Slit Lamp:

• •
Ехапппайоп


and
Photography
Revised and fxpanded
Third fdition

Csaba L. Martonyi, CRA, FOPS

Emeritus Associate Professor and Former Director of Ophthalmic Photography
University of Michigan Medical School
Апп Arbor, Michigan, USA

Charles F. Bahn, МО
Bethesda, Maryland, USA

Roger F. Meyer, МО
Professor Emeritus of Ophthalmology
University of Michigan Medical School
Апп Arbor, Michigan, USA

•
· Тime Опе Ink, Ltd., Sedona, Arizona
•
• www.timeoneink.com
 Slit Lamp: Examination and Photography
Revised and Expanded Third Edition

Copyright ©1984, 1985,2007 Ьу Csaba L. Мапопут, СRЛ, FOPS

АН rights Reserved

No part of this publication тау Ье reproduced, stored in а retrieval system, or transmitted in апу form ог
Ьу апу means electronic, mechanical, photocopying, recording, or otherwise, without prior permission of
both the copyright holder and the publisher of this book.

ISBN 13: 978-0-615-16519-6

Library of Congress Control Number: 2007907357

Additional copies of this book mау Ье ordered from:

. Time One Ink, Ltd.

• Вох 2222
•
Sedona, AZ 86339-2222

www.timeoneink.com

The publisher offers special discounts оп bulk orders of this book.

Cover Design & Page Layout Ьу Р] Saine

www.pjsaine.com

Part of the material contained herein was originally published in the Journal of Ophthalmic
Photography (Volume 7, Number 1, 1984 and Volume 28, Number 1,2006) and as Clinical Slit
Lamp Biomicroscopy and Photo Slit Lamp Biomicrography, second edition.

First printing, third edition.

Printed in the United States of America

iv
То
Elnajean Beyst-Martonyi
Zonular Congenital Cataract Seen in Retroillumination from the Fundus.
 ТаЫе of Contents

Chapter 1
Historical Development 1

Chapter 2
Modern Instruments 7

Chapter 3
Сепегаl Anatomy and Physiology of the Еуе 17

Chapter 4
Principles of Slit Lamp Biomicroscopy 23

Chapter 5
Forms of IIIumination: Principles and Applications 33

Chapter 6
Photo Slit Lamp Biomicrography 77

Chapter 7
Special Techniques 89

Chapter 8
Stereo & Digitallmaging with the Photo Slit Lamp Biomicroscope 113

Chapter 9
External Photography 127

References 145

Index 147

vii
 Contributing Authors

Charles F. Bahn, MD
Bethesda, Maryland, USA

Csaba L. Martonyi, CRA, FOPS

Emeritus Associate Professor and Former Director of Ophthalmic Photography
University of Michigan Medical School
Апп Arbor, Michigan, USA

Roger F. Meyer, MD
Professor Emeritus of Ophthalmology
University of Michigan Medical School
Апп Arbor, Michigan, USA

Cary S. Michalec, BS, CRA, СОА

Zeiss-Meditec, [пс.
DubIin, California, USA

Patrick J. Saine, MEd, CRA, FOPS

Formerly: Manager of Ophthalmic Photography
Dartmouth Hitchcock Medical Center
Lebanon, New Hampshire, USA

Marshall Е.Tyler, BS, CRA, FOPS

Iпstгuсtог of Surgical Sciences
Wake Forest University Еуе Center
Winston-Salem, North Carolina, USA

viii
Preface
Among the most ubiquitous оЕ instruments at the disposal оЕ the clinician, the slit lamp biomicroscope has
grown in sophistication and versatility to Ьесоте ап indispensable extension оЕ the experienced examiner.
The slit lamp is so commonplace and accommodating as to Ье taken largely for granted. Thus, its true value
тау Ье measured only Ьу imagining its absence.
Learning to use the instrument сап Ье а challenge; but опе that empowers and invigorates. The added
complexities оЕ slit lamp photography are today moderated Ьу digital imaging. Instant feedback оЕ results
allows immediate correction and re-exposure. А monitor display permits real-time sharing оЕ results with
the ophthalmologist for guidance оп illumination techniques.
This edition contains two new chapters; опе оп stereo slit lamp photography, and another оп external pho-
tography. Over 170 new images and illustrations have Ьееп added.
It is hoped that the reader ,.уill find this text а helpful resource in mastering the techniques оЕ slit lamp
examination, and slit lamp and external photography .

•••

Reflecting оп а wholly satisfying career оЕnearly thirty years brings to mind the тапу individuals who made
that journey а most rewarding опе. Most оЕ those individuals have contributed to this book directly or indi-
rectly, in ways large and small, as teachers and mentors, as 1 slowly learned ту craft. It is their encouragement,
guidance, and examples оЕехсеllепсе t11atultimately made possible the undertaking оЕту share оЕthis project.
It is here that 1 express ту gratitude to the тапу whom 1 саппот пате individually, and to those listed below
for their invaluable contributions to this effort.
Бrепt А. Баuеr, БА; Terry J. Беrgstrom, MD; Kenneth W. Christopherson, БS, CRA; Robert J. Crossen, MD;
Kenneth Fong; Terry George, RБР, FOPS; Gerald Р. Hodge, БFА; Johnny Justice, Jr, CRA, FOPS; Denis С. Lee,
БS; Jeffrey L. Lipkowitz, MD; Michigan Еуе Бапk; Janice Е. Мцвсп, БА; Alan Sugar, MD; Баrrеtt Р. Walker; Don
Wong, RБР, FOPS; and Andrew К Уinе, MD, for their kind assistance in the preparation оЕ the First Edition.
Carolynn МсСошtnеу and Lorie Giefer оЕ Corporate Graphics for furthering ту education in PhotoShop®
and printing matters. And, for their commitment to the highest quality product, delivered оп time, in spite оЕ
the obstacles we placed in their paths.
Richard Е. Hackel, CRA, FOPS; Robert L. Prusak, БА, CRA; Linda С. Goings, БFА, CRA; and Richard А. Rice
for their most generous assistance in facilitating updated images for the Third Edition.
Robert L. Feuge, PhD, for his expert editing and тanу improvements to the text оЕt11eThird Edition.
Richard А. Lewis, MD, FOPS, for opening а door to а wonderful new world, inviting те to step throug11.
Who, as ту first teacher, introduced те to the fundamentals оЕ ophthalmic photography and the much larger
realm оЕOphthalmology. And, for the generous use оЕhis red реп to ensure the success оЕthe First Edition.
Раиl R. Licl1ter, MD, F. Бruсе Fralick Professor and Chair, University оЕMichigan Department оЕOphthalmol-
ogy and Visual Sciences, Director, W.K Kellogg Еуе Center, whose support made the First and Second Editions
(and тапу other things) possible.
Sally А. Stanley, CRA, Senior Ophthalmic Photographer; Frances Р. Mclver, CRA; and Linnea L. Бrаgg, оЕthe
Kellogg Еуе Center, for their professional dedication, loyalty, and invaluable assistance throughout the devel-
opment оЕthe First Edition.
The entire Department оЕ Ophthalmology and Visual Sciences at the University оЕ Michigan, and its stellar
faculty, for ап environment not only rich in tradition, but опе permeated with the studied pursuit оЕthe cutting
edge оЕехсеllепсе in patient саге and research.
The Ophthalmic Photographers' Society for friendship, fellowship, and а stimulating environment in which
1 could test ту wings and learn to soar.
And, foremost, ту entire family, and especially, ту wife, Elnajean Беуst-Маrtопуi, without whose love and
encouragement this book could not have соте into being.

Csaba L. Martonyi
Sedona, Al'izona

ix
 "Pictures, belonging to the first level of abstraction,
соте much closer to meaning the same thing to
different persons than do words, which usually
belong to much higher levels of abstraction."

LeeAllen (1970-2006)

х
Foreword

This book should Ье read Ьу eVerYOl1e шгегевтес ш slit lamp imagil1g, апо
Ьу eVerYOl1echarged with the геэропвйяшу of ophthalmic diagl10sis апс гпап-
agemel1t. 'Птаг шсшоев ophthalmologists, optometrists, гезшептв, fellows апо
вшсепгв.
Ргорег рапегп гпапаяетпегп depel1ds 011 accurate diagl1osis. Accurate di-
agl10sis begil1s with оозегсапоп. If ппропапг pathology is missed at the slit
lamp, it is difficult to make а proper diagl1osis. Without the proper diagl1osis,
it is рше luck if гпапаяегпепс is successful.
Оовегсапоп also depel1ds 011factors 110t limited to what we observe about
the еуе. We must see what is actually ргезепт, 110twhat should Ье ргеэепг. We
must always look for what is differel1t rather Нтап for what is the same. We
must tell ourselves that the symptomatic рапепг has pathology; we simply
must fil1d it. Also, we must 110tЬе too quick to label оцг fil1dil1gS because that
ппепегез with careful оовегсапоп.
Ошвгаткйпя оозегуапоп absolutely requires skillful use of the slit lamp. Ап
outstal1dil1g observer, such as Csaba Мапопуг, uses the Ьеат of the slit lamp
to рашг light across tissue ш much the same way that the artist's рашфгцвп
is ш сопзтагп гпопоп. The skillful slit lamp observer is easily idel1tified пл less
Нтап twel1ty весопов Ьу how dYl1amic the width, al1g1e, апо directiol1 of the
light is ш гешпоп to the oculars.
There is 110 better resource Нтап this book to teach зогпеопе how to use
the slit lamp апо to ооташ outstal1dil1g slit lamp агк! ехtешаl ocular photo-
graphs. It is also without peer ш teachil1g the critical first step ш гпапаяегпепг:
оовегуапоп.

[ау Н. Krachmer, MD
Руо/еББОУ апа Chair
Department o/Ophthalmology
UniveJ'sity о/ Minnesota

х;
 .:
/--~
/
г-:':
-. -

Figuгe 1.1 ObIique, ог condensed, illumination after Himley, 1806

 Chapter 1

а
а
•
crogra

I ntroduction
Н istorical Development

Clinical slit lamp biomicroscopy and photo slit lamp Ыо-

micrography are stimulating and 11ighlychallenging disci-
plines. With the dynamic flexibility of the slit lamp biomi-
croscope, the delicate structures of the еуе сап Ье studied
with а wide range of magnifications, angles of view, and
forms of illumination. The sophistication of modern photo-
graphic instruments makes possible the documentation of
even minute changes. The mastery of such instrumentation,
however, is not а simple task. Subtle changes that affect the
transparent or translucent structures of the еуе тау Ье dif-
ficult to visualize, and even more difficult to photograph.
Photodocumentation is further limited Ьу the inability of а
single, static photograph to replicate, in itself, the three di-
mensional, minutely detailed, composite image of а dynam-
ic, clinical slit lamp ехапцпапоп.' Success in both slit lamp
biomicroscopy and biomicrography requires а facility with
the instrument, а clear understanding of the principles and
applications of аНforms of illumination, ап appreciation of
both the normal and pathologic anatomy of the еуе, and а
keen interest in а highly chaHenging and stimulating art.

2
 Historical Development
Present day slit lamp biomicroscopes evolved over many years and embody
advances in the p11ysics of illumination, optics, traditional photography, and
digital imaging. During а period spanning over two centuries, independent
researchers described increasingly innovative methods of illuminating and
viewing the еуе. This process of evolution began in the late 1700's with the
Hartnack "[оцре." Basically а magnifying glass, this instrument enabled the
examiner to better visualize the anterior structures of the еуе. At the begin-
ning of the nineteenth century, Himley reported оп the advantages of oblique
illumination (Fig. 1.1). In 1891, Aubert presented his binocular соrnеаl micro-
scope at the Ophthalmological Congress at Heidelberg. This was improved Ьу
Czapski in 1897 (Fig. 1.2). 'Птеп, а pivotal event took place:

"Оп August 3, 1911, Alvar Gullstrand presented his first nldimentary model
0/Пи: slit lаmр be/ore the 'Versammlung ае: Deutschen Ophthalmologischen
Gesellschajt' in Heidelberg, and explained its optics and applications. "1

This new device was to rival Helmholtz's ophthalmoscope in importance to

the development of modern ophthalmology.

FIGURE 1.2 Czapski's improved version of the Aubert binocular corneal

microscope, 1897.

з
FIGURE 1.3 Gullstrand's slit illuminator, the Nernst-spaltlampe, 1911. FIGURE 1.4 Czapski's corneal microscope and Gullstrand's slit
illuminator after Henker, 1916. (Image courtesy 01Сагl Zeiss AG)

Gullstrand's slit illuminator, the Nernst-spaltlampe (Fig. 1.3), set the stage
for the modern era оЕophthalmology.
Ву 1917,Henker had devised а practical combination оЕ Gullstrand's illumi-
nator and Czapski's biomicroscope, marking the first major advance in meth-
ods оЕexamining the external еуе in more than а century (Fig. 1.4). In 1936,
Comberg established the co-pivotal and iso-centric relationship between the
biomicroscope and slit lamp illuminator in а compact, practical design (Fig.
1.5). The flexible controllever was added Ьу Goldmann in 1938, essentially
completing the basic design upon which most modern instruments аге based
to this day (Fig. 1.6). In 1943 and 1949,М. Berliner published his elegant land-
mark work "Biomicroscopy оЕthe Буе" containing over twelve hundred hand
drawn illustrations representing а veritable treatise оп slit lamp findings and
methods оЕillumination.

FIGURE 1.5 Comberg's slit lатр biomicroscope FIGURE 1.6 Goldmann's slit lатр biomicroscope with its
leaturing а co-pivotal design and а vertical illuminator, universal controllever, 1937. (image courtesy of Haag-Streit AG)
1936. (Image courtesy 01 Сагl Zeiss AG)
4
 FIGURE 1.7 Thiel's сатега arrangement for the slit lamp, 1930.

The first limited success at slit image photography was achieved Ьу Thiel in
1930 using ап instrument with carbon arc illumination (Fig. 1.7). А reflex сагп-
era attachment also Ьесаmе available for the Comberg instrument (Fig. 1.8). А
decade later Goldmann introduced а сагпета arrangement that moved with
the slit lamp and permitted photography of а sharp optical section through the
соrnеа and lens. The 1940s witnessed the relative perfection of electronic flash
illumination and, in 1965, Zeiss introduced the first practical photo slit lamp
biomicroscope based оп Littmann's design (Fig. 1.9). 2,Ц5

FIGURE 1.8
Reflex сатега оп the Comberg slit lamp, 1936.

5
FIGURE 1.9 Zeiss photo slit lamp biomicroscope after Littmann, 1965. (Image couгtesy of Carl Zeiss AG)

6
 SubIuxated Lens in Retroillumination from the Fundus
7
 Chapter 2

ern
те s

The Clinical Slit Lamp Biomicroscope

Photo Slit Lamp Biomicroscopes
Photographic Attachments
New Technology

The basic design of the slit lamp biomicroscope was es-

tablished decades ago and remains essentially unchanged.
That does not, however, imply stasis in the evolution of Нте
instrument. In fact, today's slit lamp is light years removed
from early efforts in its refinement and capabilities. From а
fairly cumbersome collection of components requiring indi-
vidual adjustment, it has morphed into а facile extension of
the ехапппег, with superb capabilities in enabling detection
of the most subtle dераrtшеs from normal.
Photo slit lamp biomicroscopes, though limited in пшп-
ber, are equally advanced; and the slit lamp continues to
play the role of host as а delivery platform for ап increasing
diversity of new technology.
8
 The Clinical Slit Lamp Biomicroscope
While slit lamp biomicroscopes are available in variable designs, their basic
operating principles are the same (Fig. 2.1). These instruments consist of two
primary components that provide: 1) illumination (slit lamp) and 2) magnifica-
tion (biomicroscope). The slit lamp illuminator provides the precise and widely
adjustable lighting required for visualization of
both gross and subtle changes in near transpar-
ent tissues. The binocular biomicroscope pro-
vides the magnified, three-dimensional image

N
that сап Ье observed or photographed. Magni-
fications obtainable with most slit lаmр biomi-
croscopes range from approximately 6Х to 40Х.
Slit lаmр biomicroscopy requires consider-
аЫе flexibility in instrument design to permit
the simple, independent manipulation of both
the slit lаmр illuminator and the biomicroscope.
Also, the slit lamp illuminator and biomicro-
scope must Ье coupled co-pivotally to provide
the necessary par-focal and iso-centric relation-
ship between the two; that is, they must focus
оп Нте same рlапе simultaneously and the slit
~ must center in the field of view regardless of
, t11eangle between the slit lаmр illuminator and
the biomicroscope (Fig. 2.2).
The slit lаmр illuminator has controls for ad-
justing the l1eight and width of the illuminating
Ьеаm.
А

в
FIGURE 2.1 (А) The Zeiss SL 120 clinical slit lamp biomicroscope (/mage courtesy of Zeiss Meditec AG). (В) The Haag·Streit ВО
900 clinical slit lamp (/mage courtesy of Haag-Streit AG). (С) The Торсап SL-D7 clinical slit lamp (/mage courtesy of Торсап Medical
9 Systems).
 Additional features mау include:
- Filteтs (green, fluorescein exciter, neutral density, polarizing, etc) that mау Ье
placed into the light path;
- А gauge to indicate t11e11eig11tо/ the slit Ьеат а! Пи:еуе [о: purposes о/ measure-
ment;
- Adjustments Пш! pennit horizontal or vertical displacement о/ the slit Ъеат
[ют t11eиэиа! iso-centric position zuith the тотиловсоре (Fig. 2.3); and
- Reorientation о/ the slit Ьеат [ют the изиа! vertical display to ап oblique or
попгопш! presentation.
The biomicroscope incorporates adjustments for observer inter-pupillary
distance and variable magnification.
Accessories that mау Ье used with clinical slit lamps include applanation to-
nometers, pachymeters, observer attachments, potential acuity meters, video
cameras, digital cameras, etc.

1+4

--

FIGURE 2.2 The slit illuminator and the biomicroscope аге mounted оп а соттоп axis (1) FIGURE 2.3 The normal iso-centric relationship
to facilitate the iso·centric and par-focal relationships essential for ease of use. The slit Ьеат between the slit lamp illuminator and the biomicroscope
(2) is in sharp focus а! the same plane as the biomicroscope (3) and they both center оп the сап Ье altered (the slit Ьеат de-centered) to facilitate
same point (4) regardless of the angular difference between the two. indirect forms of illumination.

70
 Photo Slit Lamp Biomicroscopes
The fully capable photo slit 1amp biomicroscope (PSL) represents а more
comp1ex instrument with additiona1 capabilities, although the slit 1amp illumi-
nator and biomicroscope remain the heart of the system (Fig. 2.4 and 2.5). Ad-
ditiona1 components required for optima1 slit 1amp biomicrography include:

1. Веат Splitta оу Reflex Min'or System

2. Diffuse Overall Шипипаии (Fill Light)
3. Electronic Flasll
4. Сатет Back(s)
5. Eyepiece Reticle

А Ьеаm sp1itter is аn optica1 device that produces two images (опе for t11e
examiner and оnе for the camera) Ьу dividing the light entering the biomi-
croscope. А combination of prisms, or а partially silvered mirror, the Ьеаm
splitter permits а portion of the reflected light from the subject to pass through
the oculars of the biomicroscope to the examiner whi1e the rest of the light is
deflected to the сагпета for photography (Fig. 2.6). This arrangement produces
а coaxia1 image for photo documentation. That is, the camera sees the еуе ех-
actly as seen Ьу the examiner. Precise contro1 of fie1d of view, focus, alignment,
and artifacts is thus possible. А disadvantage, however, is а considerable [овз
of light to the examiner (see Fig. 2.6). Some photo slit 1amp biomicroscopes
provide for the remova1 of the Ьеаm splitter from the light path with а simp1e
control permitting examination of the еуе wit11 100% of the available light.
Before а photograph сап Ье taken, 110wever, the Ьеаm splitter must again Ье
positioned in the light path to divert а portion of the light to the сагпета. The
ideal arrangement is а reflex mirror that, as in а single lens reflex сагпета (SLR),

А
FIGURE 2.4 (А) The Торсоп SL-D8Z photo slit lamp biomicгoscope (/mage courtesy of Торсап Medica/ Systems, /пс). (В) The Haag-Stгeit ВХ 900 steгeo
photo slit lamp biomicгoscope (/mage courtesy of Haag-Streit AG).
7 7
 FIGURE 2.5 (А) Symbols representing the objective lens 01the
biomicroscope (1), the slit lamp illuminator (2) and the lilllight (3), (8) Diagram
А
showing the components 01the photo slit lamp biomicroscope,

Slit Ьеат
Соттоп pivot point
and focus point
prism
юг biomicroscope and
slit illuminator
Slit Ьеат size
and shape
controls

Slit lamp
illuminator

Photo adapter
Веат
splitter

Binocular -----1I-----t--
assembIy

Сатега Back 2Х magnifier

о
в Ocular

72
 allows viewing with 100% оЕthe light which, while the image is being record-
ed, automatically moves to allow 100% оЕthe light to strike the Шт or digital
sensor, then returns again to the viewing position.
А diffuse illuminator, or filllight, is ап independent light source that permits
overall illumination оЕап еуе simu1taneously with the superimposed, focused
Ьеат from the slit lатр illuminator. This feature enables опе оЕthe single
most useful photographs in slit lатр imaging; опе that portrays the general
appearance оЕап еуе while highlighting specific abnormalities. Diffuse overall
illuminators are not incorporated into clinical (non-photographic) instruments
as the examiner сап easily alternate between overall and selective illumination
Ьу val-ying the width оЕНте slit Ьеат during the serial examination оЕthe еуе.
The clinical slit lатр also provides а diffusing filter for the slit Ьеат for overall
illumination of а large area. In photodocumentation, 110wever,the simultane-
ous use оЕboth illuminators is the опlу manner in which both specific infor-
mation and ап overview сап Ье recorded in а single image. For purposes оЕ
photograpl1y, the optic section should Ье approximately two to three "Еstops"
(four to eight times) brigl1ter for adequate contrast between the two.
Electronic flasl1illumination is essential for consistently good results in still
photography. Both the overall and slit illuminators must have co-axial еlес-
tronic flash capability. The intense, short duration оЕelectronic flash provides
sufficient light for good exposure at а speed (ог duration) оЕapproximately
1/1000 оЕа second (опе mi11isecond).This short duration flash ensures that
small inadvertent movements оЕthe еуе ог сагпета do not result in motion
blur during exposure. Moreover, for traditional film photography, the color
temperature (approx. 6000 К) of electronic flasl1allows the use оЕdaylight film
0

and results in excellent color reproduction.

The PSLis equipped with а сагпета body (or bodies) that is ап integral part оЕ
the system. The сагпета back is mounted оп the Ьеат splitter ог mirror unit, and
does not compromise the functionality of the biomicroscope or illuminators.
А "cross hair" reticle, located in опе оЕ the oculars, is another essential
component of the PSL. The reticle is vital to the production of consistently
well-focused photographs in ап aerial image system. It is also ап important
reference for correct centration оЕthe subject and control of the area of соуег-
age. The cross hair reticle is discussed in further detail in Chapter 6.

А в

100% 50% 100% 20%

to ocular to ocular

50% 80%
to сатега to сатега

FIGURE 2.6 Веат splitter sharing the light equally for viewing and photography (А) and а Ьеат splitter diverting 80% of the light to the сатега
and 20% to the oculars (В).
73
Photographic Attachments
Сагпета attachments to c1inica1slit 1атр biomicroscopes will produce usefu1
information in some app1ications but are 1imited in their range of capabi1i-
ties.6The simp1est, 1east expensive, but most 1imited arrangement is to mount а
сагпета in р1асе of опе ocu1ar of the biomicroscope (Fig. 2.7). This 1imits view-
ing through а sing1e ocu1ar with the resu1tant [озв of stereopsis (appreciation of
depth). Furthermore, the observer's sing1e view is severa1 degrees away from
the axis of the image (slight1y non-coaxia1) recorded Ьу the сагпета. and dis-
tracting artifacts or unsatisfactory illumination not visible to the observer тау
Ье recorded. Some attachments prec1ude the use of both ocu1ars, which neces-
sitates viewing through the sing1e 1ens reflex camera's viewfinder, or viewing
the image оп the digita1 camera's disp1ay screen. These methods of viewing
provide ап accurate assessment of the photographic fie1d, but fine detai1,
as seen through the ocu1ars, тау not Ье visible оп the camera's disp1ay screen.
[п some forms of illumination, this 1imitation is а minor опе. [п attempts to
record certain subtle findings, it сап Ье а severe 1imitation.
А more sophisticated adapter mounts to the c1inica1 slit 1атр with а Ьеат
splitter, 1eaving the ocu1ars unencumbered and avai1able for stereoscopic
viewing (Fig. 2.8). Both systems, however, will Ье 1imited Ьу the 1ack of со-
axia1 flash illumination for the slit illuminator, and the absence of а fill1ight.
Because the оп1у light avai1able for photography is that used for examina-
tion, high-speed films with 1arge grain structure and 10wer reso1ution must
Ье used. Additionally, союг temperature requirements for avai1able fi1ms do
not coincide with союг temperatures produced Ьу the bu1bs of most c1inica1
slit 1amps. The союг temperature of illuminating bu1bs is approximate1y 20000
to 30000К (Degrees Ke1vin) whi1e the союг temperature requirement of day-
light fi1m to reproduce союг accurate1y is 50000 to 60000к. Because of this in-
compatibi1ity, а significant союг shift toward the warmer tones (red, orange
and yellow) resu1ts. Союг temperature incompatibilities сап Ье reduced Ьу
using tungsten fi1m with а co1or temperature requirement of 32000к. [п either
case, considerably 10nger exposure times тау Ье needed and тау resu1t in а
blurred image due to movement of either instrument or patient, especially at
high magnifications.
Digita1 imaging is better suited
for use with such attachments.
А significant advantage is the
instant feedback regarding the
content and qua1ity of the image
just taken, allowing for immedi-
ate adjustments and re-recording
of the image. The digita1 сагпета
a1so has а variable 1SO setting,
making it much simp1er to adjust
media sensitivity to the nature of
the subject being photographed.
(Н must Ье remembered that at
the most sensitive settings the
image will Ье degraded some-
what Ьу the 10wer signa1 to noise
ratio; а re1ative paralle1 to the
1arger grain and 10wer reso1ution
of fast fi1ms.) Another advantage
FIGURE 2.7 Ап ocular tube-mounted digital сатега for use оп а clinical slit lamp biomicroscope.
of digita1 imaging is that союг (/mage courtesy of ТТ/ Medica/)
74
 temperature сап Ье set to match а specific light source ог left оп automatic for
the сагпета to adjust in response to focal conditions. Lastly, the electronic im-
age is much more readily processed, adjusted, shared and stored than its film
counterpart.
While such attachments сап produce valuable images of certain conditions in
some forms of illumination, optimal photo slit lamp Ыоппсгоагарпу depends
оп photo slit lamp biomicroscopes specificaHy designed to overcome the limi-
tations mentioned above. Оп the
other hand, instruments designed
primarily for photography тау
have reduced practical flexibility for
patient examination. А clear defini-
tion of photographic goals with аn
understanding of the capabilities
and limitations of аН available sys-
tems willlimit disappointment and
unnecessaryexpense.

