SLIT-LAMP BIOMICROSCOPY

Module 1.4
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 Published in Australia by
The International Association of Contact Lens Educators
First Edition 1997
The International Association of Contact Lens Educators 1996
All rights reserved. No part of this publication may be reproduced, stored in a
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 CONTRIBUTORS

Slit-lamp Biomicroscopy
Procedures:
Sylvie Sulaiman, BOptom, Mcom

Deborah Sweeney, BOptom, PhD

 THE SLIT-LAMP
BIOMICROSCOPE
 PARTS OF A
SLIT-LAMP

1. Mechanical support

2. Observation system

3. Illumination system
EXAMINING A PATIENT USING A
SLIT-LAMP
 SLIT-LAMP
MICROSCOPE SYSTEM
FEATURES

• Variable magnification

• Binocular system
SLIT-LAMP MICROSCOPE
 SLIT-LAMP MICROSCOPE

Low 7X - 10X General eye

Medium 20X - 25X Structure layers

High 30X - 40X Detail

 SLIT-LAMP BIOMICROSCOPY
LOW MAGNIFICATION (7x - 10x)

General eye:
• Lids
• Bulbar conjunctiva/sclera
• Cornea/limbus
• Tears
• Anterior chamber/iris/crystalline lens
SLIT-LAMP BIOMICROSCOPY
 SLIT-LAMP BIOMICROSCOPY
MEDIUM MAGNIFICATION (20x - 25x)

Structures:
• Epithelium
• Stroma
• Endothelium
• Lens fit/surface
SLIT-LAMP BIOMICROSCOPY
 SLIT-LAMP BIOMICROSCOPY
HIGH MAGNIFICATION (30x - 40x)

Details:
• Epithelial changes

• Stromal striae, folds

• Endothelial folds, polymegethism

SLIT-LAMP BIOMICROSCOPY
 SLIT-LAMP BIOMICROSCOPY
HIGH MAGNIFICATION (30x - 40x)

Epithelium

• Vacuoles

• Microcysts

• Dystrophies
SLIT-LAMP BIOMICROSCOPY
 SLIT-LAMP BIOMICROSCOPY
HIGH MAGNIFICATION (30x - 40x)

Stroma

• Striae

• Folds
SLIT-LAMP BIOMICROSCOPY
 SLIT-LAMP BIOMICROSCOPY
HIGH MAGNIFICATION (30x - 40x)

Endothelium
• Polymegethism
• Guttata
• Blebs
• Dystrophies
• Cell Density
 SLIT-LAMP BIOMICROSCOPY
SPECULAR REFLECTION: ENDOTHELIUM
STRUCTURES OBSERVED
WITH
DIFFERENT ILLUMINATIONS
SLIT-LAMP BIOMICROSCOPY

Method of illumination is
IMPORTANT
 SLIT-LAMP
ILLUMINATION SYSTEM
FEATURES
• Variable light intensity
• Filters
• Width
• Height
• Angle
 SLIT-LAMP
ILLUMINATION SYSTEM
 ILLUMINATION
TECHNIQUES

• Diffuse

• Direct

• Indirect
 ILLUMINATION
TECHNIQUES

• Retro-illumination

• Specular reflection

• Sclerotic scatter

• Tangential
 DIFFUSE ILLUMINATION

• 45 degree angle between light &

microscope
• Slit open fully
• Diffusing filter
• Variable magnification (low to high)
 BROAD BEAM

Iris

Cornea

Beam of light
Microscope
DIFFUSE ILLUMINATION

Overall view of:

• Lids and lashes
• Conjunctiva
• Cornea
• Sclera
• Iris
• Pupil
 DIRECT ILLUMINATION

Observation and illumination systems

focused on the same point
 DIRECT ILLUMINATION

Iris

C ornea

B eam of light

M icroscope
 DIRECT ILLUMINATION

• Vary angle of illumination

• Low to high magnification

• Vary width and height of light source

 DIRECT ILLUMINATION

• Optic Section
– narrow, focused light
• Parallelepiped
– wider, focused light
• Conical Beam
– small, circular light
 DIRECT ILLUMINATION
OPTIC SECTION

