 of 8 3/08/2011 9:35 p. Examine the iris. (7) (8) Use a full length Optic Section. Scan and examine the cornea. Evaluate and grade the temporal and nasal angles using the Van Herick Technique. retract the upper lid. Use a narrow Parallelepiped. Have the patient look to their left. Scan and examine the temporal bulbar conjunctiva (3) (4) Have the patient look to their right. The microscope is set straight ahead. and lock it down at the end of any procedure. (5) (6) Have the patient look down. examine the lower bulbar. 16X Magnification. The light source should be moved across to the opposite side at the midline of the eye.edu/riley/HomePage/newslitlamp/1_part_one_sli. lower Palpebral conjunctiva and inferior cornea. The light source should be moved across to the opposite side at the midline of the eye. light source at 60 degrees and the microscope set straight ahead. Illumination on low at 45 Degrees. magnification 16X. examine the upper bulbar conjunctiva and superior cornea. . The microscope is set straight ahead.. The light source should be moved across at the midline of the cornea. pull the slit lamp back. The microscope is set straight ahead.opt.. Examine both the upper and lower lids and lashes. Use a Parallelepiped. The above is only intended as a schematic and students are encouraged to develop any order with which they feel comfortable. It should be pointed out that all steps in the schematic are relevant and should be part of the procedure. Magnification 10-16x. Scan and examine the nasal bulbar conjunctiva. light source at 45 degrees and the microscope set straight ahead. 16X magnification. light source to your right at approximately 45 degrees. Important: Always. Using a broad beam or better a 2 to 4 mm wide Parallelepiped Type Illumination. light source to your left at approximately 45 degrees.Slit Lamp Biomicroscopy Part One http://www. The microscope is set straight ahead. retract the lower lid. shut off the instrument.indiana. The patient's eyes are open and the illumination source is moved at the midline of the lid. crystalline lens and the anterior vitreous body. Have the patient look up.m.
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