FIGURE 2.8 А Ьеат splitter maunted digital

сатега far use оп а clinical slit lamp biamicrascape.
(/mage caurtesy af ТТ/ Medica/)

___
__ о

-._-
_
r
--
--
__
_ А

W .•

FIGURE 2.9 The OCT-SLTM (/mage caurtesy af Heide/berg Engineering)

75
New Technology
The basic design of the slit lamp biomicroscope for examining and photo-
graphing the еуе has remained unchanged for many decades. This longevity
speaks well for its underlying principles. Оп the other hand, its universal ас-
ceptance in its traditional role тау Ье having а quenching effect оп the ршsuit
of innovative replacements. With today's rapidly changing technologicalland-
scape, however, а better way of looking at the аптепог segment тау emerge,
and it will Ье interesting to see what form such ап instrument might ultimately
take. In the meantime, the slit lamp biomicroscope has Ьесоте the host for а
technology that is making а significant impact оп ophthalmology.
In the imaging of the posterior segment of the еуе, ocular coherence tomog-
raphy (ОСТ) appears to Ье in t11eprocess of superceding fluorescein angiog-
raphy in frequency of application. Even in light of its relatively short l1istory,
ОСТ has proven а significant modality in the evaluation and саге of certain
abnormalities of the еуе. Now ОСТ technology has also been applied to the
evaluation of the anterior segment and the traditional slit lamp biomicroscope
is the platform for its clinical application (Fig. 2.9). This instrument, the SL-
ОСТТМ,produces biometric information regarding anterior segment structures
and their relationships (Fig. 2.10).7,8
Such ап innovative use of the slit lamp biomicroscope would suggest that
other changes are оп the horizon and that the process of evaluating and docu-
menting the еуе and its conditions will Ьесоте more informative and easier
to apply.

= =

1J О ~e:o~iliit3 ~
А _
FIGURE 2.1 О (А and В) lmages from Ihe OCT-SLTM wilh biomelric informalion obtained from ап еуе wilh а closed angle. (/mages courtesy of Heide/berg
Engineering)

16
 The Noгmal Еуе and Its Suггound
77
 Chapter 3

о е

External Structures
Internal Structures
The Visual System

Оцг eyes comprise а specialized sensory organ with

unique structural (anatomical) and functional (physiologi-
cal) features. Each еуе is recessed in а Ьопу orbit in the skull
for protection. The upper and lower eyelids also protect the
front surface of the еуе and lubricate this surface ,.vith tears
with each blink. These tears are produced Ьу the lacrimal
gland in the upper outer part of the Ьопу orbit as well as Ьу
other microscopic glands embedded throughout the соп-
junctiva. The lacrimal gland тау Ьесоте conspicuous as
а lump over the еуе if infected (dacryoadenitis). Tears are
"pumped" Ьу the closing action of the lids from the surface
of the еуе into small openings called puncti that are visible
in the upper and lower lids. The tears continue оп through
small ducts called canaliculi into the lacrimal sac along the
side of the nose, and finally into the nose through the па-
solacrimal duct. Drugs that are instilled topically onto the
еуе drain into the nose along the same system, and are fre-
quently tasted Ьу the patient and тау cause systemic side
effects. The lacrimal sac тау Ьесоте swollen, and protrude
as а lump if infected (dacryocystitis).

78
 External Structures
The opening between the eyelids is the palpebral fissure and the corners of
the palpebral fissure аге the medial (inner) and lateral (outer) canthi. In the
medial canthus is а rudimentary third eyelid and а small fleshy protuberance
called the caruncle. Neither of these structures is important to vision in тап,
but тау appear prominent if inflamed. The eyelids and most of the front (an-
terior) surface of the еуе (except the соrnеа) аге sheathed with а thin and deli-
cate, transparent tissue called the conjunctiva that contains some of the blood
vessels to the front of the еуе. When the еуе is irritated, the blood vessels in
the conjunctiva dilate to cause the еуе to appear red, ог "injected." The "white"
of the еуе is the sclera, which is the tough, protective outer layer of the еуеЬаll,
seen through the conjunctiva. The согпеа is transparent to allow light to enter
the еуе. The circumferential boundary between the white sclera and the clear
соrnеа is the limbus. The limbus is an important landmark for surgical inci-
sions into the еуе. Also visible from the front of the еуе, through the соrnеа,
are the iris, which gives the еуе its "color", and the pupil, which dilates and
constricts to regulate the amount of light that enters the еуе (Fig. 3.1).

NASAL TEMPORAL

Pupil

Sclera

Limbus

Orifices of Meiobian glands

FIGURE 3.1 The external еуе.

79
 'Пте соrnеа is comprised of five layers that include, from front to back, the
epitheliallayer, Боwmаn's membrane, the stroma, Descemet's membrane, and
the endothelium (Fig. 3.2). The epithelium is from five to seven сеll layers
thick and, although painful if abraded, usually l1ealsrapidly without scarring.
Боwmаn's membrane is а specialized layer of collagen between the epithelium
and stroma. Injuries that disrupt Боwmаn's membrane result in permanent
соrnеаl scars t11atmау reduce vision. 'Пте stroma forms most of the thickness
of the соrnеа and consists of collagen fibrils arranged in а "lattice" configura-
tion. Descemet's membrane is а basement membrane produced Ьу the delicate
layer of endothelial cells that line the inner соrnеа. Corneal transparency is
essential for clear vision and depends not only ироn the regular arrangement
of the constituent parts of the соrnеа, but also ироn а соmрlех physiological
process whereby water is actively pumped from the согпеа back into the еуе.
This function is performed Ьу the endothelial cells.

__

-----
---~--
.
~-~Cb --
= ----------
-~-~
--- --
--_ ••••••...:-

-
- _

-
-----
-
-----
::;:::::-.
-=-
---- --- --.-- ---с:>-- --
---.:---=

Stгoma ~

--
- - -----
-- ----- --
~=---~---
-- -
- ~ ---~--
---- -- ...... - -- ~-
----
---- - ----------

Endotheliu

FIGURE 3.2 Illustrated layers of the согпеа.

20
 Internal Structures
In addition to the соrnеа and sclera that form а protective outer layer, the еуе-
Ьаll has two other layers that include а middle vascular layer, and ап inner зеп-
sory layer (Fig. 3.3). The middle vascular layer is the uvea and is composed of
the iris, the ciliary body, and the choroid. The inner sensory lining is the retina.
А lens is situated behind the iris and is held in place Ьу thin fibrous filaments
called zonules. The zonules insert into the ciliary body. Contraction and relax-
ation of а small group of muscles in the ciliary body cause the lens to change
shape to adjust focus, or accommodate. Accommodation is а paradoxical pro-
cess. When the ciliary muscles contract, tension оп the zonules relaxes and the
lens thickens. This increases the refractive or focusing power of the lens to per-
mit the еуе to view near objects. Relaxation of the ciliary muscle causes the
zonules to stretch and thin the lens for distance viewing.
Тhe еуе also has three chambers. Тhe largest is the vitreous chamber. Сот-
prising the interior of the globe behind the lens, it is filled with а transparent gel
called vitreous humor. Vitreous humor is not produced after birth. The anterior
chamber is а space between the соrnеа and the iris that contains а clear, water
like fluid called aqueous humor. The anterior chamber "angle" (visible only Ьу
gonioscopy) is formed Ьу the base of the iris, соrnеа, and ciliary body and соп-
tains the trabecular meshwork and Canal of Schlemm, structures that are im-
portant in the outflow of aqueous humor from the еуе. The posterior chamber
also contains aqueous humor, but is only а miniscule space between tl1eiris and
the zonules. Aqueous humor is produced Ьу the ciliary processes (small finger
like projections of the ciliary body) and secreted into the posterior chamber.
Рroт the posterior chamber, aqueous humor circulates anteriorly through the
pupil and into the anterior chamber. From there, it flows through the trabecular
meshwork in tl1eangle of the anterior chamber and into the Саnа} of Schlemm.
The Саnа} of Schlemm communicates with veins that drain both aqueous and
blood from the еуе. The production and flow of aqueous humor is а dynamic
process and the contents of the anterior and posterior chambers аге replaced
about every twenty four hours. The flow of aqueous humor through the еуе is
especially important because abnormalities in this flow сап result in glaucoma
in which elevated pressure in the еуе causes damage to the орпс nerve and
eventual blindness.

-
FIGURE З.З The globe and its principal structures.
27
The Visual System
Light enters the front of the еуе and is refracted Ьу the соrnеа, passes through
the anterior chamber and pupi1, and is fine focused Ьу the 1ens t11roug11the
vitreous onto the retina. Rods and cones аге the neurosensory cells (for black
and white, and c010rvision, respective1y) in the retina that convert 1ight to the
пецга] impu1ses that аге re1ayed оп to the brain via nerve fibers in the optic
nerve. The retina and optic nerve head (optic "disc") сап Ье visua1ized and
photographed through the соrnеа Ьу ophtha1moscopy and "fundus" photog-
raphy. The retina lines the inner еуе to а region just behind the iris. This ter-
mination of the retina is the ога serrata and is best visua1ized for photography
with а three mirror contact 1ens. The retina 1ining the posterior ро!е, in direct
1inewith the pupi1 and соrnеа (the optica1 axis of the еуе), is the mаси1а. The
mаси1а is especially important for vision because а tiny centra1 area called
the fovea within the mаси1а is specia1ized to provide the fine visua1 acuity
required for reading small print.
A1though the retina itself is transparent, the red/orange hue observed dur-
ing ophtha1moscopy and photography occurs because of pigment cells in the
retina1 pigment epithe1ium (RPE) and red blood cells in the choroid. The reti-
па1 pigment epithe1ium is а sing1e 1ayer of pigmented cells just beneath the
transparent portion of the retina. (А верагапоп of the retina from the retina1
pigment epithelium is а retina1 detachment.) The choroid is part of tl1e uvea
(midd1e, vascu1ar 1ayerof the еуе) and consists of а meshwork ofblood vesse1s
that supp1y blood to the outer half of the retina (the half сювевгto the choroid
and sc1era). The blood supp1y to the inner half of the retina (the half сюзевг
to the vitreous) is achieved Ьу the centra1 retina1 artery which enters the еуе
through the optic nerve and branches out оп the surface of the retina. Because
they аге оп the inner (сювевг to the center of the еуе) surface of the retina,
the centra1 retina1 artery and vein, and their branches, аге conspicuous during
ophtha1moscopy and posterior segment photography.
The visua1 system provides for the perception of form, c010r,and stereopsis
(depth perception). Either еуе а1опе сап recognize form and c010r.Stereopsis,
however, requires the simu1taneous and coordinated function of both eyes.

22
 High Magnification Photograph of Granular Согпеаl Dystrophy Seen in Direct Focallllumination.

23
 Chapter 4

Isolation with Illumination

Optic Sectioning
Estimating Distances
Broad Веаm IlIumination

An examination with the slit lamp biomicroscope consists

of serially viewing the components of the еуе in аН avail-
аЫе forms of illumination. Illumination mау Ье direct ог
indirect, depending оп whether the object is lighted directly
in the illuminating Ьеаm or indirectly Ьу light reflected Ьу
а neighboring structure or transmitted through adjacent tis-
sue. А variety of direct and indirect forms of illumination
аге used for examining the еуе. These аге summarized and
discussed in detail in Chapter 5.

24
 Fundamentals: Isolation with Illumination
In its simplest application, the slit illuminator is analogous with а
spotlight when compared with ап ordinary source of illumination that
is neither concentrated nor specifically focused. То illustrate this, а dis-
play of several objects is illuminated with ап ordinary floodlight (Fig.
4.1А). While this source provides diffuse, even illumination to show
the distribution of large objects, it fails to demonstrate clearly those
tl1at are smaller in size ог of transparent material. With the addition of
а spotlight directed at the small objects, they Ьесоте more apparent
(Fig. 4.IВ). Such а combination of forms of illumination serves to better
demonstrate the extent and content of the entire display, as it draws
attention to those objects of а more subtle nature. When the overall, dif-
fuse illumination is extinguished, the spotlight concentrates t11eatten-
tion of the observer entirely оп the smaller objects and more informa-
tion about their specific nature сап Ье appreciated (Fig. 4.1С). As there
is по longer а wide агеа to Ье viewed, and the observer's concentration
is now directed entirely at the small objects, the natural tendency is to
step forward for а closer look (Fig. 4.1О).

~...
~ \,~:~;
-

А в

FIGURE 4.1
(А) А display of several objects seen in diffuse, overall illumination. (8) А spotlight is added to draw attention to the small objects.
(С) When the overall illumination is extinguished, the observer's attention is confined solely to the small objects.
(О) Stepping closer provides the magnification necessary to observe the features of these small objects, especially when made of transparent material.

25
 This demonstration is direct1y applicable to photo slit lamp biomicrography,
as а diffuse illuminator, ог filllight, is а critical component of such а system.
The filllight provides ап overview of the еуе (like the floodlight in the display),
while the slit illuminator (like the spotlight) provides isolated, specific informa-
tion. The desired magnification (closer look) is provided Ьу the biomicroscope.
The Ьеаm from the slit lamp illuminator is highly concentrated and is pro-
jected to fall into sharp focus at а specific distance from the source. The plane
at which the outline of the slit Ьеаm is in sharp focus is the same plane at
which the image seen through the biomicroscope is in focus. (This distance
is established Ьу the focallength of the biomicroscope and slit illuminator.)
This par-focal relationship between the biomicroscope and the slit illumina-
tor is critical to the correct function of the instrument. The slit lamp illumina-
tor is so designed that the illuminating Ьеаm assumes the size and shape of
the Ьеаm control aperture. The control aperture, namely the height and width
controls of the slit Ьеаm, becomes the actual object projected onto the surface
under study. 'Пте outlining edges of the control aperture mау Ье compared
to а slide in а slide projector which, when properly focused, is sharp оп the
screen. Thus, w11enthe slit illuminator is the correct distance from the еуе, а
sharply outlined form of the slit Ьеаm will Ье seen оп the surface under study.
Whether the Ьеаm is а full circle (ог square, depending оп the design of the
instrument) of illumination or а highly selective narrow slit, the outline will
always Ье sharp when properly focused (Fig. 4.2). It is also evident that the slit
Ьеаm will Ье sharply outlined only at its intended plane, and will Ье blurred
both in front of and behind that plane. Therefore, correct focus and the proper
relationship between components of the slit lamp biomicroscope are essential.
Inherent limitations in depth of field further underscore the need for accuracy
in focusing the instrument.

FIGURE 4.2 (А) А sharply outlined, full circle Ьеат from the slit illuminator. (8) А sharply focused narrow slit Ьеат.

26
 Optic Sectioning
The most signifieant property of the slit Ьеаm is its ability to produee ап
optie seetion of the согпеа, lens, and other transparent tissues of the еуе. This
is aehieved Ьу tlle projeetion of а very narrow (approx. О.1mm), preeisely de-
lineated and highly eoneentrated slab of light through these transparent strue-
tures, without illuminating adjaeent areas. The visibility of the optie seetion
is dependant equally оп the brightness of the seetion itself, and the darkness
of its surround. Ап optic seetion mау Ье likened to а surgieal seetion where
half of the еоrnеа is eut away, produeing а eross seetional view (Fig. 4.3). In ef-
feet, the slit illuminator produees а blade of light enabling а dynamie easeade
of infinite seetions through transparent tissue. This eross seetional, or end-on
view of the еоrnеа permits the simultaneous examination of the epithelium,
stroma and endothelium and is best seen when there is а eonsiderable angular
differenee between the position of the slit illuminator (angle of ineidenee) and
the biomicroseope (angle of view). When the slit illuminator is plaeed in а
nearly eoaxial position with the biomieroseope, the
optie seetion eollapses, greatly limiting information
about deeper layers of the еоrnеа. То produee ап
optimal seetion, the biomicroseope and the slit illu-
minator should Ье plaeed approximately 30 degrees
оп opposite sides of the optie axis of the еуе. As the
angle between the slit illuminator and biomicro-
seope inereases, the informative value of the optie
seetion inereases dramatieally (Fig. 4.4).

\
\

в
FJGURE 4.3 (А) А cutaway 01the согпеа simulates the "ело-оп" view that is produced Ьу ап optic section with а narrow slit Ьеат. (8) Diagram showing the
position 01the biomicroscope relative to the slit illuminator to produce ап optimum cross section. (С) The resultant section producing good delineation 01corneal
layers. С: 1. Теаг lilm layer, 2. epithelium (normally transparent), З. anterior stroma with high density 01 keratocytes, 4. posterior stroma with lower density 01
keratocytes, and 5. Descemet's тепЬгапе and endothelium.
27
 \
\

А-1 8-1

FIGURE 4.4
With the slit illuminator in а nearly coaxial position with the biomicroscope (А-1), the optic section collapses and по cross-sectional information сап Ье derived
(А-2). However, а! а relative angle of approximately 600 (8-1), the section becomes highly informative (8-2).
28
 Estimating Distances with the Slit Веаm
With а standard relationship between the еуе, the biomicroscope, and the
slit illuminator, relative distances between certain surfaces сап Ье easily de-
termined. For example, а narrow slit Ьеаm is projected onto the cornea at an
angle of 450. From the resultant section, the relative thickness of the соrnеа
сап Ье estimated (Fig. 4.5). Similarly, а reasonable estimate of anterior cham-
ber depth сап Ье made from the distance between the corneal section and the

FIGURE 4.5
(А) Keratoconus shows the characteristic thinning 01ectatic соrnеа. (В) Bullous keratopathy
exhibits а thickened, highly edematous согпеа.

29
Ьеаm of light falling оп the iris surface (Fig. 4.6). (А more precise method of estimating anterior chamber angle
depth with the slit lamp has been described Ьу Van Herick, W., et аР) Other applications of this technique are
further described in this section under "Direct Focal Illumination."

t
\ t
\ t
\t

А-2 8-2

FIGURE 4.6
(А) А noгmal anteгioг chambeг is evidenced Ьу the distance between the beams of light falling оп the coгnea and iгis. (8) Following successful coгneal
tгansplantation, this еуе suffeгed а penetгating foгeign body injuгy collapsing the anteгioг chambeг. The absence of а chambeг is cleaгly evident in the
contiguous гeflections from the согпеа and iгis.

за
 Broad Веат Illumination
Some conditions аге best illuminated with а wide Ьеаm. Once the location of
the clinical pathology has been determined, а larger агеа mау Ье illuminated
simultaneously to show а greater expanse of the abnormality (Fig. 4.7). Broad
Ьеаm illumination is especially useful when the opaque structures of the ап-
terior segment, or opaque abnormalities within the соrnеа and lens, are to Ье
recorded photographically (as described under "Tangential Illumination" оп
page 47).
Slit lamp illumination, however, is а compromise. When а wide area is Шц-
minated simultaneously, subtle changes within that area Ьесоmе more difficult,
or perhaps impossible, to see. Conversely, to obtain а view of fine detail, а паг-
row slit Ьеаm is required, greatly limiting the area seen at any given moment.
During biomicroscopy, this limitation is not of practical сопсегп as the exami-
nation is а dynamic process. The еуе is viewed within а Ьеаm that is constantly
varied in width and kept in motion to scan the entire еуе. This makes use of the
discriminating nature of а narrow Ьеаm to elicit fine detail, while the process
of scanning produces ап overview. The result is а mental, composite image of
the areas examined, including both detail and context.
This dynamically gathered composite image, however, саппот Ье reproduced
in а single, static photograph. Photo slit lamp biomicrography, therefore, re-
quires the best possible compromise between fine detail and area. Ыеаllу, ап
area of sufficient size to provide context for the detail is included in each pho-
tograph. However, this will Ье impossible to accomplish at times, and only
very selective illumination will effectively demonstrate essential detail. In such
cases, additional photographs are taken to provide context sequentially.
While some opaque changes in the соrnеа mау Ье best visualized Ьу illumi-
nation covering а large area, corneal sectioning with а broad Ьеаm is not very
efficient. Depending оп the angle at which the slit Ьеаm strikes the соrnеа rela-
tive to the position of the Nomicroscope, а variable amount of overlap of the
illuminated anterior and posterior corneal surfaces will Ье seen. The smaller
the angle between the illuminator and the Nomicroscope, the greater the over-
lap. То diminish this overlap, the angle between the two should Ье increased
as much as possible. In addition, careful positioning of the Ьеаm maximizes
the information about the abnormality under study. If it is located at the level
of the endothelium, its features will Ье diffused if viewed through illuminated
epithelium and stroma. If the Ьеаm is directed at an oblique angle and the аЬ-
normality illuminated so as to place it at the trailing edge of the Ьеаm, stromal
and epithelial interference wШ Ье reduced considerably (Fig. 4.8). Judicious
use of slit width and angle of incidence will provide optimal гезцйз."

37
FIGURE 4.7 (А) А narrow slit Ьеаm identilies the location 01 the abnormality in epithelial dystгophy. (8) А broad Ьеаm provides ап expanded view.

FIGURE 4.8 Keratic precipitates (КР) оп the posterior suгlace 01 the согпеа аге best seen а! the trailing edge 01 the Ьеаm (1) where their clarity is much
greater than 01those viewed through illuminated epithelium and stгoma (2).
32
 Haab's Striae 01 the Согпеа in Axenleld's Syndrome Seen in Retroillumination Iгот the Fundus.
33
 Chapter 5

Direct Illumination
Diffuse, Overall IlIumination
Slit Веат Plus Diffuse
Direct Focal Illumination
Indirect Forms of Illumination
Proximal Illumination
Sclerotic Scatter
Retroillumination

The following descriptions of forms of illumination are

fundamentally applicable to both clinical slit lamp Ыо-
microscopy and photo slit lamp biomicrography. Strictly
speaking, some are variations of basic forms of illumina-
tion. However, for the photographic process in particular,
the subdivisions аге important to treat individually, espe-
cially as they relate to exposure. As these subdivisions are
described, photographic considerations will Ье emphasized
where necessary. Prior to attempting photo slit lamp biomi-
crography, the reader is asked to carefully review Chapter 6
"Photo Slit Lamp Biomicrography."

34
 Direct Illumination
Methods of direct illumination for examination and photography include:
а. diffuse, overall illumination,
Ь. direct focal illumination with а илае Ьеат,
с. direct focal Шиттайоп шith а narrow slit to include optic sectioning,
d. direct focal illumination applied tangentially,
е. pinpoint Шипипаиоп (Tyndall's рпепотепоп), and
f specular reflection.

Diffuse, Overall Illumination

Diffuse illumination at the clinical slit lamp is achieved Ьу placing а dif-
fuser into the light path of the slit illuminator (Fig. 5.1). The slit Ьеат height
and width controls аге set to а size that produces sufficient illumination for
discrimination of detail, but without causing undue discomfort for the patient.
Used at low to moderate magnifications this method is simple to apply and
facilitates а general examination of а large агеа for gross abnormalities (Fig.
5.2). Diffuse illumination represents ап excellent initial step, particularly for
individuals at ап early stage of experience.
Diffuse illumination is also highly effective in slit lamp photography. As in
the example above, а diffuser is placed in the path of the full Ьеат from the
slit illuminator. The resultant images аге quite useful, but show the limitations
of а single light source with its characteristic shadowing оп the contralateral
side (Fig. 5.3). When only опе source is available, саге should Ье taken to avoid
placing in shadow the
area of the еуе that in-
cludes the information
to Ье recorded.
Thefullycapablephoto
slit lamp biomicroscope
overcomes this limita-
tion with an additional
element, the fill light.
The fill light is а second
source of illumination.
When used in conjunc-
tion with diffused light
from the slit illuminator,
an evenly illuminated
image of а large агеа is
made possible. The size
of the slit aperture is ad-
justed to produce а level
of diffuse illumination
matching the intensity
of the fill light, and the
exposure adjusted ас-
cordingly (Fig. 5.4).

FIGURE 5.1
Diffuseг foг the slit illuminatoг.
35
 А

FIGURE 5.2
Oiffuse illumination demonstгating:
(А) Poliosis,
(8) collaгettes in staphylococcal keгatoconjunctivitis and bIephaгitis,
(С) conjunctival injection in anotheг case of staphylococcal keгatoconjunctivitis,
(О) а pigmented lesion of the гight caгuncle,
(Е) tгachoma with lineaг scaггing, and
(F) а noгmal iгis.
36
 А
FIGURE 5.3 The disadvantage 01 using а single light source is shown Ьу the shadow created оп the contralateral side in а case 01 (А) Lisch nodules and
(8) aphakic bullous keratopathy.

:~
t

FIGURE 5.4 Dual diffuse illumination is highly effective in obviating shadows.

37
Combining Diffused Illumination with the Slit Веаm

The filllight also serves to moderate а significant limitation of photography.

During аn examination, whether at the clinical slit lamp or the photo slit lamp,
the examiner sees much more of the еуе simultaneously than what is directly
illuminated at аnу moment. Light scattered and transmitted Ьу the tissues of
the еуе beyond the агеа of direct illumination is sufficient to place the area of
direct illumination into context. The photographic process, however, саппот si-
mu1taneously record the extremes of light seen in the агеа of bright, direct illи-
mination and the much darker surround of illumination produced Ьу normal
scatter. The exposure must Ье adjusted to еппег record the area of bright, direct
illumination, ог the much darker surround. Digital imaging mау Ье somewhat
less limiting, but neither film пог digital media сап duplicate the range of the
human еуе in its ability to function simultaneously in both bright and low
light conditions. The filllight provides overall, background information in slit FIGURE 5.5
image photographs without relying оп а diffuser in the path of the slit Ьеаm. (А) Localized согпеаl edema following
penetrating foreign body injury seen in
This allows for the use of the slit Ьеаm for focal illumination of specific abnor-
diffuse illumination.
malities, while the diffuse illuminator provides background information and
(8) Addition of ап optic section provides
context. Аn excellent compromise between the dynamics of аn examination specific information regarding location
and the limitations of а static photograph is thus achieved (Fig. 5.5). and severity of edema.

