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Slit lamp biomicroscopy

OP1201 Basic Clinical Techniques


Part 2
Dr Kirsten Hamilton-Maxwell
A few notes before we begin
I am about to describe a systematic procedure that
will seem like a recipe
This is strictly for beginners!
As you get better at slit lamp, the lighting and
magnification changes become second nature, and
your routine will start to flow
It wont be long before you can examine both eyes
within 10 minutes
Hygiene
Good hygiene is very important!
Clean the chin and forehead rest of your slit lamp
between patients using an alcohol wipe
Wash and dry your hands thoroughly before and after
each patient; do this when the patient can see you
wherever possible.
As a patient, you have the right to ask your practitioner
if they have washed their hands
Dispose of any used tissues immediately in the bin
Anything that has come into contact with the eye
needs to go in the yellow biohazard bin
Slit lamp safety
Slit lamp 15x irradiance of
ophthalmoscope
Macula injury with fundus
exam possible
IR thermal injury
UV photochemical
damage
Greater risk in
Children
Aphakes
Macula pathology
Prior exposure within last
24hrs increases risk



Safe viewing time for
fundus with dilated pupil
with Haag-Streit
21 secs at lowest setting
8 at highest
FDA recommends
Limit brightness
UV and short wave blue
filters (<420nm)
However, dont risk
missing important lesions
by trying to do the exam
without enough light

A basic slit lamp routine
Set-up
Slit lamp preparation
Disinfect yourself and the slit lamp
Focus eyepieces
Adjust table height
Patient preparation
Explain what you are doing
Adjust chin height, chair height, and ask patient to rest
forehead against forehead rest
You are now ready to begin
How to focus eyepieces
With focusing rod
Insert the rod into the slit lamp you will find
the correct hole at the pivot point for the
illumination and biomicroscope arms. Turn
the rod so that so that the flat part is facing
the eyepieces.
Adjust the slit to a width of about 1mm.
Swing the illumination from side to side to
ensure that the slit remains still.
If it moves, the previous user has
decoupled the system, or the slit lamp
needs to be returned to the
manufacturer for servicing
Without focusing rod
Adjust the slit to a width of about 1mm
and position on the flat part between
your patients eyebrows.
Without looking through the eyepieces,
move the slit lamp backwards and
forwards until the slit is as sharp as it
can be. Swing the illumination from
side to side to ensure that the slit
remains still. It must be still for this to
work.
The dioptric focus of both eyepieces should be screwed towards the plus as far as
possible (usually anti-clockwise).
Close one eye, look at the slit beam image through one eyepiece and gradually
turns the eyepiece clockwise (towards minus) until the surface of the rod is just in
focus.
Repeat for the other eyepiece.
Look through both eyes; do you have clear comfortable vision?
This will take some practice to get right, because you will need to learn to relax your
accommodation.

What to examine
Adnexa
Eyelids and lashes
Cornea and tear film
Tear meniscus
Anterior chamber
Iris including pupillary ruff
Lens
Anterior vitreous


What does scan mean?
Since we are using a narrow beam of light, we need to
move the slit across the eye to see everything
We scan from left to right, or right to left, in a systematic
way
The scanning procedure is always the same
When viewing the temporal eye, the light should be on the
temporal side
When you reach the midline, switch the light to the nasal
side and continue scanning watch out for the nose
The slit should be set at full height unless otherwise stated
You will need to refocus (by moving the slit lamp forwards
or backwards) as you go because of the curvature of the
eye
Adnexa
Patient has eyes closed
Illumination
Wide beam with a
diffuser
Magnification
Low (6x)
Angle
Microscope: straight
Illumination: about 45

Method
Scan across upper and
lower adnexa
Look for colour, texture
or elevation changes
Record
Normal and abnormal
findings
Draw unusual findings
Xanthelasma
Eyelids and lashes
Patient has eyes closed
for superior lid and open
for inferior lid
Illumination
Parallelepiped (3-4mm)
Magnification
10x
Angle
Microscope: straight
Illumination: about 45
Remember to switch
sides

Method
Scan across upper and
lower lids and lashes
Look for colour, texture,
elevation changes,
abnormal eyelid position,
meibomian gland
appearance, lash colour
and regularity
Record
Normal and abnormal
findings
Draw unusual findings

Eyelid margin is vascularised and the Meibomian glands appear blocked
Cornea
Patient has eyes open
from now on
Illumination
Parallelepiped (2mm)
Magnification
Moderate (10x to 16x)
Angle
Microscope: straight
Illumination: about 45
Method
Divide the cornea into
thirds and scan central,
upper, lower separately