• Indicates depth
– localize: - nerve fibres
- blood vessels
- infiltrates
- cataracts
• Anterior chamber angle
PRINCIPLE OF OPTIC SECTION

Iris

B
Cornea
A

Aerial View
OPTIC SECTION

A B
 DIRECT ILLUMINATION
PARALLELEPIPED

• Broader view

• Illuminated block of the cornea

• More extensive examination

PRINCIPLE OF THE PARALLELEPIPED

Iris

B B'

A A' Cornea

Aerial View
PARALLELEPIPED

B B'
A A'
 DIRECT ILLUMINATION
CONICAL BEAM

• Inflammatory cells/flare in the

anterior chamber

• Darkened room
 CONICAL BEAM

Beam cross-section

Iris

Cornea

Conical Beam

Conical beam Microscope

 INDIRECT ILLUMINATION

Observation and illumination systems are

not focused at the same point
INDIRECT ILLUMINATION

Iris

Cornea

Beam of light

Microscope
INDIRECT ILLUMINATION

• Vary angle of illumination

• Slit beam is offset

• Vary beam width

• Low to high magnification

INDIRECT ILLUMINATION

Valuable for observing:

• Epithelial vesicles
• Epithelial erosions
• Iris pathology
• Iris sphincter
 RETRO-ILLUMINATION

Object of regard is illuminated only

by reflected light
 RETRO-ILLUMINATION

Iris

Cornea

Beam
of light

Microscope
 RETRO-ILLUMINATION

• Vary angle of illumination

• Moderately wide beam
• Slit beam is offset
• Medium to high magnification
• Reflected light from iris or fundus
 DIVERGING CONVERGING
REFRACTOR REFRACTOR (AFTER Brown, 1971)

• Observer

• Transparent intra-corneal
object

• Background for marginal

retro-illumination

• Unreserved (U) and

reversed (R) appearance
U R
 RETRO-ILLUMINATION

Alignment of reflected beam with

area under observation

TYPE ALIGNMENT

Direct Direct and full view

Indirect Adjacent
Marginal Margin or edge
 RETRO-ILLUMINATION

Valuable for observing:

• Vascularization
• Epithelial oedema
• Microcysts
• Vacuoles
• Dystrophies
• Crystalline lens opacities
• Contact lens deposits
 SPECULAR REFLECTION

Angle of incidence equals

angle of reflection
 SPECULAR REFLECTION

Iris

Cornea

Beam Microscope
of light
SPECULAR REFLECTION

Valuable for observing:

• Endothelial cell layer

• Tear film debris

• Tear film lipid layer thickness

 SCLEROTIC SCATTER

Valuable for observing:

• localised epithelial oedema (CCC)

• corneal scars

• foreign bodies in the cornea

SCLEROTIC SCATTER

Corneal feature disclosed

SCLEROTIC SCATTER
 TANGENTIAL ILLUMINATION

Large angle of 70o - 80o between

illumination and observation system

 TANGENTIAL ILLUMINATION

Iris

Cornea
Beam of light

Microscope
 TANGENTIAL ILLUMINATION

Valuable for observing:

• Iris freckles

• Tumours

• General integrity of cornea and iris

FILTERED ILLUMINATION

• Cobalt blue

• Green (red-free)

• Neutral density
FILTERED ILLUMINATION

Most valuable:

Cobalt blue

+
Wratten # 12
 FILTERED ILLUMINATION

Valuable for observing:

• Tear layer

• Ocular staining

• RGP lens fitting patterns

 GRATICULE

Useful for lens fitting assessment

ROUTINE EXAMINATION OF
THE EYE USING THE
SLIT-LAMP
 BASELINE EXAM FLOWCHART

Lids
Bulbar
Conjunctiva
Limbus Palpebral
Cornea
Tears
Anterior Chamber
Iris
Lens
SLIT-LAMP OBSERVATIONS OF
CONTACT LENS
COMPLICATIONS
 LID EXAMINATION