А-2

В-2
38
 :~
t

А-2

В-2

С-l С-2

FIGURE 5.6 Corneal ulceг lollowing keгatoplasty and гejection. (А) Geneгal арреагапсе in dual diffuse illumination. (В) Ап optic section
defines the degгee 01coгneal thinning but does по! pгovide good context. (С) Combined loгms 01illumination to pгovide both specific and
geneгal inloгmation in а single image. (Photogгaphs weгe taken lollowing topical application ollluoгescein.)

39
 А corneal ulcer following keratoplasty in а case of rejection is seen in dual,
diffuse illumination (Fig. 5.6А). While ап excellent overview that shows the
general condition of the еуе, it fails to demonstrate the degree of cornel thin-
ning inferiorly. The next logical step is to use the highly selective property of
the narrow slit Ьеат to show topographic information. With the filllig11t ех-
tinguished, the most definitive image of the defect is produced, but at the сот-
promise of context (Fig. 5.6В). However, when the slit Ьеат is used in сотЫ-
nation with the filllight, the result clearly demonstrates that both ате necessary
to convey the key elements in а single, static photograph (Fig. 5.6С).
Another example shows а case of aphakic bullous keratopathy in dual dif-
fuse illumination (Fig. 5.7А). It serves as а good overview but does not dem-
onstrate the large bulla (separation of the anterior corneallayers) that becomes
dramatically evident with the addition of the optic section (Fig. 5.7В). А third
example emphasizes the important difference between а dynamic, binocular
examination and а static, two dimensional photograph. At low magnification
with dual diffuse illumination, the forward bowing of the iris would Ье аррат-
ent during ап examination. However, in а static, two dimensional photograph,

А-l А-2

8-2

FIGURE 5.7 Aphakic bullous keratopathy seen in (А) dual diffuse illumination and (8) with the addition of the optic section, without which the
large, characteristic bulla is по! evident.

40
 the degree of anterior bowing сап only Ье stated accurately Ьу the addition of
the slit Ьеат (Fig. 5.8). In Figure 5.9, ап optic section of а mature cataract is
seen in context with the use of the filllight. Such photographs, including both
general and specific information, аге fundamental. They should serve as intro-
ductions to additional images taken with more selective forms of illumination,
as dictated Ьу the condition present.

FIGURE 5.8
(А) Diffuse illumination 01ап еуе with а shallow chamber. (8) Addition 01the optic section produces delinitive inlormation regarding chamber depth.

FIGURE 5.9 А single image 01 а mature cataract demonstrates both specilic and general inlormation providing
context lог the principal агеа 01 interest.
47
Direct Focal IlIumination
Broad Веаm Illumination
Direct focal illumination with а moderate to wide slit Ьеат is one of the sim-
plest means of appraising the general condition of the еуе at moderate mag-
nification. It is often the first step in the slit lamp examination and the process
of scanning the entire еуе area provides an overview that will prompt further
investigation with more selective forms of Шц-
mination. The Ьеат width is varied dynamically
as is the angle of incidence to elicit maximum in-
formation about the condition of the еуе. Photog-
raphy with а wide Ьеат is also easily achieved
from an exposure standpoint. It is best applied to
conditions with increased optical density (high
ref1ectivity). Dynamic variation of Ьеат size
will determine the setting for maximum cover-
age without scatter and distracting ref1ections.
Many alterations from the normal cornea, апте-
rior chamber, iris, lens and anterior vitreous тау
thus Ье examined and photographed (Fig. 5.10).

FIGURE 5.1 О Tangentially applied broad Ьеат illumination to illustrate (А) prominent corneal nerves, (8) posterior согпеа' changes in
Fuchs' dystrophy, (С) vitreous presenting in the anterior chamber, (О) polychromatic deposits оп the anterior lens surface and
(Е) prominent vitreous strands and cellular debris.
42
 Optic Sectioning
As the slit Ьеат is narrowed, it beeomes highly effeetive in the examination
of transparent struetures sueh as the eornea, aqueous humor, lens, and vitreous.
The thinner the Ьеат, the finer and more seleetive the optie seetion beeomes.
Seanning these struetures in this manner produees
ап infinite series of optie seetions, or sliees, provid-
ing ап aggregate impression of the eondition of the
tissue being examined. А photograph, however, сап
doeument but а single seetion оп eaeh exposure, пе-
eessitating several sueh photographs to adequately
doeument the eondition present. As ап example, а
right to left penetrating foreign body traek through
the еоrnеа is well doeumented in а series of images.
These eonsist of аn introduetory photograph taken
in diffuse illumination followed Ьу four optie see-
tions to provide dimensional information regarding
the eourse of t11eforeign body (Fig. 5.11). While eas-
ily visualized at the biomieroseope, the optie seetion
сап Ье а ehallenge to reeord photographically. Gener-
А аllу, it will require the maximum light output of the

в с

о Е

FIGURE 5.11 (А) Dual diffuse illumination showing the right to left track of а trans-corneal foreign body. (В) Combining diffuse illumination with the optic
section provides context and specific information regarding the entry site, (С and О) the track through the stroma, and (Е) the exit site.
43
photo slit lamp to produee ап adequate exposure. Oeeasion-
аllу, the slit Ьеаm must Ье broadened slightly to produee а
suffieiently exposed image, but should always Ье kept to
а minimum width to produee а true seetion. То maximize
information within the seetion, the filllight is not used.
These images would follow the eombination of illumina-
tions diseussed above. Several examples of this definitive
teehnique аге shown in Figure 5.12.Additional examples of
optie seetioning аге seen in Figures 4.3 and 4.4.

FIGURE 5.12 The optic section is used without the filllight to best delineate the features of (А) elevations in the bulbar
conjunctiva, (8) fragmented specular reflection from the corneal surface indicating ап inadequate tear film layer, ап uneven
epithelial surface, ог both, (С) abnormal degree of reflection from the endothelium in Fuchs' dystrophy, (О) ап edematous
epithelium with edema clefts, and (Е) the disturbed architecture of Descemet's тетЬгапе in pseudophakic bullous keratopathy.
44

FIGURE 5.1 3 А separation of layers
keratoplasty is demonstrated Ьу the doubIed corneal Ьеат.
Topography and Measurement
Narrow slit illumination establishes surface relationships and provides topo-
graphic information. Figure 5.13 shows ап еуе following lamellar keratoplasty
with а separation between host and graft. (Note that filllight was added to
place the information into context.) In Figure 5.14, the аЬ-
sence of normal tissue, as these examples of corneal defects
demonstrate, is seen as а deviation of the slit away from the
light source. Elevations аге also graphically emphasized
with this technique. Ап iris cyst, producing focal elevation
of the iris, deflects the slit toward the light source (Fig. 5.15).
In another example, ап еуе had undergone successful сог-
neal transplantation but later suffered а penetrating foreign
body injury. The resultant iris adhesion to the posterior сог-
neal surface is clearly evidenced Ьу the light Ьеат оп the
iris rising anteriorly to соте into contact with the optic sec-
tion of the соrnеа (Fig. 5.16). Another iris lesion (Fig. 5.17) is
shown to contain ап elevated component Ьу the deviation of
the slit Ьеат toward the light source. The angle of displace-
ment between the slit illuminator and the Nomicroscope,
and the degree of a1teration from the normal plane (eleva-
tion or depression of the lesion), will determine the amount
of deviation of the slit Ьеат that is seen. The same iris tumor
is again shown with the slit illuminator at а small angle of
displacement from the axis of the biomicroscope. The mini-
mal deflection of the slit Ьеат gives the false impression that
the lesion is but modestly elevated (Fig. 5.18). То Ье effective,
the slit Ьеат must Ье projected at ап angle approximately 450
from the axis of the biomicroscope. When repeated examina-
tion or photo documentation is planned over time, such а
condition тау Ье more accurately followed when the initial
settings (angle of illumination, s1it width, magnification, ех-
following lamellar posure, etc.) are recorded and repeated at each visit.

FIGURE 5.14
Deflection of the Ьеат away fгom the light souгce indicates а depression as seen in (А) ап epithelial defect and (8) а perforated coгneal ulcer.
45
FIGURE 5.15 Deflection of the Ьеат toward the light source indicates ап FIGURE 5.1 б The Ьеат is deflected toward the light source Ьу adhesion
elevation as demonstrated Ьу ап iris cyst with focal, forward displacement of iris to the posterior согпеа following а penetrating foreign body injury.
ofthe iris.

FIGURE 5.17 Ап iris lesion shows elevation Ьу the degree the FIGURE 5.18 The elevation, clearly identified in Fig. 5.17, is artificialiy
tangentially applied Ьеат deviates from normal. minified with а nearly coaxially applied Ьеат.
46
 Tangential lIIumination
The effectiveness of tangential, broad Ьеат illumination rests in its ability
to visually enhance surface texture. Because it creates distinct highlights and
shadows, even normally smooth appearing surfaces Ьесоте vividly dimen-
sional (Fig. 5.19).
The iris of the еуе is а marvelous surface to examine and photograph in tan-
gential illumination. Its natural topography is beautifully enhanced and the
diffusing effect of frontally illuminated cornea is greatly reduced (Fig. 5.20).
When ап image of ап iris taken in frontal illumination is compared to the same
iris taken in tangential illumination, the effectiveness of this technique is read-
ily apparent (Fig. 5.21). Many conditions тау Ье effectively illuminated in this
manner. Pseudoexfoliation of the lens capsule, а deposition of abnormal mate-
rial оп the anterior lens surface, is well demonstrated in tangential illumina-
tion. Note that the corneal reflection is at the margin of the cornea and does not
interfere with the subject of interest (Fig. 5.22). The same еуе is again photo-
graphed at higher magnification and the image cropped to isolate some of the
salient features of this condition (Fig. 5.23). An example of Rieger's syndrome,
demonstrating iris changes and pigment deposition оп the lens surface, is well

FIGURE 5.19
(А) А slab of sandstone appears smooth and
featureless in coaxial (frontal) illumination
but becomes highly dimensional (8) when
/
illuminated tangentially.

А в

FIGURE 5.20 Tangential illumination portrays elegantly the features of (А) the погтаl iris and (8) the iris of а patient with а history of plasmacytoma.
47
 А

FIGURE 5.21
Comparison of а погта/ iris seen in (А) dua/ diffuse illumination and in (8) tangentia/ illumination. The latter shows surface texture much тоге effective/y.

FIGURE 5.22 Overview of pseudoexfo/iation of the lens capsule in FIGURE 5.23 Higher magnification, cropped image of pseudoexfo/iation
tangentia/ illumination. of the /ens capsu/e.
48
 portrayed in tangential illumination (Fig. 5.24А). А luxated, mature lens nucle-
us rests in the anterior chamber in Figure 5.24В. The tangentially applied light
obviates reflections from the соrnеа and adds considerable dimensional infor-
mation to а flat, two-dimensional image. In another example, specific features
of corneal granular dystrophy are highlighted at increased magnification (Fig.
5.24С). At even greater magnification, а "Christmas tree" cataract is isolated
in tangential illumination in Figure 5.24D. А large pupil is required for quality
images of changes within the lens.
When illumination is not sufficiently tangential, the contrast between high-
lights and shadows is reduced. Additionally, the specular reflection and diffuse
reflections from the surface of the соrnеа and lens will compromise underlying
information. The filllight is not used in conjunction with tangential illumina-
tion as it would fill in the shadow areas and counteract its effectiveness. The
filllight would also reduce contrast, and produce additional, distracting reflec-
tions from the соrnеа. The iris lesion seen earlier in Figures 5.17 and 5.18 is now
illuminated axially (frontally) with а full Ьеаm, resulting in corneal reflections,

FIGURE 5.24 Tangential illumination demonstrating (А) а case of Rieger's syndrome showing iris changes and deposition of pigment оп the anterior lens
surface, (В) а mature, luxated lens nucleus in the anterior chamber, (С) granular dystrophy and (О) а "Christmas tree" cataract.
49
[овз оЕ contrast and [озв оЕ dimensional information (Fig. 5.25А). Tangential
illumination obviates reflections, increases contrast, and greatly enhances the
dimensionality оЕthe subject. Higher magnification serves to crop the image
to concentrate оп key elements (Fig. 5.25В).
А tangentially applied moderate slit Ьеат is highly effective in isolating аЬ-
normalities in transparent media. Ап intralenticular foreign body (fragment оЕ
steel in the lens) is isolated with oblique illumination. The slit Ьеат is directed
to strike the object without illuminating the surfaces that lie in front оЕ,or Ье-
hind, the object (Fig. 5.26). When such surfaces аге illuminated (unavoidable
with more coaxial illumination), contrast and clarity оЕ the foreign body аге
reduced, producing ап effect similar to 100king through а fogged or frosted
windowpane. In Figure 5.27 а free-floating vitreous cyst is seen as it drifts Ьу
the dilated pupil. Due to the depth оЕthis abnormality within the еуе, а large
pupil size is needed to рlасе the incident Ьеат at а sufficiently tangential angle
to avoid illuminating overlying surfaces. The light area to the left оЕ the cyst
is the Ьеат striking the соrnеа and lens. Without adequately oblique illumi-
nation, the area оЕilluminated соrnеа and lens could overlay the cyst, greatly
diluting the desired information. For the examination and, in particular, the
imaging оЕthe lens and anterior vitreous, а well dilated pupil is essential.

FIGURE 5.25 (А) Ап iris lesion (previously seen in Figuгes 5.17 and 5.18) is illuminated coaxially with а wide Ьеат producing little
dimensional information and а bright artifact from the согпеа. (8) The same lesion а! higher magnification and in tangential illumination is
seen in much greater clarity and appears much тоге dimensional.

50
 FIGURE 5.26 А langenlially applied moderale Ьеат is used 10 isolale ап iпlгаlепliсulаг fогеigп body (fгаgmепl of sleel iп Ihe lепs).

FIGURE 5.27
А free floaling vilreous cysl is sееп in good clarily wilhiп а lапgепliаllу applied beam.lhal does поl slrike surfaces (согпеа апd lепs) direclly iп fгопl of Ihe cysl.

51
Pinpoint Illumination for Detecting Aqueous Cells and Flare
(Tyndall's Phenomenon)
Tyndall's phenomenon (named for John Tyndall, British physicist, 1820-1893)
is described as "the rendering visible оЕа transverse Ьеаm оЕlight through its
being broken ир Ьу solid particles suspended in а liquid or gas" (Dorland's,
24th edition). In Fig. 5.28, roadside sunbeams аге visible due to light reflected
Ьу dust particles isolated against а darker background.
Direct focal, tangential illumination witl1 the slit Ьеаm adjusted to а pinpoint
оЕligl1t, permits detection and quantification оЕаоцеоцв cells and Пате.' The
anterior chamber is normally optically empty; that is, the Ьеаm оЕlight, еуеп in
its most selective form, is not visible as it traverses the normal aqueous humor.
In the presence оЕinflammation, however, abnormal particles (immune cells)
floating in the aqueous mау reflect light, much as snowflakes or raindrops are
visible in the Ьеаm оЕа car's headlamp at night. Turbidity оЕthe aqueous also
mау оссцг due to the presence of abnormal protein, where pinpoint illumina-
tion simulates the headlamp Ьеаm while driving оп а foggy night (Fig. 5.29).
Aqueous cells and protein аге referred to as "сеll" and "flare" (or "ray") re-
spectively, and аге graded оп а scale оЕ"1+ to 4+" depending оп severity. This
condition сап Ье fairly easily appraised during the examination, but is among
the most difficult to photograph. Сеll and flare have а very low reflectivity: а
level not usually sufficient for imaging. Exposures should Ье attempted only

F,GURE 5.28 Roadside sunbeams аге visibIe due to dust particles in F,GURE 5.29 Aqueous cells and flare within а tangentially applied
the air reflecting isolated light against а darker background. "pencil of light" exposed а! ап 180 of 1000.
52
 оп ISO 400 or greater film or digital media, with the light output of the photo
slit lamp set to maximum. The focal point of the Ьеат should Ье placed over
the dark background of the pupil to provide greatest contrast. А dilated pupil
will make this task much easier. Figure 5.30 shows the results of 4+ сеll and
flare exposed оп Kodak Ektachrome film processed to ап ISO of 3600.
While the "pencil of light" technique of illumination used above provides
greatest discrimination for photography, а common practice during the exami-
nation is to use а short, narrow Ьеат, approximately 1тт х 3тт in size, to
simultaneously illuminate а larger area. In the presence of considerable abnor-
mal material, it сап Ье highly effective even for recording images (Fig. 5.31).

FIGURE 5.30 Fouг-plus aqueous cells and Ilare exposed оп Ektachrome lilm а! ап ISO 01 3200,

FIGURE 5.31 А dramatic expression 01louг-plus cells in а case 01endophthalmitis,

53
 Specular Reflection
А specular reflection (from the Latin specularis, meaning "mirror-like") is the
reflected image of the light source itself. Snell's law of optics, which states
"The angle of reflection equals the angle of incidence" dictates that the specular
reflection will only Ье seen when viewed from the same but opposing angle
relative to the reflecting plane (Fig. 5.32). The brightness, or шгепвпу, of the ге-
flection depends оп the reflectivity of the surface оп which it is seen; that is, the
efficiency with which the incoming light is reflected. The clarity or definition
of the reflection is influenced Ьу the texture of the reflecting surface. Соттоп
examples include the bright reflections from а fl'eshly polished Поог or the
sun's reflection оп the surface of а lake. The undisturbed water reflects а пеаг
mirror image of the sun. The Ьгокеп гейеспоп indicates ап irregularity of its
surface (Fig. 5.33).

~'oO~<1S0

: ">;>
/.

FIGURE 5.32
Snell's law of optics states that
the angle of reflection equals
'-- ---' the angle of incidence.

FIGURE 5.33 (А) The pond's relatively smooth surface reflects the image of the sun faithfully. (8) Ап interrupted ог altered
specular reflection indicates ап alteration of the reflecting surface.
54
 Observing specular reflections permits rapid assessment of optical surfaces.
The reflections from the anterior соrnеа (tear film layer) is bright and mirrors
the shapes of illuminating sources faithfully. When the соrnеаl surface is тг-
regular, or when the tear film is compromised, the specular reflection will Ье
interrupted. (Fig. 5.34).
Because the согпеа is а convex surface, specular reflections of illuminating
sources аге nearly impossible to avoid. During ап examination, such reflec-
tions will move dynamically witl1 the lateral movements of the slit illuminator
and biomicroscope. During ап appropriately dynamic examination, they will
not interfere with Нте process of gathering information. In а static photograph,
however, (unless the purpose is to record the specular reflection) they will Ье
undesirable artifacts and should Ье minimized. Illuminators should Ье posi-
tioned to prevent these bright reflections from masking the area of interest. The
angle of view between the oculars is ап important factor in the exact [осапоп
of specular reflections. The observer's right еуе mау see а specular reflection
whereas the left mау not. The tendency is to mentally cancel out the reflection.
However, if the сагпета body is mounted оп the right, it will faithfully record
that reflection. Therefore, before а photograph is taken, the observer's еуе that
is contralateral to the side оп which tl1e сагпета body is mounted should Ье
closed. Observing only with the ipsilateral еуе just before exposure will ensure
that the image is free of artifacts and maximized for recording.
А frequent application of specular reflection is the examination of the endo-
thelial celllayer of the соrnеа. The normally flat surface of the endothelial cells
is highly reflective whereas their borders, being of slightly uneven topography,
are relatively non-reflective and are seen as dark lines between cells. Simi-
larly, disturbances in the normally flat cellular layer result in alterations in the
specular reflection, defining certain abnormalities as dark, non-reflective areas,
or areas of reflection that аге brigMer than normal ог of а different color. At
magnifications of 25Х and 40Х, individual cells mау Ье seen (Fig. 5.35). То
[осате the reflection from the endothelium, center and focus the bright reflec-
tion from the tear film. Using а moderate Ьеаm, with the slit illuminator at
approximately 250 from the biomicroscope, the endothelial reflection will Ье
seen adjacent to the reflection from the tear film layer. It will Ье юсатес оп the
side opposite the incident Ьеаm, and will Ье far more demure than the reflec-
tion from the anterior соrnеа. Ву moving the microscope forward the distance
corresponding to the thickness of the соrnеа (approximately 0.52 to О.57mm)
the endothelial cells should Ьесоmе visible (Fig. 5.36). Ву moving the subject
еуе (with the contralateral fixation target) rather than the slit illuminator, а

А в
FIGURE 5.34 (А) The normal согпеа produces well delineated specular reflections. (8) Altered reflections indicate ап abnormal corneal surface.
55
 I
I \

/
" II ~ \ \,
/.
------2S.----1-20.~
FIGURE 5.35 Specular геflесtiоп from the епdоthеliаl surface shows а погmаl cellular раttегп with the ехсерtiоп ofthe small агеа superiorly, iпdiсаtiпg а
focal аltегаtiоп iп the topography of the епdоthеliаllауег.

FIGURE 5.36 Normal епdоthеliаl cells sееп iп specular геflесtiоп.

56
 considerable area of the endothelium тау Ье examined. Slight movements
of the patient's еуе, not only horizontally but also vertically, will help greatly
in locating the endothelial reflection. Only that portion of the cornea that is
parallel with the front surface of the objective lens of the biomicroscope will
produce axial specular reflections. In the presence of corneal abnormalities the
cells тау Ье difficult or impossible to see (Fig. 5.37).
Using the same technique, the specular reflection тау Ье seen оп the an-
terior lens surface as well. As the central агеа of this surface is relatively flat,
the vertical position of the еуе is ап important factor in locating the specular
reflection. If the еуе is turned ир ог down, so that the anterior lens surface is
out of parallel with the front surface of the objective lens of the biomicroscope,
the specular reflection cannot Ье seen regardless of how far the еуе is moved
right ог left. With the еуе positioned correctly, the normally textured surface of
the lens сап Ье identified easily (Fig. 5.38). Reflections from the posterior lens
surface сап also Ье obtained Ьу focusing the microscope to the appropriate
depth (Fig. 5.39).

FIGURE 5.37
(А) The normally homogeneous specular reflection is altered Ьу ап irregular surface. (8) Severe Fuchs' dystrophy preventing а view of endothelial cells.

57
 FIGURE 5.38 80th horizontal and vertical planes of а flat surface (such
as the lens) must Ье parallel to the objective lens of the biomicroscope to
visualize the specular reflection.

FIGURE 5.39 The specular reflection seen оп the posterior lens surface.
58
 Indirect Forms of Illumination
А p1ant is seen in retroillumination, producing а transillumination effect of
the seed pods and enhanced visibi1ity of the fine cilia covering the p1ant. As
this image demonstrates, indirect illumination сап provide considerable ad-
ditiona1 information about many subjects and conditions (Fig. 5.40).
Indirect illumination is especially usefu1 for examining and photographing
subt1e changes that require enhancement of contrast for visualization. Many
such abnorma1ities within the transparent structures of the еуе are over-
powered Ьу direct illumination and remain e1usive. То visua1ize these subt1e
changes, more subt1e forms of illumination are required. These forms inc1ude
proxima1 illumination, sc1erotic scatter, and retroillumination.
Indirect illumination is the secondary illumination of а structure Ьу 1ight
transmitted through tissue or reflected Ьу another surface. Instead of direct-
ing the 1ight to strike the subject itself (primary or direct foca1 illumination),
the 1ight is directed toward ап adjacent агеа, or another surface, which in turn
becomes the actua1 source of illumination (secondary, ог indirect illumination)
for а specific target (Fig. 5.41).
Indirect illumination effective1y p1aces an illumination source within the еуе,
either behind or beside the subject of interest. Visua1ization Ьу indirect Шц-
mination is easi1y accomplished. Photographing that
same view, however, сап Ье а considerable challenge,
due main1y to the considerable [овв of 1ight intensity
at the area of secondary illumination. On1y а fraction
of the direct Ьеат intensity remains in the агеа of in-
direct illumination, necessitating adjustments in ехро-
sure. Each form of indirect illumination requires its
own consideration for correct exposure, further сот-
p1icated Ьу natura1 variations in the optica1 density of
tissues used to transmit ог reflect 1ight.
Whi1e not a1ways essentia1 during ап examination,
centration of the principa1 area of interest in the re-
corded image is very important to а p1easing and in-
formative presentation. АН indirect forms of illumi-
nation require а disp1acement of the slit Ьеат from its
norma1 iso-centric position with the biomicroscope.
The biomicroscope is centered оп the area to Ье i1-
1uminated indirect1y and the 1ight Ьеат de-centered
using the appropriate contro1. The optimum degree
of de-centration is best determined Ьу dynamically
altering the position of the direct Ьеат while observ-
ing the effect оп the principa1 subject area. The result
S11OU1d Ье а well centered principa1 subject, and а
de-centered light Ьеат. (The importance of this tech-
nique is illustrated in Figure 5.58, in the section "Ret-
rоЩuminаtiоn from the Fundus.")
With the possible exception of а demonstration
photograph used to provide context, the fill light is
never used with indirect illumination. The fill light
wou1d counter the effects of аН indirect forms and di-
minish the information both during an examination
FIGURE 5.40
and in а recorded image. То obtain the best resu1ts
from аН forms of indirect illumination, the fill1ight
А plant is seen in retroillumination, producing а transillumination effect and
ап enhancement of fine detail against а dark background. must Ье оН.
59
FIGURE 5.41 (А) А glass object (purposely speckled with а soapy solution to produce abnormalities) is seen in direct, lосаl illumination. (8) Indirect
illumination (direct retroillumination Iгот the wall) silhouettes changes 01greater opacity, and the greater density 01the vessel's outline. (С) The most selective
lогт 01 illumination (indirect retгoillumination lгот the wall) produces the most inlormation about changes which аге transparent ог translucent and аге по!
visibIe against а bright background. (О) Using а darker background (as а dilated pupil) amplilies the effectiveness 01this lогт in enhancing subtle lindings. ба
 Proximal lIIumination
An abnormality that lies within tissue mау Ье difficult to see when illumi-
nated directly. The light striking the overlying tissue is reflected to varying
degrees and mау not penetrate sufficiently to the level of the lesion. А more
effective technique is the use of proximal illumination. А moderate slit Ьеаm is
de-centered and directed to an area adjacent to the area of interest, where the
absorption and scattering of light Ьу surrounding tissue produces а retroillu-
mination effect. This сап increase contrast and provide more accurate informa-
tion regarding size, shape, density and location (Fig. 5.42). For photography,

FIGURE 5.42 А lid lеsiоп is sееп iп (А) diffuse illumiпаtiоп апd iп (8) pгoximal illumiпаtiоп.