For lower cornea, ask
patient to look up
For upper cornea, ask
patient to look down and
hold lid against upper
brow
Look in the illuminated
(direct) and non-
illuminated (indirect)
areas for irregularities
Record
Normal and abnormal
findings
Draw unusual findings
Corneal foreign body with rust ring and associated inflammation
Tear film meniscus
The pool of tears that is
adjacent to the lower lid
Illumination
Parallelepiped (2mm)
Magnification
Moderate (16x)
Angle
Microscope: straight
Illumination: about 45

Method
Measure directly by
matching to slit height
and reading off scale
If you have a slit lamp
with set positions only,
set a fixed height and
calculate meniscus
height via comparison
Record
Meniscus height in mm
Tear meniscus stained with fluorescein
Conjunctiva
Illumination
Parallelepiped (3-4mm)
Magnification
Moderate (10x to 16x)
Angle
Microscope: straight
Illumination: about 45
Method
Scan nasal, temporal, inferior,
superior bulbal conjunctiva
separately
You can see the inferior tarsal
conjunctiva and fornix but not
the superior counterparts
without lid eversion

Remember to ask your
patient to look right, left, up,
down, so that you can see the
full extent of the conjunctiva
Use your fingers to move the
eyelids when necessary
Look in the illuminated
(direct) and non-illuminated
(indirect) areas for
irregularities
Record
Normal and abnormal
findings
Draw unusual findings

Pinguecula

Concretion
Iris
Illumination
Parallelepiped (2-3mm)
Magnification
16x
Angle
Microscope: straight
Illumination: about 45
Remember to switch sides
Since the iris is a deeper
structure, push the slit lamp
forward to bring it into focus
The anterior chamber
should appear empty!

Method
Scan across the upper and
lower iris
Look for colour, texture,
elevation
Record
Normal and abnormal
findings
Draw unusual findings
Iris pigment in a sector of the iris
Pupil
This is actually an
examination of the
pupillary ruff, pupil
shape
Illumination
Parallelepiped (2-3mm)
Magnification
16x
Angle
Microscope: straight
Illumination: 20-30
Method
Inspect the pupillary
ruff and pupil shape
Record
Normal and abnormal
findings
Draw unusual findings
Persistent pupillary membrane (not easy to see in photographs)
The pupillary ruff is the brown ring at the edge of the iris
Lens surface
Ideally, the pupil should
be dilated prior to a
thorough lens examination
Illumination
Parallelepiped (2-3mm)
Magnification
16x
Angle
Microscope: straight
Illumination: about 30
Method
Remember that the
anterior lens is in the
same plan as the pupil
margin, so little
refocusing needed
Use direct illumination
and/or specular reflection
Look for the texture of
orange peel
Record
Normal and abnormal
findings
Draw unusual findings
Lens surface
Lens body
Illumination
Parallelepiped (2-3mm) to
examine overall lens
condition via retro-
illumination
Optical section to examine
lens structure
Magnification
16x
Angle
Microscope: straight
Illumination: for retro-
illumination 5-10, for optical
section, as large as pupil
size will allow
Method
Retro-illumination as
described in the last lecture
For optical section, scan
temporal then nasal lens,
switching sides
Look for irregularities in lens
Youll know youre doing it
right when you can see y-
sutures
Record
Normal and abnormal
findings
Draw unusual findings
A y-suture in a healthy
lens
Youll need to find this in
each other
Nuclear cataract
Posterior subcapsular cataract
Anterior vitreous
Illumination
Parallelepiped (2-3mm)
Magnification
16x
Angle
Microscope: straight
Illumination: about 30
Method
Push the microscope
forward to view the
anterior vitreous
Look for vitreous floaters,
pigment
A spider web appearance
is common
Record
Normal and abnormal
findings
Draw unusual findings
Recording results
What if I see something?
Where is it? (Location)
Exact location with regard to landmarks.
Distances in mm and directions according to a clock face.
How big and how many? (Extent)
Size of anomaly and/or the number of them
Colour and density
How deep is it?
Optical section
Parallax error (swing beam or microscope from side to side)
Focus
Useful tips
When beginning your exam, position (left/right,
up/down) and focus (back/forth) the slit by looking
around the microscope you can then fine tune
through the microscope
The tear film often has a globular structure and this
moves with each blink if you see this, the cornea is
almost in focus
If you get lost, reduce the magnification to increase
the field of view and try again
Do not lose sight of the forest for the trees!

Trees and forests
While you should soon be able to see details as small as one
cell, it is the overall picture that counts
Use the full spectrum of lighting techniques and magnifications to
put together a complete story for each and every patient
Though slit lamp seems extremely technical, dont get caught
up on small details (eg. Specific slit widths or angles)
General recommendations are typically provided for each
technique
In reality, the exact setting required will vary depending on the
practitioner, patient and the equipment
Stay within the recommended ranges while you are learning, but
youll soon realise that youll be guided by what you need to see,
and not by a set of numbers
Recommended reading
Same as the previous lecture