Slit lamp Examination

DR.Prashant .P.Patel
Senior resident,
Aravind Eye Hospital,
Tirunelveli.

Slit lamp Biomicroscopy

It is a dynamic examination in which eye
and ocular adnexa are scanned
anteroposteriorly and horizontally.
Slit Lamp: It is a misnomer since slit is only
one of the various other diaphragmatic
opening present in the instrument.
Slit lamp biomicroscopy:
1) Term introduced by Mawas in 1925.
2) Examination of living eye by means of
microscope and slit lamp.

 The slit-lamp is one of the important examination tools of

ophthalmologists.
One of the most important advantages of slit-lamp examination is
that one can examine the eye structure in three dimensions (3D).
There are three basic requirements for appreciation of depth with
a slit-lamp.
The first depends upon the clinician possessing a third grade of
binocular vision called stereopsis.
The second involves the direction of the incoming light source,
and is dependent upon the fact that the light beam can be moved
so it comes in from one side or the other.
The third involves the shape of the slit.

History
Purkinje: One of the first individuals to apply
microscopy to the living eye , who studied
the iris with an adjustable microscope by
illuminating the field of view.
Louis de Wecker : He made the uniocular slitlamp combined an eyepiece, objective and
adjustable condensing lens within a tube.
It was improved by Siegfried Czapski who
added binocularity to the microscope.
However, none of the units had sufficient and
adjustable illumination.

 Allvar Gullstrand: An ophthalmologist

and 1911 Nobel laureate introduced the
illumination system which had for the first time
a slit diaphragm, therefore Gullstrand is

credited with the invention of the slit lamp.

 Henker and Vogt improved upon

Gullstrands device in 1911 by
creating an adjustable slit-lamp by
combining Czapskis microscope
with Gullstrands slit-lamp
illumination.

Basic design of slit lamp

The three main components of the
modern slit-lamp are:
1) Illumination system

2)Observation system
3) Mechanical system

Mechanical system

It is mainly concerned with:

Positioning of patient.
Adjustment for observer and patient.
Adjustment of illumination and
observations
system.
It generally contains following hard
ware.

Fixation light
Head rest
Canthal alignment
mark
Chin rest
lamp base

Lock for slit

Joy stick
Power unit

Chinrest adjust
-ment knob
Height adjustment
switch

 Mechanical coupling: Mechanical

system provides coupling of
microscope and illumination system
along a common axis of rotation
that coincides their focal planes.
This arrangement ensures that light

Illumination System
It is based on Kohler illumination

The light source L is imaged in the objective O by

the collector system K. The objective in turn
produces an image at S in the mechanical slit
located next to the collector system. The image of the
light source at O is the exit pupil of the system.
The filament is imaged on to the objective lens
but the mechanical slit is imaged on to the
patients eye.

 Khler illumination provides a very

homogeneous slit image.

Illumination System
The illumination system of most slit-lamps
consists of two different designs.
The first design: the Haag-Streit type
illumination, allows de-coupling in the vertical
meridian.
Such vertical de-coupling is particularly useful
when performing gonioscopy to minimize
reflections and for indirect fundus examination
to gain increased peripheral views.

In the Zeiss type the illumination comes from below.

The second design: the Zeiss type illumination system, does not
allow decoupling in the vertical meridian.

Illumination system control

Angle
Width
Type
1.Neutral density2.Red free
3.Cobalt blue

Height
Intensity

Observation system
Should have following
Characteristics :
Optimum stereoscopic observation.
Selectable magnification.
Large field of view.
Large depth of field.
Enough space in front of the
microscope for manipulations on the
eye.

Observation system is composed of

An objective lens: Two planoconvex
lenses with their convexities put together.
Magnifying lenses
Telescope
Pair of prisms: To reinvert the image.
Eyepiece
Converging tubes: They are converged
at an angle of 10-15 degree, to provide
good stereopsis.

 The object is located at the object

side focal point of the magnifying
lens that magnifies the object image
projecting it virtually to infinity.
The image is than viewed with
respective magnification through
telescope.

Change in magnification
Grenough type:
Galilean changer type:
Czapskiscope with rotating
objective:
Zoom system:

The Grenough type(Classical Haag

Streit)

Flip lever to change

magnification

 The Galilean
Magnification
changer

The Galilean Magnification

changer
It utilises the Galilean telescopes to
alter the magnification.
It has two optical components:
1)Positive lens 2)Negative lens
Lenses are arranged in turret
arrangement.
It provides large range of
magnifications, typically five.

The Galilean Magnification

changer

The Galilean Magnification

changer

Knob to change
magnification (3
or 5step)

Czapskiscope with rotating objectives

The different objectives are usually

placed on a turret type of
arrangement that allows them to be
fairly rapidly changed during
examination.

Zoom System
Zoom system allows continuously
various degree of magnification.
E.g, Nikon photo slit lamp &Zeiss-75
Sl

Magnification can also be changed

by changing the eyepiece power

Clinical Procedure
Before using the slit-lamp, it is important to
ensure that the instrument is correctly set up.
The eyepieces should be focused for the
observer for his/her own refractive error.
Often a little more minus correction is required
than the observers actual refractive error due to
accommodation and proximal convergence.
The Pupillary distance (pd) is adjusted for the
observer (perhaps the pd should be slightly less
than that usually measured to account for
proximal convergence).

 Check that the observation and

illumination systems are coupled,
and the slit-beam is of even
illumination and has sharply
demarcated edge (otherwise
irregularity of the beam may be
falsely interpreted as irregularity of
tissues).
The slit-lamp examination is
conducted in a semi dark room.