FIGURE 5.43 (А) А Сагdопа keгatopгosthesis iп diгect local illumiпаtiоп. Most 01the light is гellected Ьу the scleгotic согпеаl
tissue апd its flапgе is поt visibIe. (8) With pгoximal illumiпаtiоп the light scatteгs Ьеhiпd the Ilапgе, ргоvidiпg good visibility.
67
the flash intensity must Ье increased from two to four f stops to expose the area
of indirect illumination adequately. The required increase will Ье determined
Ьу the amount of light reflected Ьу overlying tissue. In Figure 5.4ЗА, the sclerot-
ic, white соrnеа reflects most of the light and requires а considerable increase in
light intensity to produce the information seen in Figure 5.4ЗВ. Ву comparison,
the lid lesion in Figure 5.42 and the intralenticular foreign body in Figure 5.44
require more modest exposure increases. Digital imaging systems provide
immediate feedback and adjustments сап Ье гпаае dynamically to produce an
optimum exposure.

FIGURE 5.44 (А) Light гeflected Ьу changes in the lens ргеуегп а good view of this foгeign body. (8) Pгoximally applied light cгeates а гetгoillumination
effect, pгoducing betteг infoгmation гegaгding the size, shape and location of the foгeign body.

62

FIGURE 5.45 Scleгotic
shows а гing of light а! the
FIGURE 5.46 (А) Scleгotic scatteг demonstгating multiple fibeгglass foгeign bodies in the anteгioг согпеа. (8) А! higheг magnification, even the subtle
edema suггounding some of the paгticles сап Ье easily appгeciated.
63
Sclerotic Scatter
Both subtle and widely distributed corneal abnormalities mау Ье demon-
strated with sclerotic scatter. Sclerotic scatter is especially useful to show the
distribution of changes within the согпеа t11at аге best seen against а dark,
un-illuminated background. With the slit illuminator offset from its usual iso-
centric position, а broad slit Ьеаm is directed at the corneoscleral junction (lim-
bus). This results in the absorption of light Ьу the sclera, which is then reflected
into and "piped" throughout the согпеа Ьу total internal re-
flection. When the согпеа is normal, nothing disturbs the pas-
sage of this light and is, therefore, not visible. Only а halo of
light is seen at the limbus where the light is reflected Ьу the
greater optical density of the scleral tissue (Fig. 5.45). When
ап abnormality is present, however, it becomes visible Ьу re-
flecting, refracting or scattering part of the light toward the
biomicroscope (Fig. 5.46).
When the slit illuminator is left in its normal iso-centric posi-
tion, it is impossible to illuminate the limbus and center the
еуе simultaneously. The Ьеаm is deflected maximally, as seen
in Figures 5.45 and 5.46, to allow centration of the соrnеа. Тhen,
while viewing the согпеа through the biomicroscope, the slit
deflector control is moved slightly from side to side until the
best level of illumination of the corneal abnormality is оЬ-
served. Figure 5.47 shows а relatively subtle corneal finding.
The соrnеа verticillata in Fabry's disease is seen in direct, тап-
gential illumination and again in sclerotic scatter. Direct illumi-
nation provides some corneal information but also illuminates
the lens, producing а relatively light background that reduces
I
I contrast. The subtle, translucent verticillate pattern is much
е::э better seen against а dark background (dark-field Шиminа-
tion), which is possible with sclerotic scatter and а widely
scatteг in а погтаl согпеа meгely dilated pupil. The maximum flash output from the power sup-
limbus. ply is generally necessary to produce а good exposure. Sclerot-
ic scatter is а valuable form of illumination for various corneal
abnormalities as it provides information of subtle conditions
over а wide area of distribution in а single image (Fig. 5.48).
,
е=з в
FIGURE 5.47 (А) The subtle согпеа verticillata iп Fabry's disease iп direct focal illumiпаtiоп. (8) Sclerotic scatter illumiпаtеs the
согпеа without directly illumiпаtiпg the lепs, епhапсiпg сопtгаst апd visibility of the раttегп.

FIGURE 5.48 Согпеаl гiпgs sееп iп sclerotic scatter.

64
 FIGURE 5.49 (А) Glass object in direct retroillumination from the wall silhouetting some changes of greater optical density. (8) Corneal new vessels in
direct retroillumination from the iris. (С) Multiple foreign bodies (from homemade fireworks) seen in direct retroillumination from the iris.

65
Retroillumination
Light reflected from the iris or fundus provides а bright background against
which some abnormalities within structures anterior to these surfaces тау Ье
more easily seen. Direct and indirect retroillumination from the iris are excel-
lent techniques for demonstrating subtle corneal abnormalities that тау Ье
only slightly less transparent than normal соrnеа. The interface between direct
and indirect retroillumination from the iris is опе of the most important zones
of information in the examination and photography of the соrnеа. Retroillu-
mination from the fundus makes possible the simu1taneous examination and
photograp11Yof extensive areas of the lens and соrnеа, and is the most practi-
cal method of demonstrating iris transmission defects.

Direct Retroillumination from the Iris

With the biomicroscope focused оп the соrnеа, the normally iso-centric slit
is deflected to опе side and the Ьеат directed to illuminate the iris surface
behind the region of соrnеа being observed. Thus, the cornea is indirect1y,or
secondarily, illuminated from behind Ьу light reflected Ьу the directly illumi-
nated iris. Abnormalities in the соrnеа of considerable optical density are well
delineated as they are silhouetted against а light background (bright-field il-
lumination). А moderately wide slit Ьеат is most effective and should Ье di-
rected at а sufficiently tangential angle to avoid directly illuminating the агеа
of соrnеа under study (Fig. 5.49). In another example, а pigmented posterior
cornealline is identified in dual diffuse illumination. With direct retroillumi-
nation from the iris and increased magnification, its features are much better
demonstrated (Fig. 5.50).Photographic exposure is similar to that required for
direct focal illumination of the iris. The color of the iris will determine the
amount of light reflected and thus the base exposure. А brown iris will require
more light than а blue iris.

А в •
FIGURE 5.50 (А) А pigmented posterior cornealline is seen in dual diffuse illumination (arrows). Contrast is low and the left side specular rellection
obscuгes а portion 01the abnormality. (8) Direct retroillumination Iгот the iris moves the single specular rellection away Iгот the агеа 01 interest and
enhances contrast.

66
 FIGURE 5.51 (А) Glass object in indirect retroillumination lroт
the wall is dramatically demonstrative 01subtle, transparent and
translucent changes. (8) Folds in Descemet's тетЬгапе seen in
tangentia/ illumination (arrow). The abnorma/ity is /arge/y overpowered
Ьу direct illumination. (С) As this abnorma/ity is primarily relracti/e, it
is well demonstrated in indirect retroillumination from the iris, а! the
А
interface of /ight and dark backgrounds.

с
67
Indirect Retroillumination from the Iris
In а modification of tl1e direct technique, indirect retroillumination from
the iris is even more effective in delineating subtle pathologic changes. Ву de-
centering the slit Ьеат further from its normal iso-centric position, the intend-
ed агеа of соrnеа is seen against а region of dark, un-illuminated iris ог the
even darker background of the pupil (dark-field illumination). Light scattered
Ьу adjacent, illuminated iris provides sufficient illumination to Ье reflected or
refracted Ьу subtle changes that тау otherwise Ье.difficu1tto see (Fig. 5.51).
While easily visualized, recording images of these subtle changes тау prove
chaHenging. The агеа of indirect retroillumination receives but а sтаН fraction
of the light that strikes the iris directly. Without ап increase in flash output,
the area of indirect retroillumination will Ье under-
exposed in а recorded image. Тоеnhапсе the desired
detail, exposure must Ье increased, at times dramati-
саНу.This will resu1t in ап overexposure of the агеа
directly illuminated Ьу the slit Ьеат, but is а neces-
sary element in recording the required information
in the агеа of secondary, or indirect, illumination (Fig.
5.52).
Figure 5.53 provides а review of the three princi-
pal types of illumination that occur when the соrnеа
is examined with а moderate, tangentiaHy applied
Ьеат. Zone 1 shows the Ьеат striking the соrnеа
and represents direct, focal illumination. Zone 2, the
агеа of illuminated iris, represents direct retroillumi-
nation from the iris, which is useful for silhouetting
dense changes against а bright background. Zone 3,
цп-Шшпшагес iris just adjacent to illuminated iris,
represents the агеа of indirect retroillumination from
the iris. Indirect retroillumination from the iris excels
at demonstrating changes of low density that refract
or scatter light, and аге best seen against а dark back-
ground. Note the now visible corneal edema sur-
rounding the opaque foreign bodies.

t
t
t

FIGURE 5.52 Indirect retroillumination lгот the iris 01keratic precipitates FIGURE 5.53 The three principal lorms 01 illumination 01the согпеа
(КР). Ап overexposuгe 01the directly illuminated iris is necessary lог good when using а moderate Ьеат: (1) Direct local illumination, (2) direct
exposuгe 01the агеа 01 indirect illumination. Best contrast is provided Ьу the retroillumination Iгот the iris and (3) indirect retroillumination Iгот the iris.
dark pupil.

68
 Combined Direct and Indirect Retroillumination from the Iris
Representing two distinct forms from the standpoint of how they func-
tion, direct and indirect retroillumination from the iris are most informative
when used together. This combined technique is the most important to the
thorough examination of the соrnеа. It actually produces three types of illu-
mination with corresponding zones of information. Of greatest importance is
the interface between light and dark backgrounds, zone 3+, where the most
subtle changes тау Ье seen (Fig. 5.54А). Abnormalities that both refract and
reflect light Ьесоте most dimensional in this zone between light and dark

FIGURE 5.54 (А) А case 01Thygeson's superlicial punctate keratitis showing the zones 01 illumination: (1) direct lосаl illumination, (2) direct
retroillumination Iгот the iris, (3) indirect retroillumination Iгот the iris and, (3+) the actual interlace between direct and indirect retroillumination Iгот the iris.
(8) Lattice dystrophy demonstrating classic lindings in zone 3+, the actual interlace between light and dark backgrounds (arrows).
69
backgrounds. Technically tl1is[цпсшге is an interface rather than а true zone.
However, as the biomicroscope (and therefore the slit Ьеат) is focused at the
level of the cornea, the interface оп the iris is formed Ьу postfocal, divergent
rays, resulting in an un-sharp image. As this un-sharp image of an un-sharp
interface appears to оссиру space Ьу virtue of its broader appearance, it Ье-
comes а narrow zone in the practical sense, especially at higher magnification
as seen in Figure 5.54В.When possible, the dark background of the pupil сап
Ье used to produce greater contrast {отthe detection of certain corneal changes.
Рот certain conditions, however, tl1elower contrast interface overlying the iris
will provide тоте dimensional information (Fig. 5.55). The entire cornea сап
Ье examined in this таnnет for both subtle and gross a1terations погп the пог-
mal. The Ьеат of light is applied tangentially and moved across the cornea
while observing the three main zones simultaneously, with particular апеп-
tion to zone 3+; the interface between light and dark backgrounds. То ensure
that аНinformation about the cornea has been gathered with this modality, the
scan should Ье repeated, with the light applied from both the temporal and
nasal sides.
Once the abnormality is identified, photography сап Ье carried out. А good
result, however, requires strict consideration of the specific mode, от zone, of
illumination used, t11enature of the abnormality, and the color (brightness)
of the reflecting iris for
accurate exposure.

FIGURE 5.55 (А) Lattice dystrophy sееп а! the interlace 01 light and dark backgrounds. (8) The microcysts in Meesmann's epithelial dystrophy аге most
diтепsiопаl in zone 3, indirect геtгоilluтiпаtiоп Iгот the iris, and 3+, the interlace between light and dark backgrounds. The dark pupil increases contrast
but does по! enhance dimensional iпlогтаtiоп in this example. The lower contrast zone and interlace over the iris аге тоге inlormative in rendering the
micгocysts in а dimensional таппег (aггows).
70
 FIGURE 5.56
Retгoillumination fгom the
fundus showing а posteгioг
coгneal гejection line following
penetгating keгatoplasty (РКР)
seen against the chaгacteгistic
oгange backgгound,

Retroillumination from the Fundus

Ву directly illuminating the retinal pigment epithelium, а bright background
is created that serves to secondarily illuminate or silhouette abnormalities in
the anterior vitreous, lens, anterior chamber and соrnеа (Fig. 5.56). А close
analogy would Ье the observation and photography of а subject against the
warm glow of the setting sun (Fig. 5.57).
То begin, the slit illuminator is left in its normal, iso-
centric position (as used for direct forms of illumi-
nation) and is placed in а nearly coaxial alignment
with t11ebiomicroscope. The instrument is then lined
ир with the well dilated pupil (essential for this form
of illumination) and а moderately wide slit Ьеат is
introduced into the еуе. As the еуе is centered in the
biomicroscope, the Ьеат will fall across the center of
the pupil. The Ьеат will illuminate the fundus that
lies directly behind the area of interest and the red re-
flex should Ьесоте visible. If it does not, small move-
ments of the slit illuminator either right ог left of сеп-
ter should produce the red reflex (Fig. 5.58А). The
next step is to place the Ьеат at the pupillary margin
to facilitate examination of the central соrnеа ог lens.
If the slit illuminator is left in its iso-centric position,
t11eЬеат сап only Ье moved to the pupillary margin
Ьу de-centering the entire instrument. This places the
еуе off center and, at higher magnifications, тау pre-
clude а simultaneous view of t11eentire area of Шц-
mination. W11ileап examination could Ье conducted
in this manner, а photograph would fall short of the
ideal outcome (Fig. 5.58В). The most effective tech-
nique, especially for photography, is centering the
еуе in the biomicroscope and de-centering the slit il-
luminator. The image in Figure 5.58С represents the
ideal starting point from which further refinements
FIGURE 5.57
сап Ье made to realize optimal results. The size and
guгe silhouetted against the waгm glow of the setting вцп.
shape of the Ьеат, while effective to the initial steps
77
FIGURE 5.58 (А) The inilial slep in preparing lог relroilluminalion Iгот Ihe lundus wilh bolh Ihe biomicroscope
and illuminalor in а coaxial posilion wilh Ihe еуе. (8) The еуе decenlered 10 place Ihe Ьеат аl Ihe pupillary margin.
(С) The соггесl posilion ollhe microscope cenlered оп Ihe pupil wilh Ihe Ьеат decenlered.
72
 described, is counter productive if left in this configuration. Considerable light
falls оп the iris surface, creating ап undesirable distraction and light scatter
that interferes with the clarity of the area of interest. The Ьеат must Ье соп-
figured to fit inside the pupil as much as possible. Ыеаllу, it would assume а
half-moon shape when that is facilitated Ьу the instrument (Fig. 5.59). When а
half-moon shape is not possible, а short, fairly broad oblong Ьеат should Ье
used to limit artifacts of illumination from the iris (Fig. 5.60).
The optimum position of the slit illuminator is determined visually Ьу the
intensity of the light reflected Ьу the fundus, which imparts its characteristic
orange color to the reflection. (The color and density of the retinal pigment
epithelium and choroid, and therefore, their reflectivity, сап vary widely, in-
fluencing individual exposure requirements for photography.) With modest
excursions of the illuminator to either side of center, the optimum position is
established when the greatest retroillumination effect is achieved.
А major advantage of this lighting modality is that it producers excellent
delineation of subtle changes over а wide агеа of distribution. In that regard, it
is similar to sclerotic scatter. The principal difference between the two is that
sclerotic scatter produces dark-field illumination (il-
lumination of the соrnеа against а dark background),
whereas retroillumination from the fundus is а bright-
field technique (the соrnеа and lens are silhouetted
against а light background). Dark-field excels at
demonstrating changes that primarily reflect or scat-
ter light, whereas bright-field produces best contrast
for opaque changes which absorb light, and changes
that refract light.
Figure 5.61Aillustrates another starting point at low
magnification with the fill light left оп intentionally.
While this image shows both the external еуе as well
as the subluxated lens against the bright background
of illuminated fundus, it serves only as an introduc-
tion to the еуе' s general condition. The filllight acts
to diminish the retroillumination effect as it reduces
contrast and degrades the desired information with
FIGURE 5.59 When facilitated Ьу the instrument, а half-moon shaped light reflecting from the соrnеа and lens. When the
Ьеат is ideal for maximallight input without creating light artifacts from the iris. fill light is extinguished, as demonstrated in Figure
5.61В, the essential information becomes much more
apparent. And, as the area of retroillumination does
not fill the frame effectively, higher magnification
takes better advantage of the available format (Fig.
5.61С). Retroillumination from the fundus is an ех-
cellent technique with which to demonstrate а vari-
ety of findings in the соrnеа and lens (Fig. 5.62)
An additional maneuver (also applicable to iris
transillumination, discussed below) тау Ье used
to increase the intensity of retroillumination. In the
presence of а small pupil or media opacities, this tech-
nique сап Ье very effective in producing sufficient ret-
roillumination for examination and photography. Ву
rotating the subject еуе nasally, the optic nerve head
сап Ье positioned to act as the reflecting surface for
the slit Ьеат. Because of its greater reflectivity, more
intense retroillumination тау Ье obtained (Fig. 5.63).
FIGURE 5.60 Ап obIong Ьеат should Ье sized to fit into the availabIe
pupil as much as possibIe to reduce artifacts of illumination.
73
 FIGURE 5.61
Traumatic subIuxation of the lens with
hemorrhage.
(А) Ап introductory image showing
retroillumination from the fundus, but
with the filllight left оп intentionally to
provide perspective.
(8) With the filllight off, contrast is
increased. Now, however, the image по
longer fills the format.
С) Increased magnification makes good
use of the availabIe format.

FIGURE 5.62 Retroillumination from the fundus demonstrating (А) epithelial fingerprint dystrophy,
(8) Haab's striae in Axenfeld's syndrome and (С) cellular overgrowth of ап intraocular lens (IOL).

74
 FIGURE 5.63 When the retinal pigment epithelium (RPE) does по! reflect sufficient light for optimum exposuгe (А), the optic nerve head сап pгovide а
much brighter background (В) for the lens vacuoles seen in ап early cataract formation.
75
 Iris Transillumination
Figure 5.64Аshows the effects of а contusion injury resu1ting in lens changes and
iris atrophy. It is а good record of both conditions. However, when iris transillumi-
nation is the primary goal, а completely dilated pupil is counterproductive. А mild
mydriatic, such as 0.5% tropicamide is applied topicaHy and the pupil monitored
until а dilation of 3 to 4 mm is attained. In that presentation, the iris is still suf-
ficiently attenuated to demonstrate even subtle expres-
sions of transillumination. The slit illuminator is placed
in а coaxial position with the biomicroscope and ап iso-
centric, fuH circle or square Ьеаm is directed through the
available pupil. The Ьеаm should approximate the size
of the pupil, preferably without striking the iris, and the
biomicroscope focused at the iris plane. Defects in the iris
pigment layer аге seen Ьу transmission of light reflect-
ed Ьу the fundus (Figs. 5.64В & 5.64С). Photography of
subtle trапsШumiпаtiоп defects, as those seen in pigment
dispersion syndrome (Fig. 5.64D), requires а significant
increase in light intensity and will invariably produce an
artifact of illumination. Ап alternate method of demon-
strating iris transillumination defects has Ьееп described
Ьу Verdick and Thompson, using infrared videography.l1

FIGURE 5.64 Ап еуе following contusion injuгy showing lens changes and ап агеа о! iris transillumination due to focal iris atrophy (А). Iris transillumination in
(В) ocular albinism (oculocutaneous type), (С) essential iris atrophy with geographic defects, and (О) subtle, radial defects seen in pigment dispersion syndrome,
requiring maximum illumination for documentation.
76
 Trans-corneal Foreign Body Track
77
 Chapter 6

Focus
Centration
Magnification
Format
Control of Artifacts
Exposure

While the fundamental principles of clinical slit lamp

biomicroscopy and photo slit lamp biomicrography аге es-
sentially the same, additional considerations аге necessary
for successful photodocumentation. Several components
have been discussed as essential to the photo slit lamp Ыо-
microscope in Chapter 2. Additional factors must now Ье
considered to produce consistently accurate and pleasing
photographs. Correct mechanical focus, centration, mag-
nification, control of artifacts, and exposure аге elements
which must Ье combined to achieve desired results.

78
 Focus
The maintenance of а sharp image through the biomicroscope is а сопшш-
ous element of а dynamic slit lamp examination. Focus is а perpetual, flowing
transition as the s1itЬеаm is played over the gently curving surfaces of the
еуе. For practical purposes, there are по specific individual images, but rather
а compendium of infinite, transitional views producing ап aggregate цпргез-
sion. Each photograph is restricted to the capture of а single moment of that
examination. Therefore, preparations for photodocumentation must include
the selection of one optimal view and the perception of how that view will
look as а digital ог film image. То ensure а sharp image, precise mechanical
focus of the biomicroscope, at the time of exposure, is critical.
А conventional, fixed plane method of focusing, such as in а single lens re-
flex (SLR)camera, uses а ground glass type of focusing screen onto which the
incoming image is projected, and through which the image is viewed. This
method сап Ье compared to а rear projection television ог геаг projection slide
system where the image is projected onto the back surface of the screen and
viewed tl"lrough the material of the screen. However thin or fine the screen
material, its substance and texture will Ье imposed оп the image and mау
compromise some fine detail (Fig. 6.1).

.\==

в
FIGURE 6.1 (А) Diagrammatic cross-section of the single lens reflex (SLR) саmега. (8) Diffusion of
the image Ьу the texture and density of the focusing screen.
79
 в
FIGURE 6.2 (А) Undiffused, direct aerial image. (8) The image viewed through а ground glass screen.

In the SLR сагпета. the viewing screen provides а definitive, fixed plane of fo-
cus that corresponds exactly to the distance to the film plane. When the image
of the subject is sharp оп the focusing screen, the image will also Ье sharp оп
the film ог digital imaging sensor. The screen is used for viewing and focusing
only. The actual exposure is not made through such ап intervening surface.
Ап aerial image system does not utilize а focusing screen. Rather than pro-
jecting the image onto such а diffusing, fixed surface, the aerial image remains
"suspended" in the optics of the system. This design permits ап uninterrupted
passage of light to the oculars. Optical instruments such as the biomicroscope
(and other microscopes, telescopes, and binoculars) are designed for the visu-
alization of fine detail at high magnification. This fine detail would Ье compro-
mised considerably if viewed through а focusing screen (Fig. 6.2).
While seemingly а simple task, the aerial image seen in the biomicroscope
demands attention to а specific technique of focusing. As discussed in Chapter
2, the biomicroscope will produce а sharp image when it is the correct distance
from t11esubject plane. However, the plane at which the image is seen sharply
within the biomicroscope сап Ье shifted Ьу accommodation оп the part of the
examiner. Through accommodation, the physical relationship between the Ъю-
microscope (including the camera back) and the subject еуе mау Ье misjudged,
resulting in un-sharp photographs. А sensitivity to the difference between ап
aerial image system and а conventional, fixed plane system of focusing will
greatly limit this problem. The biomicroscope is designed to Ье used with the
accommodation completely relaxed; that is, the image within the system must
Ье treated as а distant object seen at infinity. Therein lies the paradox. The sub-
ject еуе is very close, yet it must Ье regarded as а soothing view of far-away
mountains. The problem does not lie in the design of the biomicroscope, but
rather in а natural response to the nearness of the physical subject that should,
in fact, Ье treated as а distant, optical image of the subject.
Accommodation is а constant function of vision as our eyes move rapidly
between distant and near objects. Observation of а пеаг object requires both
convergence (both eyes turn in to center оп the object of regard) and, of greater
importance to this discussion, accommodation. Accommodation occurs when
the lens in the еуе becomes thicker in the center, creating а greater "plus" re-
fractive element, thus enabling focus оп пеаг objects (Fig. 6.3). It is quite natural
for the uninitiated or undisciplined examiner or photographer to respond to
the nearness of the subject еуе with accommodation. During biomicroscopic
80
 FIGURE 6.3
As accommodalion occurs, Ihe lens becomes Ihicker
(dashed red oulline) and the poinl а! which the image
is sharp will Ье closer to the examiner's еуе producing
Ihe lendency 10 move Ihe biomicroscope lorward. This
results in а sharp image seen Ьу the accommodating
examiner, ап un-sharp cross hair relicle that
the examiner is now ignoring, and, 01grealest
consequence, ап un-sharp image аl Ihe lilm plane,
resulting in ап un-sharp photograph. The oulline ollhe
еуе in Ihis diagram represents the еуе 01the examiner,
with accommodalion relaxed [solid bIack line], and
duгing accommodation [dashed red line].
(The disparity is exaggerated (аг i//ustrative purposes.)

examination, accommodation has little consequence since the examiner need

suit only his or her visual needs. When the goal is photography, however, the
system becomes rigidly demanding of correct mechanical focus of the biomi-
croscope. То avoid un-sharp photographs due to accommodation, а cross hair
reticle is incorporated into the optical system.
The cross hair reticle, usually located in just оnе ocular, occupies the opti-
cal plane at which а focusing screen would Ье placed in а conventional (SLR)
system. Rather than trapping the image оп such а diffusing screen, the reticle
provides the reference for correct focus without interfering with the quality of
the image. Generally, the reticle is used in the ocular sharing the view with the
camera back for best control of the агеа to Ье recorded. When the examiner is
strongly left еуе dominant, а reticle should Ье used in both oculars. Correct
use of the reticle will result in the accurate physical focus of the biomicroscope
in relationship to the subject еуе. Neglect of the cross hair reticle mау gener-
ate accommodation and yield un-sharp photographs (Fig. 6.4). То avoid this
problem, оnе must:
1) establish tl1e сопес! eyepiece setting to сотрепзале for опе'з individual refl'active
етл, апа
2) keep the reticle continuously sharp шhilе тесlшniсаllу focusing йи: biomicroscope
оп the subject еуе.
Only а sharp image of the cross hair reticle superimposed over а sharp image
of the subject еуе will result in consistently sharp photographs. The eyepieces
of the slit lamp biomicroscope аге adjustable over а plus-minus diopter range
to compensate for individual refractive error (Fig. 6.5). То establish the correct
setting for each observer, the following steps are suggested:

1) Place а light эпее: о! paper т jront о! tl1e Ьюписювсоре т а

position шl1е1'еit шill Ье out о!focus but итеп: it сап Ье diffusely
illuminated.
2) Тит the eyepiece setting (usually соuntеrсlосkшisе) to its
тахлтит "ршв" setting befo1'e looking tl1rough the
biomiaoscope.
3) Wl1ile looking througl1 tl1e тописюзсоре, шith accommoda-
tion1'elaxed, юипе the eyepiece setting аоитлоат (сlосkшisе) to-
шап: йи: ттиз side, т а smooth, сопипиоиз тоиоп. Сопипие
this adjustment until а slшrрlу defined геис;« is зееп against йи:
light background. Stop at this point! Continuing beyond this
point о! initiпllу sha1'p сюзз паи» encoumges accommodation.
4) Repeat steps 2 апа 3 until the same setting has Ьееп
achieved consistently several times. When зеиет] individuals
иве the вате тыпстеп), the eyepieces sl10uld Ье +езе! to еасп
FIGURE 6.5 Diopter adjustment 01oculars.
резьоп'в predetamined setting 01' the above ехеплзе гереие«.
81
 D

FIGURE 6.4
(А) Соггее! teehnique of foeusing the biomieroseope. (О) Ineorreet position of the biomieroseope due to aeeommodation.
(8) The examiner's view. (Е) Examiner's view. Note the un-sharp eross hairs.
(С) The resultant, sharp image reeorded Ьу the сагпета. (F) The resultant, un-sharp photograph.