• Lids
– redness, swelling, defects,
growths, discolouration
• Puncta
– clear, functioning
• Caruncle
– swollen, inflamed
 CONJUNCTIVA

• Redness
• Inflammation
 LIMBUS

• Redness

• Neovascularization

• Staining
 CORNEA

• Transparency

• Tissue damage/insult
 DETECTION OF OEDEMA

• Corneal clarity

• Striae/folds

• Corneal thickness measurement

 STRIAE

• Refractile effect

• Fluid separation of collagen fibrils

• Minimum 5% corneal swelling

• Refit with higher Dk/t lenses

 CORNEAL OEDEMA vs STRIAE

(La Hood & Grant, 1990)

Striae (number)
25
striae = 1.45 x oedema - 6.5
n = 192
20 r = 0.88
p < 0.001

15

10

0 5 10 15 20 25
Oedema (%)
 FOLDS

• Physical buckling of Descemet's

membrane and the endothelium
• Minimum 8% corneal swelling
• Severely compromised cornea
• Immediate refit with higher Dk/t
FOLDS
 CORNEAL OEDEMA vs STRIAE

1 Striae = 5.2%

Oedema

additional
striae
Each
= 1% Oedema
 CORNEAL OEDEMA vs STRAIE

1 Fold = 7.7% Oedema

Each
additional = 1% Oedema
striae
 CORNEAL OEDEMA vs FOLDS
(La Hood & Grant, 1990)
Folds (number)
25
folds = 1.33 x oedema - 9
n = 166
20 r = 0.87
p < 0.001

15

10

0 5 10 15 20 25
Oedema (%)
 DAYTIME STRIAE RESPONSE
HIGH WATER 74% vs LOW WATER 43%
(La Hood, 1991)
Striae (Grade 0-4)
1.5
+5.00 D n=11
High Water
Low Water
1.1
1.0
1

0.6

0.5
0.3

0.1
0 0 0
0
0 2 4 6
Time after lens insertion (hours)
 MICROCYSTS

• Small, irregular shape (15-50 m)

• Reversed illumination
• Slow onset
• Cyclic phenomenon
• Asymptomatic
 MICROCYSTS
DISPOSABLE HFDROGELS (Grant et al., 1990)
Microcysts (number)
50

40

30 6-13N

20

10 DW

0 4 8 12 16 20 24 28 32 36
Time (months)
 MICROCYSTS
PATHOLOGY

• Basal epithelial cells secrete intra-

epithelial sheets
• Disorganised cell growth
• Pockets of dead cells
• Slowly pushed to surface
 MICROCYSTS
ONSET AND RECOVERY
Microcysts (number)
35
HWC HWC
n=51 n=29
30
CCLRU GOTEBORG

20

10

0
0 2 4 6 8 10 12 0 2 4 6
Time (months)
 MICROCYSTS (Zantos, 1981)

. . . Break through the anterior

corneal surface and manifest as
corneal ‘dry spots’
 ENDOTHELIUM

Detection with slit-lamp:

• High magnification (30x - 40x)

• High illumination

• Specular reflection
 POLYMEGETHISM
SIGNS

• Increasing variation in endothelial cell size

• Increased ratio of large/small cells

 CCLRU POLYMEGETHISM SCALE
GRADE

1 2 3 4
CLINICAL SIGNIFICANCE
OF POLYMEGETHISM
 POLYMEGETHISM
CAUSES

• Age

• Diseases (diabetes, etc)

• Trauma

• Contact lenses
TEAR EXAMINATION

• Quality

• Lipid layer

• Debris
 TEAR EXAMINATION

Quality
– BUT (fluorescein)
– Tear prism height
– Movement of debris
– Rose Bengal staining
 ANTERIOR CHAMBER

Transparency

– Cells and flare

– Persistent pupillary membrane

IRIS EXAMINATION

Architecture
– Inflammation
– Pigmentation
– Naevi
– Iridectomy
– Colobomas
CRYSTALLINE LENS EXAMINATION

• ‘Orange Peel’
• Opacities
• Pigment on capsule
• Centration
• Iris attachments
 THANK YOU

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