82
 Centration
The biomicroscope and slit lamp i1luminator, while moveable independently,
are in а co-pivotal, iso-centric, and par-focal relationship (see Figure 2.2). When
the instrument is correctly aligned, the slit Ьеаm is sharp and centered оп the
cross hairs and оп the sharply focused image of the subject еуе plane. When
the cross hairs, the slit Ьеаm, and the image of the subject еуе plane аге not si-
multaneously sharp and centered, either the instrument is out of alignment or
the photographer is accommodating. Ву recalling that the slit must normally
center in the field of view to Ье sharp, the photographer сап avoid ассогп-
modation more easily. Placing the slit i1luminator and the biomicroscope in а
coaxial position and placing the focusing target into place at the pivot point
wi1l immediately indicate whether the slit Ьеаm is in its correct, iso-centric
position.

FIGURE 6.6
(А) Examineг's view with
magnification changeг а! 10Х.
(8) Actual field гecoгded Ьу сагпета.
Magnification
In some photo slit lamp biomicroscopes, the size of the image (area of cov-
erage) recorded Ьу the сагпета mау differ greatly from that seen through the
oculars. While this mау Ье an inconvenience, it сап Ье overcome as long as ап
awareness о! the disparity is maintained.
The photo slit lamp mау produce а photograph of the subject еуе at оnе half
the magnification seen through the oculars. If this relationship is maintained,
or if по compensation is made, photographs wi1l Ье continually disappointing
since they will not concentrate adequately оп the area о! interest. Furthermore,
additional and unwanted areas о! the еуе, perhaps including distracting arti-
facts, will also Ье recorded. With the field о! view so much smaller through the
oculars, peripheral areas are not controlled easily (Fig. 6.6).
Оnе solution is to observe the еуе at the magnification desired for photogra-
phy and, just prior to making the exposure, increase the magnification опе step.
The resultant photograph should more closely represent the area о! interest
(Fig. 6.7).
Another method is to use eyepieces о! lower power to match the magnifi-
cation оп film or digital media. Conversely, some instruments accept optical
magnifiers that mау Ье placed between the Ьеаm splitter and the camera back,
matching the observed magnification to that in the recorded image (Tables 6.1
and 6.2). When such magnifiers аге used, appropriate compensation (оnе f stop,
or more) must Ье made to maintain proper exposure levels.

аз
FIGURE 6.7 (А) Examiner's view with magnification changer а! 16Х. (В) Corresponding field recorded Ьу сатега.

ТаЫе 6.1 Photographic Magnification (Linear)

With Full frame 35mm Film/ Full Frame Digita/ Sensor & Zeiss Standard Photo S/it Lamp Biomicroscope*

Magnification Changeг 6Х IOХ 16Х 25Х 40Х

Without 2Х magnifieг О.7Х 1.0Х 1.75Х 2.8Х 4.4Х

With 2Х magnifieг 1.4Х 2.1Х 3.5Х 5.6Х 8.8Х

ТаЫе 6.2 Photographic Magnification (Linear)

with Haag-Streit ВХ 900 Photo SIit Lamp Biomicroscope*

Magnification Changeг 6.3Х IOХ 16Х 25Х 40Х

Magnification in Plane of Chip О.63Х 1.0Х 1.6Х 2.5Х 4Х

Field Size in тт
24х36тт Мопо 38х57 24х36 15х22.5 9.5х14 6х9

15х22.5тт Мопо 23.8х35.7 15х22.5 9.4х14.1 6х9 3.88х5.6

24х36тт Steгeo 38х28.5 24х18 15х11 9.5х7 6х4.5

* Digital сатега sensor size сап уагу, affecting magnification. In cameras with sensors smaller than full frame (24Х36тт), effective magnification is
increased. Image size should Ье appraised before optical magnifiers аге selected.

84
 FIGURE 6.8 Circular lield seen Ihrough Ihe oculars compared 10Ihe
тоге reslricled reclangular lield recorded Ьу Ihe сатега (dashed lines).

Format
Ап awareness of the difference between the observer's format and that docu-
mented Ьу the camera will further improve photographs. The view through
the oculars is circular while the format of the captured image is rectangular.
Therefore, when the magnification ratio is the same, а larger field will Ье seen
through the oculars than will Ье recorded оп film. The additional information
will Ье seen in the crescents created Ьу the circular field at the twelve, three, six,
and nine о'clock positions (Fig. 6.8). The photographer must think in terms of
а rectangular field when viewing the еуе prior to photography. А more reliable
method might employ а rectangular mask corresponding to the сагпетаformat.
А mask of translucent material will outline the field for photography without
curtailing the visualization of the more encompassing circular field. Ап еуе-
piece reticle shaped in the саптега format might represent the most desirable
arrangement (Fig. 6.9).

FIGURE 6.9 (А) Absolule mask conlormed 10Ihe camera's lormal. (В) Translucenl mask. (С) Relicle outline 01Ihe camera's lormal.

85
FIGURE 6.1 О (А) An artilact (specular rellection) recorded Ьу а сатега mounted оп the left side 01а stereo photo slit-Iamp biomicroscope that the
photographer neglected due to selective concentration оп (8) the ideal image оп the right.

Control of Artifacts
А slit lamp photograph that is equally informative and pleasing to view is de-
pendent not 01l1уоп correct focus, centration and format, but also оп the detail
of its content. То Ье effective, а photograph must first include the principal sub-
ject area. Of equal importance is the elimination of unwanted elements that ei-
ther obscure the desired detail or distract attention from the principal subject.
During а dynamic, stereoscopic examination of the еуе, тапу artifacts (harsh
reflections, shadows, eyelids,lashes, etc.) тау Ье present at опе time or another
as the positions of the biomicroscope and illuminator are constantly changed.
Generally, the examiner is not conscious of these distractions since they аге
momentary and сап Ье ignored mentally. А static photograph, however, will
faithfuHy reproduce аН artifacts present at the time of exposure. Without а keen
awareness of these distractions and the general appearance of the entire field to
Ье photographed, results тау fall below expectations. Each exposure must Ье
approached with а preconception of the specific information that it will contain.
The field must Ье examined as if it were the resultant slide or digital image. The
principal subject must Ье enhanced maximaHy, the field appraised carefully for
magnification, position, and format, and аН elements that аге unnecessary or
potentially distracting eliminated or minimized. Even the slightest departure
from the ideal will Ье immediately apparent in the photograph.
It is virtually impossible to eliminate the specular reflections of illuminating
sources from the curved corneal surface. теп simultaneous stereo photog-
raphy is required, it is less important that а reflection is Бееп through опе of
the oculars. Its аозепсе оп the other side will help "cancel out" the distraction
when the images аге viewed in stereo. Nor is it of great consequence which
ocular contains the cross hair reticle, вшсе the overall quality of the two images
viewed together is the only issue of importance. With single frame photogra-
phy, however, the quality of the single image оп the side оп which the сагпета
is mounted is critical. А mentally "cancelled out" artifact in а stereoscopic view
тау Ье present in the single photograpll taken (Fig. 6.10). То avoid this poten-
tial problem, the ocular with the cross hair reticle should always Ье used оп Нте
side to which the (single frame) сагпета is attached and, as а final step in quality
control (especiaHy critical in retroillumination from the fundus), the photogra-
pher тау momentarily close the contralateral еуе to concentrate entirely оп the
image to Ье recorded. 86
 FIGURE 6.11
(А) Coгneal loreign bodies viewed Ьу indirecl relroilluminalion Iгот Ihe iris. Соггесl exposuгe 01Ihe iris produces ап underexposuгe 01 Ihe corneal changes.
(8) Оуег exposuгe ollhe iris is necessary 10 produce а good exposure ollhe corneal loreign bodies (Iiberglass parlicles) seen againsl Ihe dark pupil.

Exposure
А good exposure results from the correct balance of film ог digital sensor sen-
sitivity, subject reflectivity, intensity of illumination, and duration of exposure.
Film sensitivity or "speed," expressed in 1SO numbers, indicates а fi1m's re-
quirement of light for correct exposure. "Fast" films need less light but do not
resolve fine detail as well as "slow" films. Similarly, digital imaging systems
will produce better image quality at lower sensitivity settings than оп high sen-
sitivity settings. Subject reflectivity refers to the efficiency witl1.which а surface
reflects light. А brown iris requires more light for good exposure than а blue iris,
and much more than white sclera. 1ntensity of illumination is the brightness
of the source of illumination. Electronic flash, for example, is very bright сот-
pared with the tungsten viewing light of the slit illuminator. Duration of ехро-
sure is the length of time the film or digital sensor is exposed to light (regulated
with shutter speeds in conventional, naturallight photography, but restricted
to the non-variable, ideally short duration of electronic flash in slit lamp biomi-
crography).
[п photo slit lamp Nomicrography, exposure adjustments are made Ьу regu-
lating the intensity of light. Гп most cases, it is accomplished Ьу selecting the
appropriate setting оп the power supply. Some instruments also regulate in-
tensity with ап adjustable aperture (f stops) located ahead of the camera body.
The location and reflectivity of the pathologic change within the еуе тау dic-
tate highly variable exposure requirements. Direct, focal illumination of the iris
тау produce ап ideal exposure at а given setting. The same size slit Ьеат at the
same intensity will, however, Ье inadequate to demonstrate fine corneal changes
seen in indirect retroillumination from the iris. То ensure ап informative image,
exposure must Ье increased. Тhis will result in ап overexposure of the area di-
rectly illuminated Ьу the slit Ьеат, but is а necessary element in recording the re-
quired information in the агеа of secondary, ог indirect, illumination (Fig. б.11).
Each PSL must Ье tested initially for exposure with each form of illumination.
Several test rolls of film ог а fuHy representative number of digital images, with
а record documenting forms of illumination, exposure, angle of illumination,
magnification, and reflectivity of the subject (light or dark iris, etc.) are needed
to establish ап accurate exposure guide for each individual instrument.
87
 Interrupted Теаг Film in Corneal Lattice Dystrophy

89
 Chapter 7

s еса •

Accessory Lenses
- Gonioscopy & Goniophotography
- Examination & Photography
of the Vitreous and Retina

Vital Dyes
- Sodium Fluorescein
- Rose Bengal
- Lissamine Green

Other Techniques
- Specific to Keratoconus
- Lid Eversion
- Topical Glycerine to Clear Corneal Edema

Some structures within the еуе are not directly accessible

for examination and photography with the slit lamp. These
include the peripheral соrnеа and filtration angle of the ап-
terior chamber, and the peripheral and posterior vitreous
and retina. The purpose of accessory lenses is to provide
visual access to these areas Ьу neutralizing the refractive
power of the соrnеа and to provide ап oblique view into
peripherally located areas.

90
 FIGURE 7.1 The Hruby lens (among others) is а соттоп accessory to clinical slit lamps.

Non-eontaet lenses (Hruby, Bayadi, ete) аге aeeessories to elinieal slit

lamp biomieroseopes and some photo slit lamps (Fig. 7.1). They do not
require eontaet with the еоrnеа for visualization of the eentral and pos-
terior vitreous and posterior retina. These lenses are relatively simple
to use. Additional non-eontaet hand held lenses, sueh as the 90 diopter,
тау also Ье used to image the eentral vitreous and posterior retina.
They do not, however, permit the examination of the angle ог periph-
eral vitreous and peripheral retina.
Contaet lenses for gonioseopy and goniography are available in vari-
ous shapes and sizes and are either of the direet ог indireet type (Fig.
7.2). Only the indirect lenses, utilizing internal mirrors, are ideally
suited for use at the slit lamp biomieroseope. These are available in
numerous eonfigurations and their seleetion is based оп speeifie ар-
plieation and personal preferenee. For example, а three mirror design
makes possible the 3600 serial examination of the fi1tration angle and
the peripheral vitreous and retina. The eentral optie of the same lens
will image Нте eentral vitreous and retina. (Fig. 7.3).

А в
FIGURE 7.2 (А) The Коерре contact, direct diagnostic lens. (8) А three mirror Goldmann style contact, indirect diagnostic lens.
97
FIGURE 7.3
The thгee miггoг lens
and appгoximately
coггesponding aгeas of
coveгage pгovided Ьу
the angle of the miггoгs
and the centгal optic.

92
 Gonioscopy and Goniophotography
Gonioscopy (visual examination of the angle) and goniography, or go-
niophotography (photography of the angle), are concerned with the ех-
amination and imaging of the filtration angle of the anterior segment of
the еуе (see Anatomy and Physiology"). То obtain
11

а view of this indirectly accessible агеа, а gonio lens

is placed оп the соrnеа (Fig. 7.4).Without such а lens,
the angle of the anterior chamber саппот Ье seen Ье-
cause the oblique viewing angle exceeds the critical
angle of the соrnеа and light arising from that агеа
is completely reflected internally. Only а distorted
view of the iris is seen (Fig. 7.5). The contact lens
eliminates the refractive element of the соrnеа and
the mirror provides а more central access (Fig. 7.6).
Examination and photography of the angle should
Ье conducted with the pupil in its normal, un-dilated
state. When the pupil is dilated, the iris is drawn to-
ward the angle and тау block the view of some angle
structures. Also, prior applanation of the согпеа тау
temporarily compromise its transparency, reducing
the quality of photographs.

Preparations for Conioscopy and

FIGURE 7.4 The Ihree mirror lens оп the еуе. The 590 mirror (Iop) is
generally used 10 examine and pholograph Ihe anlerior chamber angle.
93
Соп iophotography
А procedure involving direct contact with а ра-
tient's еуе must Ье undertaken with appropriate
preparation and conducted with considerable care.
Of potential intimidation to both patient and ехат-
iner, the procedure should Ье approached with ап
assured manner and а high regard for the patient. А
standard routine of preparation will reduce variables
and facilitate а ыпоотп transition through the neces-
sary steps. Мапу controls оп the slit lamp biomicro-
scope тау Ье pre-adjusted based оп available infor-
mation about the nature and location of the condition
to Ье examined or photographed. The position of the
chin rest and the height of the instrument and chairs
should Ье adjusted for the comfort of both patient
and examiner before contact lenses аге placed. The
maintenance and manipulation of the contact lens оп
the еуе сап Ье demanding and, if the examiner is not
physically comfortable, а compromise to ассшасу,
especially during photography, тау result. А cush-
юпес elbow rest сап provide additional comfort and
stability.
Prior to the placement of the lens оп the еуе, а topi-
cal anesthetic is applied to reduce corneal sensitivity.
Next, the concave, contact end of the gonio lens is
filled with а viscous solution of methylcellulose to
produce the necessary optical interface between сог-
пеа and lens (Fig. 7.7). It also serves as а protective
cushion between these surfaces.
 FIGURE 7.5
The filtration angle саппо! Ье visualized directly. Light
emanating from that агеа is reflected internally Ьу the
согпеа. Accessory lenses аге needed to visually access
the peripheral согпеа and angle.

FIGURE 7.6 А goniograph showing аЬпогтаl pigment deposition in the angle in pigment dispersion syndrome.

FIGURE 7.7
Preparing а diagnostic contact lens for placement оп the еуе.
94
 Placing the Lens оп the Еуе
Cautionary Stateтent: When indicated Ьу the patient's condition, or Ьу т-
traтural protocol, protective gloves should Ье worn when contact with bodily
fluids is а possibility. (www.aao.org/education/statements/transmission.cfm)
When the patient is situated comfortably in the chinrest and forehead аз-
sembly, the patient is asked to look ир. The lower eyelid is gently retracted
and the leading edge of the contact lens is placed оп the lower eyelid margin.
The lower eyelid is then deflected further downward with the lens and, while
the upper eyelid is retracted with the other hand, the lens is rotated onto the

FIGURE 7.8
The sequence
01 placing а
diagnostic contact
lens оп the еуе:
(А) Retraction 01
the lower lid.
(В) Placement 01
the lens оп the
lower lid margin.
(С) Further
retraction 01the
lower lid with the
lens and retraction
01the upper lid.
(О) Rotation 01
the lens onto the
соrnеа.
С D
95
FIGURE 7.9 Circular rotation 01the lens to lubricate the eyelids and place the desired mirror opposite the агеа to Ье examined ог imaged.

согпеа (Fig. 7.8). Опсе in р1асе, the 1ens is carefully turned, using both hands
for stabi1ity. То reduce the potentia1 for а see-saw effect оп the lids during 1ens
manipu1ation, the lens shou1d Ье rotated а full 3800 in опе direction to lubricate
the lid margins and the entire circumference of the lens.1t also he1ps to seat the
lens оп the cornea, reducing the possibility of inadvertent [овв of contact. The
1ens is then rotated further unti1 the desired mirror is directly opposite the агеа
to Ье examined (Fig. 7.9).
The ang1e тау Ье scanned for abnorma1ities using а narrow Ьеат to pro-
vide topographic information. This method is usefu1 for examination but will
se1dom produce good photographs. The narrow vertica1 Ьеат provides litt1e
simu1taneous information (Fig. 7.10А) and а wide vertical Ьеат сап resu1t in

FIGURE 7.1 О А vertical slit will identily abnormalities in the angle but will
по! provide ап overview without considerabIe light scatter (А). А horizontally
disposed Ьеат сап maximize inlormation and provide context. А Iгее
Iloating pigment clump is seen а! the 6 o'clock position (8).
96
 distracting reflections and light scatter, reducing contrast and detail. When
photographing the 12 and 6 о' clock positions, rotating the slit into а horizontal
disposition provides better control over its overall effect and а much more
complete photographic document is created (Fig. 7.10В). As with аН slit lamp
views, and especially photographs, the best compromise between area and
specific detail must Ье found. Begin with а slit Ьеаm of sufficient size to illu-
minate the entire angle агеа under study. Then Ьу dynamically reducing the
width and length of the slit, а set of parameters will Ье established which will
demonstrate the maximum detail within the area of interest. From this point,
while carefully observing the detail within the principal subject area, the slit
Ьеаm mау once again Ье increased in size to cover а larger area, but not to а
level that will cause diffusion of the essential detail. Light spilling onto areas
of the contact lens adjacent to the mirror should Ье minimized (Fig. 7.11). Оп
occasion, а slit Ьеаm configured into an elongated half moon shape (when fa-
cilitated Ьу the instrument) is more efficient at illuminating the агеа of interest
wit110ut also illuminating areas of the contact lens that сап cause distracting
artifacts (Fig. 7.12). These techniques mау Ье helpful for slit lamp examination,
but аге essential to successful photo-documentation.
The second largest mirror within the lens is set at an
angle of 64 to 670 for the study of the peripheral retina,
vitreous and lens through а dilated pupil. It is also ап
excellent method for imaging the iris. With the pupil
in its normal, un-dilated state, this intermediate mir-
ror produces а less oblique, more of а "birds-eye" view
of the iris and angle. It is effective in covering larger
expanses of iris surface and makes better use of the
limited depth of field available at higher magnifica-
tions. The result is а wider view of iris with more areas
simultaneously sharp in the photograph (Fig. 7.1ЗА).
With the pupil slightly dilated, this technique сап also
produce the red reflex (retroillumination from the fun-
dus) to demonstrate additional findings, such as the
abnormal deposition of pigment onto the peripheral
FIGURE 7.11 lens and zonules in pigment dispersion syndrome (Fig.
Specular rellections 01 light sources should Ье minimized as much as
7.IЗВ) and, with the pupil fully dilated, а clear iris cyst
possibIe. (Fig.7.IЗС).

FIGURE 7.12
When lacilitated Ьу the instrument, а Ьеат configured into а hall-moon shape will better conlorm to the angle агеа, reducing artilacts 01 illumination. Two
views 01the peripheral соrnеа аге seen in ап individual with Axenleld's syndrome. Findings include (1) а prominent Schwalbe's line with (2) adherent iris
strands. Haab's striae (3) аге seen as unsharp curvilinear abnormalities in the согпеа (see also Figure 5.628).
97
 Specular reflections, readily elicited from the flat, anterior surface о! the соп-
tact lens сап dramatically reduce the quality of ап image (Fig. 7.14А). These
should Ье minimized for examination and eliminated for photography. This
сап Ье accomplished Ьу simply tilting the lens slightly, causing it to project
this disturbing artifact above ог below the objective lens (Fig. 7.14В). Such аг-
tifacts аге amazingly easy to disregard at times in а stereoscopic view, espe-
cially during а procedure that requires concentration оп several factors simul-
taneously. Careful appraisal о! the image (left or right) prior to exposure will
ensure that such artifacts do not Ьесоте permanent distractions in а photo-
graph. То ensure the quality о! the image to Ье recorded, it should Ье appraised
in а monocular view through the ocular sharing the beam-splitter with the
сагпета back. The photographer's contralateral еуе should Ье closed to draw
[иН attention to undesirable elements within the field before the image is re-
corded.
When the contact lens is allowed to lose contact momentarily with the сог-
пеа, bubbles о! air will form in the layer о! methylcellulose. Оп occasion, these
bubbles тау Ье adequately manipulated away from the immediate field and
the examination тау continue. However, if photographs are to Ье taken, these
same bubbles, however inoffensive they тау seem at the time, will result in
highly distracting artifacts in the static, recorded image (Fig. 7.15). Although
inconvenient, only the removal, cleansing, and reapplication о! the lens will
result in satisfactory photographs.

FIGURE 7.1 3 Use of the 64 (о 670 miггor сап improve photographs Ьу producing а тоге "birds-eye" view (о better take advantage of а shallow depth
of field. (А) А presumed (Ьу history) caterpillar hair in the angle. (8) Pigment dispersion syndrome with pigment in the angle. Pigment is also seen оп the
peripherallens (Scheie's stripe) in retroillumination from the fundus. (С) А clear iris cyst is imaged with а fully dilated pupil.
98
 в
FIGURE 7.14 А distracting reflection that сап Ье obviated Ьу tilting the lens slightly up, down ог to the side.

Following use, аН lenses should Ье cleansed of methylcellulose Ьу rinsing

under lukewarm running water. If allowed to dry, methylcellulose will harden
and тау damage а lens surface during attempts at removal. Finally, аН lens-
es should Ье disinfected according to established protocol prior to reuse. It is
recommended that lenses with antireflection coatings (similar to coatings оп
photographic lenses) Ье purchased for photographic applications and carefully
maintained for that purpose only. Lenses that have suffered compromise due to
excessive or improper handling or storage make poor media for photography
(Fig.7.16).

FIGURE 7.15 FIGURE 7.16

Air bubbIes in methylcellulose will compromise а static image. А marred lens surface will produce unwanted reflections and сап seriously
compromise the quality of а recorded image.

99
Examination and Photography
of the Vitreous and Retina

Central and Posterior Vitreous and Posterior Retina

Note: А/иНу dilated pupil is а prerequisite to tl1eprocedures described below.

The anterior central vitreous mау Ье examined and photographed directly,

without the use of а lens (Fig. 7.17). То image beyond the anterior vitreous,
accessory lenses are necessary. The mid- to posterior vitreous and posterior
retina mау Ье observed with the use of non-contact, slit lamp accessory lenses
(Hruby, Bayadi etc) mentioned earlier, ог with hand held lenses like the 90 di-
opter (Fig 7.18). These devices are used when direct contact with the patient's
соrnеа is contraindicated ог simply not desirable at the moment.
То produce the best view or image of the posterior vitreous or retina, а соп-
tact lens should Ье used. With either the central optical zone of the previously

FIGURE 7.17 The апtегiог vitreous is the limit of the slit lamp's ability to produce а sharp image without ап accessory
lепs. Ргоmiпепt vitreous stгапds and cellular debris аге seen.

FIGURE 7.18 (А) The 900 hand held, поп contact lens and (8) ап example of the image it сап produce.
700
 А

FIGURE 7.19
(А) The Goldmann fundus lens. (В) А гepгesentative image of the posteгioг гetina showing haгd exudates and (С) ап eaгly maculaг hole.

FIGURE 7.20
(А) А fundus photogгaph showing exudates but failing to pгovide infoгmation about the shallow serous detachment of the neuгosensoгy гetina that is pгesent.
(В) Ап optic section within the агеа of detachment cleaгly shows а sepaгation of the neuгosensoгy гetina fгom the undeгlying pigment epithelium.
707
deseribed three mirror lens, or with а fundus lens without mirrors, а direet view
of the posterior pole is obtained. The Goldmann fundus lens is lightweight
and easier to handle (Fig. 7.19). The lens neutralizes аН or most of the refrae-
tive power of the еоrnеа and provides а flat, elear window through whieh the
posterior pole is visualized. Even without the use of а biomieroseope the optie
nerve head сап Ье seen through sueh а lens, illuminated with а penlight. The
biomicroseope, of eourse, adds the neeessary magnifieation.
5urfaee relationships mау also Ье appraised and doeumented with the use
of а eontaet lens. А s11allowserous detaehment of the neurosensory retina was
suspeeted but not eonfirmed with ophthalmoseopy or fundus photography. At
the slit lamp, however, the diagnosis eould Ье made easily. While simultane-
ous stereo slit lamp biomieroseopy makes this disparity most obvious, even а
single, two-dimensional slit lamp photograph will elearly identify the separa-
tion of the two layers. As seen in Figure 7.20, the normally single slit Ьеаm is
now doubled, identifying t11epresenee of serous fluid between the neurosen-
sory retina and pigment epithelium. Only а very narrow slit Ьеаm is effeetive
in delineating sueh fine alterations in the normal relationship between retina
and pigment epithelium. Due to the low refleetivity of the translueent retina,
а narrow optie seetion requires аn inerease in exposure and ап 150 setting of
400 or higher.
Proximal illumination (deseribed оп page 61) is ап exeellent form to use in ех-
amining and photographing the retina and pigment epithelium (Fig. 7.21). То
inerease the information within the areas indireet1y illuminated (areas adjaeent
to the Ьеаm), the area within the Ьеаm must Ье overexposed. The exposure is
eaIculated for the subjeet of interest in the агеа of seeondary illumination.

FIGURE 7.21
Ап агеа 01 pigmentation 01the optic пегче head is seen in proximal illumination with а moderate Ьеат.
702
 FIGURE 7.22
Peripheral exudates iп а case 01 posterior uveitis аге sееп iп the 670 mirror 01the Gоldmапп style three mirror lепs.

Peripheral Vitreous and Retina

With the pupil dilated maximally, using опе of the two larger mirrors within
the three-mirror lens, the peripheral vitreous and retina сап Ье serially ехагп-
ined and photographed. Т11еprinciple is identical to that of gonioscopy ог go-
niography; the difference is the zone of the еуе being addressed. Initially, the
examination is conducted at 10w magnification with а broad Ьеат from the
near1y coaxial slit illuminator. The mirror is placed opposite the area to Ье оЬ-
served and the lens manipulated to produce the best definition of the subject,
with unwanted reflections moderated. Опсе located, the intrinsic character-
istics of the abnormality under study will dictate illumination requirements.
The subt1e nature of тапу such changes, especially in the vitreous, requires
selective illumination (Fig. 7.22). Exposure a1so becomes а highly variable fac-
tor, since the reflectivity of these changes тау Ье low and тау dictate the use
of rather narrow beams for de1ineation. The final photograph should Ье taken
at moderately high magnifications to ensure а practical image size оп fi1m.
Magnification, however, should not Ье used to the detriment of resolution and
depth of field when а highly dimensional subject is being considered. As in
goniography, the examiner's еуе that is contra1atera1 to the side оп which the
сагпета is mounted should Ье сювес just before exposure to ensure overall
quality of the image (Fig. 7.23).

FIGURE 7.23 (А) А peripheral геtiпаl vessel shоwiпg shеаthiпg iп posterior uveitis. (8) А peripheral horseshoe tear 01the геtiпа.
703
Vital Dyes
Vital dyes, ог stains, тау Ье used to provide additional information about the
external tissues of the еуе. Fluorescein stains areas that are de-epithelialized
whereas Rose Bengal and lissamine green сап identify more discrete areas of
devitalized epithelium. Of the three, fluorescein is t11emost effective in applica-
tions using pooled dye.

Sodium Fluorescein: Staining

Тhe topical application of fluorescein is а simple task with the individually
wrapped sterile strips (Fig. 7.24).The end of the strip is moistened with ап ар-
propriate sterile solution and then applied to the еуе. With the patient's eyes in
upgaze, the lower eyelid is retracted and the fluorescein applied gent1y,and in
moderation, to the palpebral conjunctiva (Fig. 7.25А).As а general rule, direct
contact with the соrnеа is avoided when possible. The patient is asked to blink
опсе or twice and the remaining fluorescein is rinsed from the еуе with а sterile
irrigating solution (Fig. 7.25В). The importance of irrigation is shown in Figure
7.26,which demonstrates the possible false impression of tissue damage, ог аЬ-
sence of, suggested Ьу pooled fluorescein, especially in а static photograph.
High levels of fluorescein are readily visible with white light. However, ап
exciter fi1ter wi1l great1y еnhanсе visibility, especially important when only
minute quantities are present (Fig. 7.27).Today's instruments are equipped with
high efficiency interference filters for this purpose and the commonly seen blue
background in record-
ed images is а direct
result of the color of the
filter. The yellow-green
В/О GLO,,, SТERILE STRI'Pr-'" of the excited fluoresce-
1 mg Fluогеsсеш Sodluln OphtholmlC Strtp и5Р
Dlstnbuted Ьу Rose Бюпе Ente~pnl:>t::I~
9622 Вазеное яоео AJta гогпа СА 2"
in is seen in high relief
against this blue back-
ground. When greatest
selectivity is desired,
а matched barrier fil-
ter (yellow) тау Ье
usedY Тhe barrier filter
is placed either at the
camera back in front of
FIGURE 7.24 Fluoгescein slrip for lopical applicalion.

А
FIGURE 7.25 (А) Applying а moislened fluorescein slrip 10 Ihe infeгior palpebгal conjuncliva. (8) Rinsing excess fluoгescein from Ihe еуе.
104
 FIGURE 7.26 The presence of pooled fluorescein, especially in а static image (А-1 and 8-1), obviates its value as а reliabIe record of the extent of staining.
With the excess fluorescein rinsed fгom the еуе (А-2 and 8-2), the remaining fluorescence сап only
represent true staining.

the film plane or directly over the objective lens of the biomicro-
scope. Dlle to the density of the Ыце exciter filter, ехроsше соm-
pensations пшвт Ье made.

FIGURE 7.27 А соrnеа following а penetrating keratoplasty procedure stains vividly with fluorescein. It is shown in (А) white light and
705 (8) illuminated through the exciter filter to enhance fluorescence. (С) Fine, punctate staining in symptomatic Meesmann's epithelial dystrophy.
Pooled Fluorescein
Some conditions аге best demonstrated when fluorescein is allowed to pool.
These include, among others, the fit of а contact lens, tear film breakup time
and the effectiveness of the eyelids in distributing tl1e tear layer across the
соrnеа (Fig. 7.28).13 It сап also Ье used to еnhаnсе the appearance of papillary
hypertrophy оп the inner surface of the eyelids, which is generally done with-
out ап exciter filter (Fig. 7.29).

FIGURE 7.28 Pooled fluoгescein is highly effective in demonstгating (А) the fit о! а contact lens, (8) teaг film bгeak-up time in а погтаl согпеа,
(С) teaг film bгeak-up in lattice dystгophy and (О) согпеаl filaments.

F,GURE 7.29
Pooled fluoгescein сап Ье used to outline papillaгy hypeгtгophy.
706
 Seidel Test
The Seidel Test is used to determine the patency of the соrnеа. When а
corneal perforation is suspected, the application of fluorescein сап demonstrate
the leakage of aqueous humor from the anterior chamber (Fig. 7.30). The moist-
ened, flat end of а fluorescein strip is applied directly to the suspected site of
leakage and the photographs are taken immediately after application. When
aqueous is, indeed, flowing
from the anterior chamber, the
dark background of поп-Пцо-
rescing, concentrated fluores-
сеin will Ье disrupted Ьу а
growing stream of diluted and
now excited Пцогезсеш." Fig-
цге 7.31 shows three stages of
а positive Seidel Test. When
а brisk leak is photograp11ed,
several applications of dye
тау Ье required to demon-
strate the stages photographi-
саНу. Prealignment and focus
of the biomicroscope will help
in capturing the precise то-
ment desired.

FIGURE 7.30 Positive Seidel Test in а filtering ЫеЬ.

FIGURE 7.31 Three stages of а positive Seidel Test in а perforated согпеа.

707
Rose Bengal
Rose Bengal permits definition of early epithelial damage. In а case ROSE GLO" STERllE STRIPS
of toxic epithelial keratopathy, the fine, punctate areas of Rose Bengal Rose Вengol OphlholmKSI"p 1.5 mg
"""«1 .~I*;' '_f~
!i!f; ~ Ra;1Idr.IU:W" ~ '10

staining of the corneal epithelium аге seen in direct illumination (Fig.

7.32). Rose Bengal сап demonstrate such fine areas of staining that
mау not Ье evident with fluorescein. Additionally, ап exciter filter is
not necessary, permitting the use of normal settings for correct ехро-
sure. As these changes аге frequently subtle, а sligl1tunderexposure А
mау yield greater information than using too much light. Rose Веп- L...- ----'

gal must also Ье rinsed from the еуе to avoid confusion of the desired
information with pooled dye.
Combining fluorescein with Rose Bengal adds another dimension
to the delineation of certain abnormalities. When viewed with the
fluorescein exciter filter, Rose Bengal will appear dark as it absorbs
Ыие light (Fig. 7.33). White light сап also produce some striking re-
su1tswhen using this dye combination (Fig. 7.34).
Rose Bengal mау Ье poorly tolerated Ьу some patients as it сап
cause corneal irritation.

с
FIGURE 7.32 (А) Rose Bengal stгip foг topical
application. (В) Toxic keгatitis (polyuгethane vapoгs)
showing punctate staining with Rose Bengal.
(С) Rose Bengal staining of а согпеа with heгpes
simplex keгatitis.

FIGURE 7.33 Rose Bengal in combination with fluoгescein pгoduces FIGURE 7.34 А combination of Rose Bengal and fluoгescein showing а
anotheг dimension in images as the bIue light is absoгbed Ьу the Rose coгneal ulceг in white light.
Bengal, cгeating а daгkeг signatuгe wheгe it is pгesent. Images А and В
both demonstгate heгpes simplex keгatitis.
708

L1SSAМINE GREEN SТERILE STRIPS
Eo(h ,Ir;p (0"10;"' oppro •. 1.5 mg.lll,oml"'
Lissamine Green
Lissamine green dye is а useful alternative to Rose Bengal in certain applica-
попе." Rose Bengal сап Ье irritating to the patient and has antiviral properties
that mау adversely affect results of viral cultures obtained after dye instilla-
tion. Lissamine green, а synthetic organic dye with а staining pattern similar
to Rose Bengal, is apparently well tolerated Ьу the patient and has not Ьееп
shown to exhibit antiviral properties. It is available in sterile strips for topical
application (Fig. 7.35).
Lissamine green, when applied to conditions where Rose Bengal staining
loses definition due to the presence of new or engorged vessels, will produce
better contrast against such а dominantly red background
(Fig. 7.36). When staining а corneal abnormality, the color of
the iris should Ье considered before choosing between the
two dyes. Iris color will influence the visibility of both dyes
Green with potentialloss of information, especially in а static, two
dimensional photograph (Fig. 7.37). Lissamine green is espe-
cially effective in demonstrating conjunctival staining as it
contrasts well with conjunctival vessels (Fig. 7.38)

FIGURE 7.35 Lissamine green strip for topical application.

А в
FIGURE 7.36 (А) Rose Bengal staining of а squamous celllesion with reduced contrast against the engorged conjunctival vessels. (В) А similar lesion
stained with lissamine green shows greater contrast. (/mages courtesy of Тimothy J. Bennett, CRA, FOPS.)

FIGURE 7.38
Lissamine green contrasts well with the background in а case of superior limbic
keratoconjunctivitis. (/mage courtesy of Тimothy J. Bennett, CRA, FOPS)
709
 FIGURE 7.37
(А) Punctate Rose
Bengal staining
in superior limbic
keratoconjunctivitis
(SLK) and
(В) the same еуе
stained with lissmine
green.
(С) Herpes simplex
(HSV) keratitis
stained with Rose
Bengaland
(О) the same
еуе stained with
lissamine green,
which appears to
produce reduced
contrast against this
lightly pigmented iris.
(Images courtesy 01
Timothy J. Bennett,
CRA, FOPS)

Other Techniques

Keratoconus: Fleisher Ring

Visibility of the Fleisher Ring, the iron line commonly seen as the line of de-
marcation in keratoconus, тау Ье enhanced with the use of а blue filter. 'Пте
blue filter in this application is not used as ап exciting agent. Instead, the red
iron line absorbs the blue color, resulting in а darker, more apparent pattern.
The Fleisher ring is frequently difficult to see and is best demonstrated against
а light iris (Fig. 7.39). (It тау not Ье visible against the dark background of а
dilated pupil). Аn increase in light is required for adequate exposure when us-
ing the blue filter.

FIGURE 7.39 Fleisher ring in keratoconus seen in (А) white light and (В) in bIue light. The bIue light is absorbed Ьу the red iron line and produces greater
contrast 01the abnormality when viewed against а lightly pigmented iris.
770
 Keratoconus: Munson's Sign
Munson's Sign in keratoconus demonstrates tl1e abnormal corneal сцг-
vature simply and effectively. As the patient looks down the cone shaped
cornea is appar-
ent as it deflects
the lower eyelid
margin from its
normal position
(Fig. 7.40).

FIGURE 7.40 Munson's sign in keratoconus (А). Mild keratoconus

shown in profile against the illuminated nasal bridge (В).
777
Lid Eversion А в
Eversion of the lower eyelid
is а simple task. Ву asking the
patient to look ир while the
lower lid is retracted, а great
expanse of the desired area
mау Ье viewed. The eversion
of the upper eyelid, however,
is considerably more chal-
lenging. The patient is asked
to look down and to maintain
that gaze. The stem of an ар-
plicator is placed horizontally
across the upper eyelid, two
thirds of the way ир from its
lower edge, at approximately
the level of the lid fold. The
eyelashes of the upper еуе-
lid are grasped and pulled
out and ир in order to turn С D
the eyelid over the applicator
stem (Fig. 41). Тhis maneuver
сап Ье uncomfortable for the
patient and should Ье соп-
ducted with care.

Topical Glycerine to
Clear Corneal Edema
When corneal edema is
present to the degree of
precluding examination or
photography of the anterior
chamber structures, topical
glycerine mау Ье applied
to the surface of the соrnеа.
This results in а temporary
osmotic dehydrating effect
FIGURE 7.41 Stages of upper lid eversion: (А) Patient is asked (о look down, (В) ап applicator stem is placed
that mау clear the cornea
а! the lid fold, (С) the upper eyelashes аге grasped and (О) the lid is inverted over the applicator stem.
sufficiently to allow exami-
nation and photography of
the anterior chamber angle, iris, or lens. The topical application of
glycerine is, however, very uncomfortable for the patient, and should
Ье applied only after the administration of а topical anesthetic.

772
 Anaglyph Gonio Steгeo Photogгaph: Metallic Intгaoculaг Foгeign Body

773
 Chapter 8

Stereo &.
е
ат
•
юпцсговсоре
Marshall Е. Tyler, CRA, FOPS
Gary s. Michalec, BS, CRA, СОА

Stereo Photo Slit Lamp

Biomicroscope
Slit Lamp Stereo Gallery
The modern slit lamp biomicroscope provides а magni-
fied, three dimensional view of the еуе. 'Пте ophthalmic
photographer' s challenge is to record this three dimension-
al informa tion.
The slit lamp examination produces а single mental согп-
posite image that includes height, width, and, of crucial
importance - depth. The third dimension is essential to цп-
derstanding certain structural relationships, without which,
the examination would Ье considerably less informative.
Similarly, stereo s1it lamp photography is far more effective
in describing certain conditions and relationships than the
single, two dimensional image. Stereo s1it lamp photogra-
phy produces а permanent record that is the closest possible
approximation to the view seen Ьу the clinical examiner. For
educating students, the stereo photograph сап make the dif-
ference between just seeing the pathology and truly under-
standing the pathology.
Not surprisingly, the significant advantages of stereo pho-
tography are commensurate with the disadvantages of in-
strument complexity and cost, as well as the effort required
to view the results.
774
 Stereo Photo Slit Lamp Biomicroscope
Stereo slit lamp biomicrography requires dedicated instrumentation. Un-
like ocular fundus photography, where stereo pairs are usuaHy obtained in
а sequential manner, the stereo photo slit lamp must capture both images si-
пшйапеоцыу." Inadvertent movement of the subject еуе amplified Ьу high
magnification (and other factors) essentiaHy eliminates the option of sequen-
tial recording of stereo images at the slit lamp.
Stereo imaging is accomplished with either а two camera system or опе
based оп а single camera, using а split-frame system. РиНframe systems pro-
duce larger individual images at higher resolution, as each frame utilizes the
fuH resolving capability of the filт or digital sensor used. Split-frame systems
record both left and right sides of the stereo pair оп а single frame of film
or digital sensor. These images contain approximately опе half the resolution
of fuH frame images. А split-frame system, however, has the advantages of
greater simplicity in instrumentation and а permanently fixed, non-variable
juxtaposition of the left and right images (Fig. 8.1).
The Haag-Streit ВХ 900 is the only digital stereo photo slit lamp biomicro-
scope in current production. It is ап integrated, fuHy capable photographic
instrument equipped with co-axial electronic flash for the slit illuminator and
the filllight. Images are recorded as split-frame stereo pairs оп the fuH frame
(23.9х 35.8тт) sensor of the Сапоп 5D digital сагпета (Figs. 2.4 and 8.2). The
сагпета is mounted оп а mirror housing providing sequential, 100% illumina-
tion intensity for both examination and photography.

Single Image Digital and Simultaneous Stereo Photography

with the Zeiss Standard Photo Slit Lamp Biomicroscope
While this instrument is по longer in production, there are тапу still in use,
and more that сап Ье restored to use with certain additions and modifications.

These options include:

• Single digital camera with foot switch
• Stereo (dual) digital cameras with а thumb button
• Stereo (dual) digital cameras with а no-delay foot switch circuit
• Stereo (dual) film cameras with аfoot switch

А variety of digital and film сагпета backs and accessories тау Ье considered.
For the foHowing modifications, Nikon D100 сагпет-
as were chosen for their relative есопоту and remote
shutter trip capability.

Single Digital Саптега with Foot Switch

FIGURE 8.1 Unmasked split-Irame stereo image lгот Haag-Streit ВХ
900 photo slit lamp. Images сап Ье masked lог а cleaner presentation. For
the masked presentation 01 this image, see Figuгe 8.22 оп page 124.
775
А single Nikon D100 digital сагпета is mounted
оп the photo slit lamp. То remotely trip the shutter
with а foot pedal or thumb-button, а Nikon MB-D100
шшп-пшспоп battery pack is used with а Nikon МС-
22 cable (Fig. 8.3).
When the shutter button оп the D100 (and
most digital cameras) is depressed, the сагпета
is put into its "ready state" in which it will acti-
vate the shutter instantly as the button continues
its downward travel. This "ready state" is main-
tained for about 8 seconds. The сагпета then re-
 FIGURE 8.2 (А) Haag-Streit ВХ 900 with Сапоп 50 full frame digital саmега. (В) Stereo image adapter. (С) Stereo prism head shown withdrawn
from imaging рог! of mirror housing.

turпs to its stапdЬу mode. [п most сопvепtiопаl аррliсаtiопs this has little
sigпificапсе. However, whеп usiпg а remote trip аrrапgеmепt, whеп the сагп-
ега is ш stапdЬу mode, there is а % sесопd delay Ьеtwееп асtivаtiоп of the
shutter firiпg switch апс actual exposure. Such а delay is impractical for ра-
tiепt photography.
То eliminate the shutter-trip delay, а sесопd foot switch сап Ье used to pre-
pare the сагпета for photography. This fuпсtiоп сап also Ье automated, as de-
scribed оп pages 117 апd 118 ш the dual stereo сагпета sесtiоп.
То provide а large image for immediate review of photographic results, а
video monitor mау Ье attached to the composite video output from the digital
сагпета body (Fig. 8.4).

FIGURE 8.3 Nikon МС-2210 pin саmега contгol саЫе with Nikon 0100 FIGURE 8.4 Video monitor in use with the Zeiss photo slit lamp
~ Nikon МВ-100 multi-function battery pack. biomicroscope equipped with dual рог! Ьеаm splitter and two Nikon 0-100
digital cameras for stereo imaging.
776
 Stereo (Dual) Digital Cameras with а Thumb Button
Two Nikon DI00 сагпетаbodies are mounted оп the рпого slit lamp. То acti-
vate both shutters simultaneously, two Nikon МС-З0remote cables are severed
and re-wired in parallel to а single thumb-switch (Fig. 8.5).When the pushbut-
ton is depressed, the internal, two position micro-switch automatically рто-
vides the requisite, sequential ready-trip signals to both cameras (Fig. 8.6).

FIGURE 8.5 Modification of а Nikon мс-зо thumb switch to control two cameras for stereo imaging. (А) Location of junction Ьох. (8) Wiring connections.
(с) Modified controllever with adapted Nikon мс-зо thumb switch.

Stereo (Dual) Digital Cameras with а No-Delay Foot Switch Circuit

FIGURE 8.6
Internal view of Nikon мс-зо
thumb switch showing the two
position activation of the dual
micro-switch. The first position
initiates the 'ready state" and
the second position trips the
shutter.
The modified Nikon thumb-button, described above, sends two, sequential
signals to the cameras. With а foot-switch design, this sequential, dual signal
must Ье replicated to prevent the сатета bodies from going into their custom-
ату "s1eep mode" after approximately 8 seconds of inactivity. То obviate the
consequent 1,4 second lag described earlier, and to ensure that both cameras
synchronize with the flash, а small circuit is added to the dual сагпетасоппес-
tion (Fig. 8.7). This modification sends а signal to the сашегаз at seven second
intervals to ensure that they ате always in the ready mode. This is ассот-
plished Ьу а timing circuit that controls the shutter-ready wires attached to the
D-I00 сатета bodies via tlle Nikon МВ-23cables.
Stereo (Dual) Film Cameras with а Foot Switch
Film based slit lamp photomicrography has long been the gold standard of
academic institutions (Fig.8.8).Tripping two Nikon Р-3 cameras equipped with
Md4 motor drives сап Ье accomplished with simple electronics. In addition
to on/off switches for each сатета, in-line diodes in the shutter release wires
provide isolation between cameras. А small, plastic utility Ьох provides соп-
nections for сатета power, foot pedal, and flash synchronization (Fig. 8.9).
The location of the aperture control in the Zeiss photo adapters creates im-
age vignetting when smaller apertures ате used (smaller than и34). То elimi-
nate this problem, optical magnifiers are used to fill the 35тт film format.
Although the 2Х magnifier is most often used, it absorbs considerable light.
The 1.6Хmagnifier is more light efficient but produces some vignetting at the
lmage corners.

777
 FIGURE 8.7 Schematic of circuit

1Meg Q
used to maintain the сатега backs
in their ready mode and provide
synchronization with the electronic
flash. This circuit also isolates the
input of the foot switch with ап
Foot
Switch inexpensive 2N3904 PNP, general
N.O. puгpose amplifier transistor. The base
of the transistor is held high Ьу а 4Л
•..
ф
рцй-цр resistor. When the foot pedal's
Е momentary switch is closed to gгound,
i= the сатега shutters аге tripped via
IRFS11
PowerFET
То Cameras а power FET transistor, IRF511. The

:IJTD г::
G

:
input transistor also resets ап LM555
Ready timer which cycles every seven
seconds to "wake up" both cameras.
This is accomplished Ьу а second
power FET transistor that brings both

:IJ1D г::
G of the "впцпег-геаоу" wires from the

Trip
: cameras to ground. The circuit тау Ье
powered Ьу а 9 volt transistor battery
ог а small АС to ОС power supply in
the 8 to 12v ОС range. When powered
Ьу battery, ап on/off switch сап Ье
added to the circuit to prevent power
drainage when по! in use.
This circuit was developed and
designed Ьу Т. Martin & М. Tyler and
тау Ье used freely.

FIGURE 8.8 Oual Nikon F3HP 35тт film cameras and Md4
motor drives оп а Zeiss photo slit lamp.

FIGURE 8.9 (А) Oual сатега stereo configuгation with wiring harnesses and connection switch Ьох. (8) Nikon F3 and ап МО4 motor drive with wiring
harness for quick release. Electrical connections include common/ground, flash sync, сатега power (12vOC), and сатега trip. (С) Switch Ьох containing
diodes to isolate the cameras from each other electrically while providing voltage from the motor drive power supply. А foot switch with а single, normally
ореп, птогпегпагу-согпас! switch is connected to the shutter·trip terminals of the МО4 motor drives. Oiode isolation also permits taking а photograph with а
single сатега Ьу mechanically depressing its shutter release.
778
 Other Considerations
Mechanical and Optical Adapters
Both Nikon film and digital сагпета backs use the same Zeiss dovetail adapter.
The Zeiss adapter with the centering pin locks into the dovetail adapter of the
biomicroscope to prevent the сагпета from rotating (Fig. 8.10). Precise horizon-
tal alignment of the image pairs is essential for viewing the stereoscopic result.
The sensor in the Nikon D100 is 23.7х15.6тт, smaller than the 24х36тт
format of а standard 35тт film ог full-sized sensor digital сагпета. This in-
creased magnification factor of the D100 obviates the need for optical magnifi-
ers to control vignetting. With the 2Х magnifiers removed, four times the light
(2 f-stops) becomes available to facilitate lower flash settings and/or smaller
apertures for greater depth of field. Combining this increased light efficiency
with а higher IS0 setting makes possible the documentation of more subtle
findings, such as сеll and flare.
1mages recorded with the D100 are slightly larger than the horizontal field
of the 12.5Х oculars, placing the corners of Нте image outside the ехапцпегв
view (Fig. 8.11).

-"-
-11-

FIGURE 8.10 FIGURE 8.11

Nikon сатега 10 Zeiss dovelail adapleг (30-15-77) wilh cenleгing pin Diagram campaгing Ihe view Ihгaugh Ihe 12.5Х acular and Ihe image агеа
added. Model 31-03-45 is supplied wilh Ihe pin already in place. 1Ishould of Ihe Nikan О100 sensar.
Ье inslalled 10 align Ihe pin wilh Ihe гed dal аl Ihe lар af Ihe сатега mount.

Flash Synchronization Voltage

The flash synchronization voltage should Ье isolated
electrically from the сагпета body. The flash synchroni-
zation circuit of the Zeiss PSL is 35 volts at а potential
th,at could damage а digital camera's internal electron-
ics. То isolate the сагпета electrically, а hot-shoe mount-
ed voltage regulator, the Wein Safe-Sync opto-isolator,
is used (Fig. 8.12).

FIGURE 8.12 Wein Safe-Sync hal shoe flash sync vallage isalalor.
779
Image Exposure
Exposure сап Ье evaluated Ьу referring to the
digital camera's histogram display. This feature
is enabled Ьу using the camera's menu: Playback
Menu ..• Display Mode: Image Only ..• Highligl1tS'"
Histogram ..• Both. Then the Left-Right rocker switch
оп the back of the сагпета is used to display the over-
exposed highlights, or the histogram (Fig. 8.13). Some
camera's histograms display only the green спаппе]
exposure information. This is most important when
photographing subjects which do not include exten-
sive green information, as is the case with the typi-
cal, mostly red, ophthalmic subject. Using the "High-
lights" setting to check for overexposure is а simple FIGURE 8.13
alternative.
Nikon сатега monitor displaying а histogram 01the image just taken. As
this represents the green channel only, it should Ье used as а general guide
when adjusting exposure lог images containing high levels 01 red.

Image File Transfer

The automated transfer of files from а dual сагпета stereo system is not sup-
ported Ьу currently available imaging systems. То obviate removal and trans-
fer of each camera' s memory card to а card reader, а direct connection to the
computer is made.
The cameras аге connected to the computer with USB cables, isolated elec-
trically Ьу а three-position USB switch (Fig. 8.14). During photography, the
switch is left in the "оН" position. For image file transfer to the computer, the
switch connects the right or left сагпета individually. In Windows ХР®, the
selected camera's memory card is displayed оп the desktop, where selected
files сап Ье copied to а folder and prepared for importing into the imaging
software.

L ." R

А в
FIGURE 8.14
(А) USB extension cabIes connecting cameras to computer. (В) USB switch lог sequential selection 01 right ог left сатега lог image download. Three 01the
lour conductors 01the USB cabIes аге switched. The ground wires тау remain connected.

720
 Stereo Pair Identification
It is essential that the left and right photographs that constitute each stereo
image remain paired throughout the imaging chain. То this end, а consistent
Шеrenaming protocol must Ье implemented.
АБ the first step, the "5equential File Numbering" feature of each сагпета is
turned оН. This resets the counters to 0000 and епвцгевthat the left and right
image of each stereo pair bears the Бате number.
То identify images ав left and right (and add other information), Photoshop®
сап Ье used to rename the files. Photoshop® supports "actions" and "drop-
lets", functions that automate portions of the process. Аn action is а series of
recorded commands that modify а single file or а batch of files, and form the
basis for droplets. Droplets аге згпа]! applications that automatically process
а group of files.
Аn action is recorded for each side of the stereo pair. The file is opened, saved
without manipulation, then assigned а prefix identifying it аз а left or right
image. А droplet is created for each of these actions and placed оп the desktop.
Image files from each сагпета аге then dropped onto the respective droplet's
icon, automatically renaming the files. When the images from both cameras,
with their identifying prefixes, are resaved into а single folder, they are ready
for transfer into the imaging system database. Their filenames will appear аз
follows:
DSC_OOOlL.jpg
DSC_OOO1R.jpg
DSC_0002L.jpg
DSC_0002R.jpg
DSC_0003L.jpg
DSC_0003R.jpg, etc.

The Future of Stereo Slit Lamp Imaging in Ophthalmology

The value of the three dimensional information derived from the two images
of а stereo pair is truly greater than the sum of its parts. Its utility to the clini-
cian should not Ье underestimated. In telemedicine, stereo images increase
the diagnostic capabilities of the consulting physicianY 5imultaneous stereo
images, taken with а fixed and reproducible stereo Ьаве, permit high-quality
computer analysis.
Considering the importance of this modality, it is essential for the ophthal-
mic photographer to master the skills required to produce consistently high
quality stereo images. А complete understanding of these theories and prac-
tices will епвцге the optimum imaging support in the саге of the patient.

727
Stereo Slit Lamp Gallery
Stereo photographs demonstrate how depth enhances the understanding
of the pathology. The left image must Ье viewed with the left еуе and the
right image with the right еуе. This сап Ье done using а Brewster viewer. Ве-
hind each of its two plus lenses, two mirrors create the effect of widening the
viewer's inter-pupillary distance to match the center-points of the two images
comprising the stereo pair (Fig. 8.15). 18,19
Stereo images with full color mау Ье turned into chromatic anaglyphs and
viewed with red-cyan glasses (Fig, 8,16), 20,21

FIGURE 8.15
With its four mirrors, the stereo viewing scope permits viewing side-by-side
stereo image pairs when the stereo base (distance between the center of
the images) exceeds the viewer's interpupillary distance.

FIGURE 8.16
Anaglyph glasses place а red filter over the left еуе and а суап filter over
the right. They separate and isolate the left and right components of the
superimposed images to the corresponding eyes of the viewer.

722
 FIGURE 8.17
А chromatic anaglyph from а stereo PSL with dual 35тт lilm
cameras, shows а metallic loreign body bridging the anterior
chamber between the iris and peripheral согпеа, imaged with
а three miггor lens. This image сап Ье viewed in stereo Ьу
placing а red lilter over the left еуе and а суап lilter over the
right.

FIGURE 8.18
Air bubbIes in the anterior chamber аге shown as а stereo
chromatic anaglyph. This chromatic anaglyph was created
Iгот а stereo image photographed with а Haag Streit ВХ
900 Stereo PSL and а Сапоп 50 сатега.

FIGURE 8.19
Stereo gonio-photograph 01 ап iris dehiscence photographed
with а Zeiss stereo PSL and Nikon 0100 digital cameras.

723
FIGURE 8.20 Fibrin growth in the anterior chamber is seen in this stereo pair photographed with а Zeiss PSL and dual Nikon 0100 digital cameras.

FIGURE 8.21 Corneal pattern in а patient with Fabry's disease, taken with а Zeiss stereo PSL and Nikon 0100 digital cameras.

FIGURE 8.22 Calcium deposits photographed as а single split-frame image оп а Haag-Streit ВХ900 stereo photo slit lamp.
724
,...

FIGURE 8.23 А square penetrating keratoplasty is seen in this stereo pair, recorded with а Zeiss stereo PSL and Nikon F3, 35тт film cameras.

FIGURE 8.24 Eyelid carcinoma photographed with а Zeiss stereo PSL and Nikon 0100 digital cameras.

FIGURE 8.25 Corneal deposits photographed using а Zeiss PSL and Nikon 0100 digital cameras.
725
Stereo Resources

Stereo Photography: John Wattie

http://nzphoto. tripod.com/ stereo
Stereo viewing systems
http://nzphoto.tripod.com/stereo/3dview /index.htm

Dimension Technologies Inc. (DТI)

http://www.dti3d.com

Visual-Eyes®
www.VisualEyes.com

Stereoscopy Website
www.stereoscopy.com
(3D Frequently Asked Questions)

726
 Two Еуе View of а Normal Subject.

727
 Chapter 9

Patrick J. Saine M.Ed., CRA

Equipment
Standards
Procedure
Follow Up

The challenge of external photography is that it appears

to Ье so easy: patient plus сагпета equals point and shoot.
But external photography is more correctly ап exercise in
information transferal. Light encodes physical aspects of
the patient into descriptive groups of colors, shapes and
lines. Successful external photography conveys specific in-
formation concerning tissue size, color, position, asymmetry,
motion, and modification. Unless careful steps аге taken to
accurately capture this visual information, photographs are
likely to display false color, distort perspective, or convey
insufficient information. This chapter describes the tools
necessary to create useful external photographs, the stan-
dards required to promote their truthfulness, and а method
for successfully completing this clinical procedure.
728
 Introduction
External ocular photography documents the external еуе, lids, and
ocular adnexa (Figs. 9.1 and 9.2). Photographs сап record the еуе and
its motion more accurately than physician chart notes or drawings.
External photography is used to follow patients, for insurance docu-
mentation, and for patient and health professional education. Clinical
research uses external photographs to objectively document findings.
Photographs of patient trauma are useful in legal proceedings. Cos-
metic surgeons use photography to document pre-existing conditions.
External photography is especially useful when а difficu1t case must Ье
discussed with а colleague, or when further study of еуе movement is
required after the patient has left the clinic.
The СРТ procedure code 92285 External Photography describes ех-
ternal photography.24 This code does not differentiate between external
and slit lamp photography, between film and digital media, or between
still and video images. External photographs аге аn integral part of а
patient's medical records, and are subject to HIPAA (Health Insurance
Portability and Accountability Act) regulations. The specialists who
most often request this procedure include pediatric ophthalmologists
and ophthalmic plastic surgeons, although virtually every ophthalmol-
ogist тау request external photography.

с
FIGURE 9.1 Using photography to document external еуе findings has ргоЬаЫу occurred since the invention of
photography in the mid 18th century. (А, В) Оп close examination, this daguerreotype (1839-1860) reveals prominent
proptosis in the subject. (С, О) This anonymous саЫпе! card (1870-191 О) portrait shows similar findings.
729
 А

FIGURE 9.2 Early collections of external photography include Ramsay's Atlas of External Diseases of the
Еуе pubIished in Glasgow Ьу James MacLehose and Sons in 1898 (А), and Greeffs's 1909 Atlas Оег Ausseren
Augenkrankheiten Fur Arzte Und Studierende pubIished Ьу Urban & Schwarzenberg in Berlin (В), This latter text
portrays wax models from the Pathoplastic Institute in Berlin, 22,23

External Photography Equipment

The obvious first requirement for external photography is а camera. But
of what specific type? If а film сагпета is chosen: should it Ье traditional ог
instant? If а digital camera is chosen: how тапу mega-pixels are required?
Should the сагпета Ье still, or video, or Ье сараЫе of capturing both? The short
answer to each of these questions is best stated as another question: How will
these external photographs Ье used? The answer to this question will assist in
matching practice needs with available сагпета and lens options.
А traditional film сагпета is preferred when easy to file hard сору, using time
tested technology, is required. For routine clinical photography, most photog-
raphers choose а single lens reflex (SLR) and expose medium speed 35тт
color slide film. Each specific сагпета. film, and processing combination will
determine the final photograph's particular color гегкйпоп." Equipping the
camera body with а motor improves framing accuracy because the сагпета is
not moved while winding the film. Interchanging the standard focusing screen
with а grid model improves composition Ьу providing alignment cues in the
viewfinder. The SLR maximizes flexibility Ьу allowing the use of interchange-
аЫе lenses (ТаЫе9.1).Its 'what уои see is what уои get' viewfinder eliminates
the problem of parallax (Fig. 9.3). Image quality is high: final images are suit-
аЫе for publication or сап Ье digitally scanned for PowerPoint presentations
and web pages.

ТаЫе 9.1 Digital Chip Size and Lens Magnification Factor

Sensoг Size (тт) Lens factoг (SLR) Wide Angle lens Noгmal Lens Poгtгait lens
Digital Chip 7.2х5.3 5.6тт 10тт 21тт
18х13.5 2.0 14тт 23тт 52тт
22х15.1 1.6 18тт 31тт 65тт

35тт film 36х24 1.0 28тт 50тт 105тт

TABLE 9.1 Digital cameras use тапу different chip sizes, This tabIe relates 3 popular chip sizes and their digitallens focallength with standard
35тт lens equivalents, Always look for the "35тт lens equivalent" statement in а fixed lens сатега, and the "Lens Factor" statement in а digital SLR,
730
 .'.'
.'
.'
..... --
.> -- --
..... -- --
.....
--
...... . . --
.... ---
--- .-
.... -- '.'.
FIGURE 9.3 Parallax describes а diffегепсе iп регсерtiоп whеп ап ....
observer views the same object from slightly diffегепt viеwроiпts. For ".
'." .....
example, the viеwfiпdег апd the lепs of а гапgеfiпdег сатега tгапsmit
two slightly diffегепt views of the subject. This effect is exacerbated as the " .
сатега moves closer (о the subject. А siпglе lепs reflex сатега does поt <.....
suffer from parallax: what you see is what you get. Iпstапt digital ог Polaroid
images allow immediate еvаluаtiоп of parallax.

Polaroid® instant cameras provide rapid results without dependence оп out-

side processing (Fig. 9.4).26 Instant prints assist with immediate patient educa-
tion and сап easily Ье slipped into ап envelope or folder in the patient's chart.
А negative feature is that image quality suffers because of the film's low resolu-
tion and the wide angle nature of instant сагпета lenses.
If electronic medical records, web posting, ог PowerPoint presentations аге
primary goals, then it makes sense to begin with а digital image.27 Each spe-
сiБс digital сагпета brand and model will exhibit inherent characteristics that
affect color rendition and contrast. Examples of this include chip size (larger
chips enhance image quality) and chip type (CCD, CMOS, and Foveon chips
аН render colors slightly differently). То preview the quality of а camera, оЬ-
tain ап image from the specific camera model before making а major purchase
decision. The specific digital camera settings chosen will affect the final image
quality. Lower IS0 choices result in higher signal to noise ratios. Lower сот-
pression ratios mean finer detail - but larger files. Гп decreasing order of im-
age quality, but increasing order of workflow speed, digital Ые format choices
include raw, .tif, ог .jpg. Each step in the digital imaging chain (camera, oper-
ating system and software color standards, monitor characteristics and room
illumination, as weH as printer settings and ink and paper choices) will affect
how the final image looks.

А
FIGURE 9.4 (А) Polaroid cameras like the CU-5 pгovide close fосusiпg. (8) The iпstапt images сап Ье used for раtiепt еduсаtiоп, thеп
labeled апd filed iп the раtiепt chart.
737
 в
FIGURE 9.5 Future cropping and enlargement decisions will impact the choice 01а digital сатега system. (А)
The high resolution, 8 mega-pixel image 01this lid lesion loses little when enlarged lог closeг scгutiny. (8) The
enlarged 1 mega-pixel image loses signilicant contrast and detail.

Specific digital camera recommendations Ьесоте quickly outdated as the

industry continues to evolve at а rapid расе. The lowest priced digital SLR that
is compatible with traditional film SLR lenses is priced in the five hundred dol-
lar range at this writing. These 6 to 14 mega-pixel cameras provide appropriate
color reproduction and resolution for medical imaging applications. Large im-
age files should not Ье а cause for соnсеrn if the office computer and storage
media are updated to current specifications. The final purpose of the image
also affects the capture resolution choice. А ЗООDРIpublication qua1ity 7х10
.tif file requires а 6 megapixel capture, while а screen resolution (web/Power-
Point use) 7х10 72 DPI image requires only а 1 mega-pixel capture resolution.
It is advisable to purchase extra media cards and а card reader to transfer the
images from the сагпета to the computer. Proactively develop а strategy for
tracking patient image files electronically - whether it is as simple as naming
the images with а patient number and filing them electronically in а set of ар-
propriately named folders, ог entering them into аn electronic medical record
ог digital angiography system.
Avoid inexpensive consumer cameras (1-2 mega-pixels), as their low pixel
resolution will not adequately capture fine detail (Fig. 9.5). Before purchasing
а mid- or high-range rangefinder-type consumer digital сагпета (4-8 or above
mega-pixels), check the camera's macro focusing function and for аnу wide
angle distortion when focusing closely. Use the electronic viewfinder of the
digital camera to overcome аnу parallax error that тау Ье evident in the opti-
cal viewfinder. Hold the сагпета in your hands to evaluate the control place-
ment and ease of use.
The appropriate сагпета recommendation for а practice depends upon its
specific clinical situation. А Polaroid solution тау Ье adequate for а small
practice with paper charts and аn occasional need for external photography.
А teaching institution with access to а digital angiography system (which
should Ье able to accept digital external photographs) and dedicated ophthal-
mic photographers will require the flexibility of а digital SLR. If the staff is
732
 uncomfortable with computers, choose film. If
the practice is migrating to electronic medical
 records, choose digital. If publication quality
images are important, choose at least а 6 mega-
pixel digital сагпета. In general, the more
топеу spent оп а сагпета and lens, the greater
will Ье the image quality and flexibility.
Documenting nystagmus or blepharospasm
and recording motion during motility stud-
А
ies requires video recording. If light use is
encountered, the low resolution, thirty-sec-
ond .mpg video clips available оп still digital
cameras тау Ье useful. For sustained use, а
high quality digital video сагпета with а ro-
tating LCD screen is recommended. То moni-
tor progress from the patient position, rotate
the viewfinder screen 1800 while moving а
в fixation device or manipulating lids. Video
resolution is 640х480 pixels, or about 0.3
mega-pixels. Auxiliary close-up lenses тау
Ье useful for decreasing the minimum focus-
ing distance. The patient video recording сап
Ье downloaded into а personal computer us-
ing а Firewire connection (!ЕЕЕ 1394). Ап al-
FIGURE 9.6 The focallength of а lens deteгmines the woгking distance foг а ternative is to use а video сагпета that records
paгticulaг magnification. (А) Poгtгait lenses (90-120тт focallength foг 35тт foгmat) directly to а CD or DVD. Using video edit-
simulate the natuгal peгspective of inteгpeгsonal communication. (В) Shoгteг focal
ing software (Adobe Premiere, Ulead Video
lengths pгoduce unusual peгspective Ьу гequiгing close woгking distances.
Studio, Apple iMovie or Final Cut Рго) and а
DVD recorder will facilitate archiving video material and preparing video clips
to insert into presentations. Selected frames сап Ье saved as .jpg files for posters
or publication.
The business of а сагпета body is to capture and record light. The business of
the lens is to gather and focus the light. Long and short lenses тау distort the
way human anatomy is perceived, causing normal perspective relationships
of the face to look distorted. (Fig. 9.6) Ophthalmic external images generaHy
faH within the reproduction range of 1:10 to 1:1 which will require а lens to
have macro, or close focusing, capabili-
ty. А portrait lens with macro capability
is recommended. Options include the
сагпета manufacturer's 90тт macro
lens or а 'Medical' lens that includes а
built-in ring flash. If the camera's built-
in zoom lens is being used, choose а
consistent moderate telephoto setting,
adjusting the distance from the subject
to modify the агеа to Ье recorded.
The light used to expose the image
сап vary in color, character, direction,
and intensity. Flash is the illumination
of choice for clinical patient photogra-
phy. For most ophthalmic clinics, а sin-
gle light source is suggested.28, 29, 30, 31, 32
А single light provides опе set of shad-
FIGURE 9.7 The clinic exteгnal сатега сап Ье used to acquiгe images in the minoг ows, mimicking the most natural of
pгoceduгe ог opeгating гоогп, А tempoгal aгteгy biopsy is being peгfoгmed.
733
light sources: the sun. The one light method also
enhances the portability of tl1e system, allowing а
photographer to image а patient at bedside or during
surgery (Fig. 9.7). Large soft-box and multi-flash set-
ups have been suggested, and are favored Ьу special-
ists in plastic surgеrу.ЗЗ,34
Photographing with either
tungsten light bulbs (yellow) or fluorescent lights
(green) тау cause unnatural discoloration (Fig. 9.8).
The position and size of the flash determines ехро-
sure and the character of the light in the final photo-
graph. For general photography, the flash is tradition-
аllу located оп the top of the сагпета. This placement
сап cause 'flash parallax' (the area illuminated Ьу the
flash is different than the area the objective lens цп-
ages), especially in close focusing situations. Attach-
ing the flash unit to the front of the lens is suggested
for close focusing situations. The position of the flash-
induced corneallight reflex (first Purkinje image) сап
Ье used to help assess strabismus.35
The relationship between the physical size of the
flash diffuser and the size of the subject determines
the depth and intensity of the shadow detail. Like the
direct sun оп а bright day, small, point source flash
units delineate fine detail; but also create harsh shad-
ows that obscure detail - especially in cavities (Fig.
9.9).36Many photographers prefer small sized light
sources that create additional texture Ьу raking the
light across the subject. Similar to the sun оп а cloudy
day, а diffused or ring flash provides even illumina-
tion which penetrates cavities; but сап also create

FIGURE 9.8 Whеп ап image is exposed оп slапdагd daylighl film uпdег

luпgslеп Illumiпаliоп, pholographs (А) have ап огапgе casl апd fluогеsсепl
lighl pholographs (8) аге gгееп. This color casl сап Ье avoided Ьу usiпg
еlесlгопiс flash 10overpower аmЬiепl lighl (С). If а flash is uпаvаilаЫе, place
а Ыие 81А filler (ог ап FLD/ЗОСС mаgепlа filler) over Ihe lепs 10 соггесl
for Ihe color shift recorded whеп usiпg luпgslеп (ог fluогеsсепl lighl) wilh
daylighl film. If Ihe сатега is digilal, sel Ihe while Ьаlапсе сопlгоl 10Ihe
'Iuпgslеп' ог 'fluогеsсепl' sеttiпgs iп siluаliопs whеп Ihere is а siпglе Iуре of
lighl source; апd 10AW8 (Aulo While 8аlапсе) whеп lighl sources аге mixed.

FIGURE 9.9 Hard shadows сап eilher iпсгеаsе iпfогmаliоп Ьу геvеаliпg lexlure ог decrease iпfогmаliоп Ьу оЬsсuгiпg delail. Whеп соmрагiпg Ihese Iwo
pholographs, поliсе Ihal Ihe shadows from Ihe hard lighl (А) leave Ihe uppeг lids iп dагkпеss while Ihe soft lighl fгom Ihe laгge source (8) гeveals the upper lids.
734
 large reflections оп shiny surfaces. Some surgeons prefer the even illumination
of ring lights as this method allows the tissue to speak for itself, without ad-
ditional emphasis from lighting placement. Newer macro flashes incorporate
lighting panels with individual on-off switches, allowing the рпотоягарпег to
choose between directional and non-directionallight (Fig. 9.10).
Other useful tools to keep in an external patient photography kit include:
• сюве-ир 1ensfilters to extend the reach о/ а macro 1ens
• теии ru1ers [о: documenting size
• small p1astic toys and а 1igbl [о: pediatric fixation devices
• cotton tipped app1icatol's and gloves /01' l'etl'acting and eveгting eye1ids,
• c1otl1or paper backgl'ound оп 'Шl1iсhto set spectacles or рюыпеыв (Fig. 9.11).

FIGURE 9.10 The Nikon S829s Масго Speedlight (А) and Сапоп Масго
Ring Light MR-14EX (8) аге examples of modern тасго flashes that attach
to the front ring of ап SLR lens. They use multiple light panels that сап Ье
controlled independently.

в
FIGURE 9.11 А simple suгgical drape serves as а background to document this post exenteration prosthesis (А, 8).

735
 А в с
FIGURE 9.12 Neulral gray ог medium bIue (А) backgrounds аге suggesled. (8) Slark bIack (аг while) backgrounds тау
Ье probIemalical as Ihere тау Ье по separalion belween Ihe background and dark (аг lighl) hair. (С) Brighl colors and busy
backgгounds draw Ihe еуе away Iгот Ihe subjecl.

External Photography Standards

Camera ready and in hand; patient seated in front of lens; but still, it is not
quite time to begin. What's missing? The photograph's background, а precise
framing and focusing plan, and аn exposure strategy. Standardization in these
areas will еnhаnсе both the quality of the images and the efficiency of the pro-
сеэв." 38, 39
The background color used in а patient photograph mау influence the per-
ception of that patient's condition (Fig. 9.12). Begin Ьу eliminating background
clutter: avoid photographing patients in front of oph-
thalmic equipment. Dedicate а blank wall (painted
г------------
ап appropriate color) and place а single patient chair 1
1
in front of it. Plan the space to allow room to retreat 1
1 r
from the patient to easily accommodate recording 1 1
of full face images and oblique views. The patient's 1 1

head or body сап Ье rotated for lateral views.

1
: <r!!> $

---lJ---,
1

1
Multiple images will Ье exposed for each patient:
i
1
different fixations or framings, multiple angles, with 1

eyes ореn or closed. Standards in framing ensure 1 1

1
1
reproducibility between visits and appropriate соm- 1 1 1 1

1 1 1 1 1
parison between patients. There are two standard ар- 1 1___ _ __ ] 1 1 1
L J

proaches to composition: the anatomic method and I~

L
1
1
reproduction ratio method (Fig. 9.13). The anatomic
method relies оп а set of patient landmarks to define
the согпровшоп." For example, plastics photographs
OU (both eyes) аге framed from the outside edge of
оnе brow to the outside edge of the other. This method
allows for easy visual comparison between patients,
especially when а difference in head size exists. The
reproduction ratio method relies upon а specific set
of predetermined magnification ratios that are pre- FIGURE 9.1 3 The analomic method 01Iraming uses delined lacial
selected for certain clinical situationsY For example, landmarks 10obtain consislenl views. (А) Full lасе image тау Ье delined
аН OU photographs аге imaged at 1:4 (ТаЫе 9.2). as either neck to top 01 hair ог chin 10 hairline. (В) Images 01 both eyes
тау Ье Iramed Iгот brow 10 brow lог plaslics ог lгот lетрогаl canlhus 10
This method facilitates accurate measurements: true
lетрогаl canlhus [ог slrabismus. (С) The reproduction ratio method uses а
physical size сап Ье calculated from the final photo- slandard sel 01 magnificalion ralios 10 obtain consislenl views. AII lull lасе
graph. However, body size сап vary, sometimes sig- photographs (regardless 01 head size) аге pholographed аl 1:10; all OU
views аl 1:4.
736
 ТаЫе 9.2 nificantly, between patients. This creates а wide variation in the tight-
Reproduction Ratio Method ness or looseness of the framing. Each practice should determine the
standardized framing method that best serves their needs.
Lens Settings
Standardized views are required to produce comparable pre- and
Full Face 1:10
post-surgery images. Additionally, the photographer сап more effi-
cient1ydocument regularly occurring patient findings Ьу implementing
OU 1:4
standardized sets of patient photographs (ТаЫе9.3). А photographic
Orbital Region 1:2
series for strabismus should include OU photographs of the 9 stan-
Single Еуе 1:1 dard directions of gaze (Fig. 9.14). If the patient presents with а head
tilt, photograph а full face view in both the natural and forced primary
These magnifications аге suggested when using positions. Document blepharoptosis using both еуе photographs with
а rigid reproduction ratio method of framing
the patient looking straight ahead normally, then again with the еуе-
photographs42 These reproduction ratios аге
engгaved оп high quality тасго lenses.
brows raised, and again with the eyebrows relaxed (ап optional ptosis
series documents the patient looking straight ahead, up, and down).
То document proptosis, begin with а full face view, photograph each
side of the patient in 3/4 and profile views, then photograph а double еуе
view from above (with the patient's head tilted forward) and below (with the
patient's head tilted back). Show Marcus Gunn jaw wink Ьу photographing
the patient's full face normally, with their mouth wide ореn (jaw down), and
with their jaws shifted to the right and to the left side (Fig. 9.15). Suggested lid
margin photographs (trichiasis, ectropion, entropion) include straight ahead
views of both and single eyes and lid photographs with the patient looking up
and the сагпетаpointing down.

FIGURE 9.14 Photographing the 9 gazes of view documents variation

in the behavior of the eight extra-ocular muscles. А patient with thyroid еуе
disease is used to illustrate the nine gazes of view. (Courtesy Chris 8аггу,
CRA, FOPS).

FIGURE 9.15 Marcus Gunn jaw winking syndrome, ог external pterygoid-

levator synkinesis, is caused Ьу abnormal innervation of the levator muscle Ьу
the 5th cranial nerve. Document this condition using four full face images: (А)
normal, (8) jaw dropped, and (С, О) jaw shifted to each side. This patient's eyes
were pharmacologically dilated for а fundus examination. It is recommended
that external photographs Ье taken befoгe dilating the patient.
737
 ТаЫе 9.3 Suggested External Ophthalmic Photography Views

Condition Suggested Views Options and Comments

81epharoptosis OU with patient's brows normal, raised, relaxed ОU with patient looking straight ahead, ир, and down

Conjunctivallnflammation OU, single еуе Retract lids and direct gaze to expose агеа of interest

Согпеа Conditions Slit Lamp Photography

Ectropion OU, single еуе: primary position & patient

looking up/camera pointing down.

Entropion, Trichiasis OU, single еуе: primary position & patient Have patient squeeze lids.
looking up with саmега pointing down. Соrnеаl slit 'атр photographs тау show abrasion.

Marcus Gunn Jaw Wink Full face with: mouth closed, moulh ореп
(drop chin), and jaw 10 right and left

Proptosis, Full face, side & 3/4 profile ОU fгom above: patient leaning forward
Orbital Fracture ОU from below: patient leaning back.
Radiographic images.

Punctum 'EslabIishing view', high magnification (1:1 - 2:1) Direct gaze in opposite quadrant to reveal punctum.

Skin Lesions 'EstabIishing view', OU, single еуе, close-up Move as close as required.
Manipulate lids as required.

Strabismus 9 cardinal gazes Natural and forced primary showing head tilt.
Bielschowsky response: ОU at 450
Videotape as requested.

Systemic Conditions Full face, OU, single еуе Апу other body areas involved.

Trauma Full face, OU, single еуе Document апу objects and radiographic images involved.
Monitor pressure оп globe when retracting lids.

738
 External Photography Procedure
Obtaining external photographs consumes more time than the fraction of
а second required for exposure. Proper preparation, standardized technique,
and careful follow-through аге vital to consistent and successful external pho-
tography.

Prepare & Position

The external photography procedure begins Ьу reviewing the physician
completed External Photography Request Form (Fig. 9.16) and апу previous
photographs of the patient. А properly completed form will help t11ephotog-
rapher recognize the patient's findings from the physician's viewpoint. Mini-
таНу, а diagnosis and location аге suggested. The greater the detail written
or drawn оп the form, the better the final images will Ье. Reviewing previ-
ous patient photographs helps the photographer to frame identical views and
choose similar (and improved) points of focus. This is especially important
when documenting pre/post findings.
Complete appropriate paperwork and prepare the external camera (power
ир, load film or media card) before the patient enters the room. If film is being
exposed, photograph а nametag to act as а guidepost during editing. If digital
is being used, enter the patient information into the computer database.
Seat the patient in а stable chair against the available photographic back-
ground. А headrest тау Ье used to keep the patient steady. Ask the patient to
sit straight and align their head so that the central axis of their face is perpen-
dicular to the floor and t11efrontal plane of their face is parallel to the plane
of the wall behind them. The patient's Frankfort line (imaginary line between
the auditory canal to the infra-orbital rim) should Ье parallel to the floor. The
photographer sits оп а height adjustable stool with the center of the lens at the
height of either the patient's eyes (OU and single еуе photographs) or nose
(full face images). The сагпета should Ье held so that the film plane is parallel
to the plane of the patient's face. Most standard photographs will Ье imaged
from this primary position.
Before beginning the session, review the patient's anatomy and plan the spe-
сШс set of views required to document the findings. If the patient has Ьееп
administered topical sodium fluorescein (ideally, they have not), then rinse the
еуе. Ask the patient to remove distracting jewelry and glasses. Hair should not
obstruct the view of апу findings.

Expose
Always begin а photographic session with ап 'establishing view', choosing
either а full face ог view of both eyes. Instruct the patient to fixate 'straight
ahead' to establish primary fixation and to avoid the appearance of daydream-
ing (Fig. 9.17). Carefully frame and focus the image, centering the subject,
checking the edges оЕthe viewfinder for intersections with the subject. At the
same time, direct or motivate the patient as needed. Patients often blink at
the wrong moment, move at the expectation of the bright flash, or, in the case
of some pediatric patients, Ьесоте а moving target. Expose as тапу photo-
graphs as required to obtain the requested view.
As t11eimage is focused, consider the large variety of planes to choose from:
from the tip of the nose to the back of the ears. Think about the layers оЕskin,
muscle and Ьопе, and about how а specific choice of focus affects their rendi-
tion. Routine photographs аге best focused оп the eyelashes at the lid margins
or оп а bright reflex оп t11eсоrnеа. It тау Ье useful to pre-set the magnification
139
 OPHTHALMIC PHOТOGRAPHY REQUEST FORM

Anterior Segment
Date Physician _

УА: HxlDx: _

Signature

External Photography
о Full Face
о Natuгal primary о
ry
о 5ide R L

• о 3/4
о
о
о
R L
OU (mark gazes)
Hold lids down gaze!
00 NOT hold lids dоwп gaze!
о 5ingle еуе: о оои о 08 оо
о Lids о Upper о Lower о Trichiasis
о Oocument proptosis (FF, side, 3/4, above/be/ow)

Corneal Photograph~
о 51it Lamp Photography
OU 00 05
(P/ease sketch ог describe)
Stаiп: о Flr. о Rose Вепg.

• о

о
Goniography
OU

Endothelial
00 05
(P/ease sketch ог describe)

Cell Count
OU 00 05

PHOТOGRAPHER _

Соор: о Good Notes:

о Fair
о Роог
Consent for Photography Oate _
INTERPRETATION & АЕРОАТ

1 hereby authorize employees of DНМС (о interview те, photograph,

ог ошегсчве illustrate portions of ту anatomy. 1 further agree that they
тау use , and репnit others (о use infomation, slides, negatives, prints,
and other video, audio, or digital recordings for medical, scientific,
educational, and other related purposes.
5igned _

МО SIGNATURE _
Witness~ _

Routing: White • Еуе Chart Yellow . Medical Records Ае. 12/97 С-З58В

FIGURE 9.16 Sample Anterior Segment Photography Form with areas for external and corneal photography.

А в
FIGURE 9.17 А different pгimary fixation сап Ье obtained with (А) the right and (8) left еуе in some strabismus patients.
740
 А в с
FIGURE 9.18 Always begin with (А) ап 'estabIishing view', (В, С) move closer to uncover additional characteristics. This patient has meibomian gland сапсет.

and 'rock' slightly forward and backward to obtain precise focus. Disable auto-
focus features, as they аге difficult to control at macro settings.
Select а standard exposure setting tl1rough empirical testing. Expose images
of three colleagues at multiple magnifications, then choose the best сотЫпа-
tion of flash power, сагпета sensitivity (ISO setting), and aperture. The natu-
ral variety in skin and lesion coloration тау require а change in this normal
exposure setting. Use the histogram function оп the digital preview screen to
confirm proper exposure оп each patient.
The efficient photographic session moves successively from "1arge view" to
"small view." Expose full face first, then OU, then single еуе, then smaller de-
tails (Fig. 9.18). Compose the photographs to maximize the ratio of informa-
tion to picture area. Select horizontal or vertical framing as the subject requires.
РШ the frame wit11 important details; but remember also that ап area of соп-
сеrn сап only Ье appreciated when some portion of the normal surround is
included within the frame (Fig. 9.19). The агеа of interest will often Ье centered,
unless а landmark is included for position information or the whole еуе is сеп-
tered while the area of interest is sharply focused (Fig. 9.20).
Prompt the patient to change their direction of gaze or ореп and close their
eyes as required. Efficiently expose the standard nine gaze series as follows:
patient looking straight ahead, to the right, up and right, up, up and left, left;
and then with the upper lids retracted: straight down, down right, down left.
Request the patient gently close their eyes to reveal upper lid findings or to
document lagophthalmos. Incorporate ра-
tient triggers to better dошmепt blepharo-
spasm (reading or bright lights) and ectro-
pion (request patient squeeze lids together).
Cotton tipped applicators or gloves
should always Ье used when retracting lids
(Fig. 9.21). А two-person technique is more
efficient for two еуе down-gaze views and

FIGURE 9.19 (А) While useful, the close-up image of а single еуе of this patient with dacryocystitis does
по! tell the whole story because it lacks context. (В) Photographing both eyes demonstrates the unilateral
aspect. (С) The 3/4 view documents the extent of the infection.
747
А в
FIGURE 9.20 Center the subject for most clinical photographs. (А) If а single еуе is involved, (8) center the еуе and focus оп the subject.

upper lid eversions. If only опе lower lid need Ье retracted, then the index fin-
ger of the patient (positioned slight1y out of the frame) тау Ье called upon.
Deviate from the rigid 'straight camera' alignment as required, capturing as
тапу views as required to tell the story. Show natural head tilt with а wide
full face view, then straighten the head ('forced primary') to
document motility changes (Fig. 9.22). Demonstrate swell-
ing, proptosis, and orbital fractures Ьу rotating the patients
head at а 450 angle and focusing оп the еуе of сопсегп, or Ьу
ti1ting the patients head forward (or backward) and photo-
graphing from above (ог below) (Fig. 9.23). Document OU
views straight ahead and with the patient's head tilted at а
450 angle (each side) to document а Вielschowsky response
(Fig. 9.24). When photographing ectropion, complete the
straight ahead views, then have the patient tilt their head
forward and raise the саптега to better document the in- А
tersection of the lid margin with the globe (Fig. 9.25). For
punctum photographs, select the highest magnification,
and then, pressing the lower cheek (ог upper lid) down and
nasally, direct the patient's gaze up (or down) and тегпро-
[аllу. Ophthalmic patients тау have systemic findings that
require additional photographs of findings not in the peri-
ocular region.43
Approach each photography session as ап opportunity for
creativity. After exhausting the standard photographic гоц-
tine, but before the patient is released, stop to ponder how
the patient's condition сап best Ье documented. Аге anyad- В
ditional images needed to best tell this patient's story?

Follow-up
Have the color film promptly developed Ьу а profes-
sional processing laboratory. Quality processing and timely
delivery are both important factors to consider when
selecting а film processing vendor. Edit and label the film
promptly, marking each slide with the patient's number,
the date taken, and the referring physician. If shooting
Рогатою", the best time to jot the patient пате, number
с
and date оп the white border surrounding the image is FIGURE 9.21 (А) А patient with scleritis with SLE (sys епнс
lupus erythematosus). А second professional is used 10retrac Ids
immediately after the exposure.
using (8) cotton lipped applicators ог (С) gloves .
74]
 Load digital images into the computer, making prints as required for refer-
ring physicians or paper chart. Edit the images, keeping the best photographs
and deleting the rest. Always take some time during the editing process to
examine each photograph with ап еуе toward improving image quality. How
could this photograph have Ьееп more effective? Would additional photo-
graphs have helped in documenting this case?

Medical Photography & Close-Up

Equipment Resources

www.bca.org
www.canfieldsci.com
www.dinecorp.com
www.opsweb.org
www.steves-digicams.com

FIGURE 9.22 (А) The natural head turn 01this patient with 8rown's
Syndrome is documented with generous lull lасе Iraming. (8) The head is
then straightened into а lorced primary position.

А в
FIGURE 9.24 This patient presented with lourth пегуе palsy. (А, 8) As he tilted his head to each side, his canthi were aligned with ап invisibIe line that
intersected the top and bottom corners 01the Iгате.

FIGURE 9.25 (А) The lower reflection indicates ап enlarged tear lake in this straight-on image 01а patient with ectropion. (8) Рhоtоgгарhiпg Iгот аооуе
while diгесtiпg the раtiепt to look up documents the lax intersection Ьеtwееп the lid mагgiп and the globe.
743
FIGURE 9.23 Pгoptosis is dосumепtеd iп а раtiепt with thyгoid еуе disease usiпg (А) fгопtаl full face, (8) both еуе view, апd (С, О) pгofile views of each
еуе. (Е, F) Тiltiпg the раtiепt's head back апd рhоtоgгарhiпg fгom below dеmопstгаtеs pгoptosis iп this sесопd раtiепt with thyгoid еуе disease. (G, Н) А two
еуе view, tаkеп fгom the vапtаgе роiпts of both iппег апd outeг сапthi, dосumепts uppeг lid edema.
744
 References

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 ciliary body 21 edema clefts 44
Index сшагу muscles 21 еlесtroпiс flash illumiпаtiоп 5, 11, 13,
ciliary processes 21 14,62,63,68,87,115,
А сliпiсаl slit lamp biomicroscope 119, 133, 134, 141, 146
accessory lелsеs 90,94,100 8,9,14, 15 еlеvаtiоп 44,45,46
accommodation 21,80,81,82 сюзе-цр lепs 133,135 епdорhthаlmitis 53
аdhеsiол 45,46 co-axial 13, 14, 27, 115 епdоthеliаl cells 20,55, 56, 57
aerial image 13,80 соllаgеп 20 епdоthеlium 20,27,31,44,55,57
albinism,ocular 76 collarettes 36 epithelial dystrophy 32, 70, 105
Айеп, L. РМх color Ьаlапсе 134 epithelial defect 45
anaglyph 113, 122, 123 color temperature 13, 14 еstimаtiпg distances with tlle
anesthetic 93, 112 Comberg 4,5 slit Ьеат 29
angle, filtration апglе composite image 2,31 exciter filter 104, 105, 106, 108
16, 21, 30, 90, 93, 94, 96, 97, 98, 112 сопшпспмз 19,36,44, 104, 109, 138 exposLlre 13,14,34,35,38,43,44,59,
апglе оЕiпсidелсе 27,31,42,54 сопtасt lепs 106 62, 63, 66, 68, 70, 73, 78, 79, 87, 102,
апglе оЕreflection 54 contact [епз, diagnostic 22, 91, 93, 94, 105, 108, 110, 120, 136, 139, 141
angle оЕYiew 27, 55 95,97,98,102,123 ехtеrпаl рпотоягарпу 128, 129, 130,
anterior спагпЬег 21, 30, 42, 49, 52, 71, сопшыоп iпjLlry 74, 76 132, 136, 139
93, 107, 112, 123, 124 convergence 80 exudates 101, 103
апtiгеflесtiоп соаtiпg 99 co-pivotal 4, 9, 83 eyepiece setting 81
aphakic bLlllous keratopathy 37,40 согпеа 19,20,21,27,29,31,32,43,50,
aqueoLls cells and flare 52,53, 119 55, 62, 63, 64, 66, 68, 69, 70, 71, F
aqueous лшпог 21,43, 52, 53, 107 73,93,96, 10~ 108, 111, 138, 139 Fabry's disease-
artifacts 11, 14,55, 73, 78, 86, 97, 98 согпеа verticillata 63, 64 соrпеа verticillata 63,64,124
Ацэеп 3 соrпеаl edema 38,90,112 fibrin 124
Ахепfеld's sупdromе 33,74,97 согпеа] foreign bodies filaments, соrпеаl 106
43,63,65,68,77,87 file tгапsfег, image 120
в согпеа] пеrvеs 42 fillligllt 11,12,13, 14, 26, 35, 38, 40,
barrier filter 104 соrпеаl perforation 107 41,44,45,49,59,73,74,115
Bayadi lепs 91, 100 corneal геjесtiоп 71 film sепsitiYity 87
Ьеаm splitter 11, 13, 15, 83, 116 соrпеаl гiпgs 64 fiпgегргiпt dystrophy 74
Вегliпег 4 согпеа] шсег 39,40,45, 108 flash parallax 134
Bielschowsky геsропsе 142 critical angle 93 flash synchronization 117,119
biometric 16 Czapski 3,4 Fleisher гiпg - поп Нпе 110
blue filter 110 Пцогевсеш, зооплп 10, 90, 104, 105, 106,
bodily fluids 95 D 107, 108, 139
Воwmап's гпегпЬгапе 20 dacryoadenitis 18 fluorеsсеiп strips 104
Brewster viewer 122 dacryocystitis 18, 141 [осцэ 9, 10, 21, 26, 55, 70, 76, 79, 80, 81,
bright-field illumiпаtiоп 66,73 dark -field illumiпа tiоп 68, 73 82,83,107,130,131,132,
broad Ьеат illumiпаtiоп depth оЕfield 26,97, 103, 119 133, 134, 136, 139, 141, 142
24,31,32,42,47,103 Descemet's membrane 20,44,67 focusillg sсгееп 79, 80, 81, 130
Вгоwп's sупdгоmе 143 digital imaging 14,38,62,80,84, foreign body 30,38,43,46,50,51,
Ьцйоцз keratopathy 29,37,40,44 87,131 62, 77, 113, 123
digital сшр, sensor 84,115,130,131 fогеigп body track 77
с digital SLR 130, 132 format 73,74, 78, 85, 86,
са'сшгп deposits 124 diffuse illumiпаtiоп 25,26,35,36,37,38, 117,119,131,133
сагпета format 85 39,40,41,43,48,61,66 foyea 22
Сапаl оЕ Schlemm 21 diffuser 35, 134 Frankfort liпе 139
canaliculi 18 dilated рцрз] 50, 53, 71, 76, 100 free flоаtiпg vitreous cyst 50,51
сапthi 19, 143, 144 diopter 81, 91 free floating рigmелt clump 96
сагсiпоmа, eyelid 125 direct focal Шцпцпапоп 23, 30, 34, 35, FLlclls' dystrophy 42,44,57
Сагdопа keratoprosthesis бl 42,59,61,64,66,68,69 fundus lепs 101, 102
саruлсlе 19,36 direct lепs 91
cataract FMvi, 41, 49, 76 direct геtгоillumiпаtiоп 60,6566,67 G
caterpillar hair, ргезшпео 98 direct гепошшпшапоп from the iris geographic atrophy of tlle iris 76
cell алd flare 52, 119 65,66 glaucoma 21
сепtгаl геtiпаl artery апd vеiп 22 dшаtiоп of exposure 87 glycerine, topical 112
сепtгаtiоп 13,59,63, 78, 83, 86 Gоldmапп 4, 5, 91, 101, 102
choroid 21, 22, 73 Е gопiоgrарhу 91,93,103
"Christmas ггее" cataract 49 ectropion 137, 138, 142, 143 goniophotography 90,93
747
gonioscopy 21,90,91,93,103 km 1~1~2L2~2~3L4~4~4~4~ рарШагу лурепгорпу
granLllar dystrophy 23 50,51,57,58,62,64,66, 71, 73, 76, parallax
groLlnd glass 79,80 97,98,130,133,134,135,136,139 par-foca!
GLlllstгалd 3,4 lелs factor 130 "pencil оЕliglLt" :;3
lid eversion 112 релеtгаtiпg foreigll body зс 3-.:: ",3 ","
н lid fold 112 релеtгаtiпg keratoplasty 55, -1, -: 3 :23
Haab's striae 33,74,97 Нгпэцэ 19,63 репрпега] retina Ч1, ~:-, -: 3
Haag-Streit 4, 9, 11, 84, 115, Lisch пошлев 37 репрлега! vitreous ,1, 103
116, 124, 145 lissашiпе green 109 perspective 74, 12i?, 133
half гпооп зпаре 73 Шппапп 5,6 p!10tograp!lic апаслгпепг 5, И. 15
Нагtласk 3 шхагес! lens 7,49,73 photo slit lашр Ыошiсгоsсоре 6" 11,
head tilt 142 12,15, 3,8-!,115
Heidelberg Елgiпеегiлg 15, 16 м рigшепt disрегsiол sулdгоше
Неlшhоltz 3 гпасго lens 132,133,135,137, 141 76,94,97,9
Нелkег 4 шаculа 22,101 рigшелt ерплелшп 22, 71, 75, 101, 102
herpes siшрlех keratitis (HSV) 108 шагшаг lLole 101 рiлроiлt [Пцпппапоп 35,52
Нiшlеу 2,3 шаgпifiсаtiол 2, 10, 14, 25, 48, 49, 50, 55, рlаsшасуtоша 47
horseshoe tear оЕгеппа 103 63,66, 70, 71, 73, 74, 80, 83, 84, Po!aroid 131, 132
Ншэу lелs 91 85,86,87,102,103,115,119,133 роlусЬгошаtiс deposits 42
шаgлifiсаtiоп ratio 85, 136 poliosis 36
1 Marcus Сцпп jaw wiлk 137 рооliлg 104, 105, 106, 108
ппгпцпс cells 52 шеdiаl саптпцв 19 posterior сапагпЬег 21
indirect ilIuшiпаtiоп 23,59, 62, 68 шеgа-рiхеls 130, 132, 133 posterior pole 22, 102
iлdiгесt lелs 91 Мееsшалл's ерппеца! dystroplLy 70, 105 PowerPoint 131
iлdiгесt геtгоilluшiлаtiол 60, 66, 67, 68, гпейэоппап g!ands 19 рroхiшаl Шцпппапоп 34,59, 61, 102
69,70,87 гпеюоппап gland сапсет 141 рsеudоехfоliаtiол 47
iлtепsity оЕilluшiпаtiоп 87 шелtаl сошроsitе iшаgе 31,114 рэецоорлеюс кегагорагпу 44
iлtегfасе 66, 67, 69, 70, 93 шеtЬуlcеllulоsе 99 рцпсплп 18, 19, 142
iлtегрuрillюу distалсе 122 шillisесолd 13 рцрт! 19,21,22,49,50,53,63,68, 70, 71,
iлtгаlелticulаг foreigll body 50,51,62 шirrог 11оusiлg 115, 116 72,73,76,87,93,97,98,100,103
iл~осu~kmООЦ ~ .~g 133 pupillary гпагяш 71,72
~~ 1~2L2~3~4~4~4~4~4~ Мuлsол's sigл 111
49, 50, 65, 66, 68, 69, 70, 73, 76, Миllег 145 R
8~93,97, 109, 110, 112, 123 шуdriаtiс 76 .raw 131
iris cyst 45, 98 ray 52
шз dehiscellce 123 N red reflex 71, 97
~is lеsiол 45, 46, 49, 50 лаsоlасгiшаl dLlct 18 reflectivity 42, 52, 54, 73, 87, 102, 103
iris tгалsilluшiлаtiол 76 егпst-sраltlаmре 4 reflex пшгог sуstеш 11, 13, 115, 116
шэ пцпог 45 пегуе palsy, fourtlL 143 геfгасtiол 21,22,63,67,68,69, 73, 90, 93
цоп Нпе - Fleisher ring 110 пецговепвогу геtiла 101, 102 refractive еггог 81
iпigаtiол 104 Nikon 115,116,117,118,119, геjесtiол line 71
isо-селtгiс 4, 9, 10, 59, 63, 66, 68, 71, 83 120, 123, 124, 125, 135 гергоduсtiол ratio 136, 137
isоlаtiоп witlL Шшпшапоп 24,25 лiлеty diopter lелs 100 resolution 14, 103, 115, 132, 133
поп-сопгасг lens 91 reticle, cross llair reticle 13, 81, 86, 119
J геппа 21, 22, 90, 91, 97,
ipg 121, 131, 133 о 100, 101, 102, 103
obliqLle illumiпаtiол 50 геtiла! dеtасhшепt 22
к OCT-SUM 15, 16 геtiпа! exudates О
:' еlviл 14 ocular аlЫлisш 76 геtiлal рigлlелt ерппейшп 22
кегапс precipitates (КР) 32,68 oculars 11, 13, 14,55,80,81, гепсзПштппапоп 59 66
егаtосопus 29,90,110,111 83,85,86,119 гепошцпппапоп погп the ftrndu :-1
~eratoplasty 39,40,45,71,105,125 oplLthalmoscopy 22, 102 Rieger's эупсгогпе ~I

eratoprostlLesis 61 optic пегое 21,22,73,75,102 ring light, flash

.' оерре lens 91 optic nerve lLead 22, 73, 75, 102 rods and сале
optical iшаgе 80 Rose Bengal
l optical iлtегfасе 93
асriшаl glалd 18 optic section 13, 24, 27, 28, 38, 39, s
аcriшal sac 18 40,41,43,44,101,102 cheie' _tПре>
amellar keratoplasty 45 Р сЫеmш' сanа! :::'1
attice dystroplLy 69,70,89,106 palpebral fissure 19 Sch,,'albe' line 7
748
 sclera 19, 21, 22, 63, 87 superior limbic tropicamide 7Е
sclerotic scatter 34,59, 63, 64, 73 kегаtосопjuпсtivitis (SLK) 109, 110 ПIМеdiсаl 14, Е
sесопdаry illumiпаtiоп 59, 68, 87, 102 sшfасе relatiollships 45, 102 tuпgstеll 14, 87, 13~
Seidel Test 107 sшfасе tехtше 47,48 Тупdаll's рhепоmелол 35
sеmiluпаг fold 19 systemic lupus erythematosus (SLE) 142
serous dеtасhmепt 101,102 systemic side effects 18 u
shutter speeds 87 ulcer, согпеа! 39,40,45,108
simultaneous stereo 86, 115, 121 т иуеа 21,22
siпglе lens reflex сагпета (SLR) tапgепtiаl illumiпаtiоп 42,47,48,49,50, uveitis, posterior 103
11, 14, 79, 131 51,52,66,67,68, 70
SLE (systemic lupus erythematosus) 142 tear film breakup 44, 106 v
slit сопtгоl арегtше 35 tear Ыm layer 27,44, 55, 89, 106 уап Herick 30
Sllell's Law of Optics 54 tear mепisсus 19 verticillate рапегп 63
зресшаг гейеспоп 35,44, 49, 54, ТЫеl 5 video 133
55,56,57,58,66,86,97,98 тпгее mirror [епз 22, 91, 92, 94, 95, 96, 97 visual acuity 2:
split-frame 115, 124 .tiff 131 vital dyes 90, 10-1
squamous сеlllеsiоп 109 Т11уgеsоп's superficial репсгаге vitreous 21, 22, 42, 43, 50, 51, 71
stаiпiпg 104, 105, 108, 109, 110 keratopat11Y (SPK) 69 90,91,97,100,103
эгарпуюсосса] kегаtо-сопjuпсtivitis- thyroid еуе disease 137, 144 vitreous chamber 21
blepharitis 36 Торсоп 9, 11 vitreous Ьцгпог 21
stereo 84,86,102,114,115,116,117, topical glусегiпе 90,112 ушеоцв зпапсз 42
118, 120, 121, 122, 123, 124, 125, 126 topographic iпfогmаtiоп 45
stereopsis 14,22 total шгегпа] геflесtiоп 63 z
strabismus 137 toxic epithelial keratitis 108 Zeiss 4,5,6,9,84,115,116,117,
stroma 20,27,31,32,43 trabecular mes11work 21 118, 119, 123, 124, 125
subject reflectivity 87 trachoma 36 zопе 1, 2, 3 алd 3+ 68, 69
subluxated lепs 7,73,74 tгапsillumiпаtiол 59, 73, 76 zOl1ll1es 21, 97

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