 Patient is seated in front of slit-lamp on an

adjustable stool and his/her head is steadied
by placing chin on chin-rest and his
forehead rests on the bar of head-rest.
Adjust the chin-rest so that the patients
eyes are approximately level with the
black marker on the side of the head rest.
Focus the slit-beam on the eye by moving
the joystick either towards or away from
the patient.

 The examination should be commenced using

the X10 eyepieces and the lower powered
objective to locate the pathology and higher
magnification should then be used to examine
it.
Use the lowest voltage setting on the
transformer.
Select the longest slit-length by means of the
appropriate lever.
The angulation between the observation arm
and the illumination arm is adjusted.

Examination methods
Types of Illumination.
Slit lamp Provides three basic types of
Illuminations.
1)Focal Illumination:
Achieved by narrowing the slit horizontally or
vertically, provides isolation of the specific areas of
eye /cornea for observation.
2) Oblique illumination: It is essential for detecting
and examining findings in different layers of the
cornea.
3)The Optical Section: The narrow slit beam slices
through the eye revealing the internal details of the
tissue at all layers.

Types of Illumination
Dffuse Illumination:
Terminology :It is the type encountered in everyday
life. For example light from sun or a light bulb that
diffusely illuminate ones surroundings.
Principle :It is a Initial survey examination of the
face, eyelids and ocular surface.
If one directly proceeds with the magnified
examination one is likely to miss skin disorders( such
as acne rosacea), eyelid lesions ( such as molluscum
contagiosum, small chalasion, mild ptosis).
Technique: It can be done with torch light ,

Diffuse illumination with slit

lamp
1)Swing the microscope aside or keep it at 3040 of angle.
2)Opening the slit beam to full height and
width.
3)Dialing in the neutral density filter.
Beam is only 8-14 mm diameter and
therefore must be moved over the eyelids
and ocular surface.
It can reveal location and general pattern of
eyelid, conjunctival, corneal lesions.

Sclerotic Scatter
Terminology :In this technique for illuminating cornea, the
slit beam is directed at the scleral limbus and illumination
is transmitted into cornea by total internal reflection.
Opacities within the cornea scatter the light back to the
observer.

Principle: Opaque sclera scatters the light at the point of

illumination, some of the light is directed in to corneal stroma,
where it travels through the entire cornea by repeatedly
reflecting from its anterior and posterior surfaces.
The light emerges around circumference of the cornea, where
it encounters the opaque sclera and create a glowing halo.

 Should be used early in the

examination because,
1) The patient acclimates to bright
light of the slit lamp before it is
directed in to the pupil.
2) It accurately reveals the presence
and pattern of corneal opacities.
3) It helps to identify faint opacities
that are difficult to see in direct
illumination.

 Technique:
SLIT BEAM : Moderate width,
Directed at the 3- or 9-oclock scleral
limbus
MICROSCOPE: Independently
focused onto the cornea.

Direct focal slit

illumination
Terminology : Projection , of a narrow slit beam at an
angle, to the corneal surface, producing an optical
section that slices through the cornea and eye.
Principle: A direct narrow slit beam optically cuts through
the cornea , providing a cross sectional view that
reveals its contour and its internal structure.
It forms two parallel curved surface, one that follows
anterior corneal surface and one that posterior corneal
surface.
Two surfaces are joined by a block of light scattered in
the stroma to create a geometric figure that resembles
an elongated ice cube.
This is known as parallelepiped/ optical block/optical
section.

 Technique:
Best used after the lesion is located
by sclerotic scatter, diffuse illumination.
Examiner than focuses narrow slit of
light over this lesion.
SLIT BEAM: Narrow
Approximately 30 angle between slit
beam and microscope, can be increased
up to 90.

Broad tangential
illumination
Terminology: A wide beam is oriented at an
extremely oblique illumination angle, causing it
to project tangentially across the corneal
surface.
Principle : Extreme angle of incidence of the
slit beam results in decrease of light reflected
and scattered by the cornea, this in turn
reduces background glare causes surface
abnormalities to stand out.
It is most useful for examining corneal
surface.

 Technique:
SLIT BEAM: wide
ANGLE between slit beam and
microscope: 70-80.
This highlights irregularities of
corneal surface such as
epithelial defect, PEES etc.

Proximal( indirect)
illumination
Terminology: It requires that the slit beam is directed
adjacent (proximal) to the area of interest to illuminate
it indirectly.
Principle: It combines the Principle of Sclerotic Scatter
and Retro illumination.
When directed adjacent to opaque area of the cornea,
the illumination of the slit beam is internally reflected
within the cornea causing light to spread throughout
the stroma, light striking the opacity is scattered and
some of the scattered light is reflected back to the
observer.
It is used to define the an opaque area of the cornea
and to identify details within the opacity.

Technique:
SLIT Beam:
Short: 2-3 mm
Slightly broad: 0.2 mm
Directed adjacent to area of interest.
Angle between microscope and slit
lamp is 15 degree.

Retroillumination from Iris

Terminology: It is a technique of
illuminating an area of cornea using
light reflected from structure
posterior to cornea such as iris.
Direct type: Cornea illuminated by
light is viewed directly.
Indirect type: Cornea viewed
adjacent to area of illuminated by
the reflected light.

Direct type of Retro

illumination

Indirect type of Retro illumination

from Iris

 Principle: When light of direct illumination

strikes a corneal opacity, it scatters and some of
the light is reflected back towards the examiner.
This form of illumination often washes out and
obscures details of the lesion and provide little
information about optical qualities and
internal structure of small lesion.
When retroillumination is used these details
stands out more prominently because the
lesion is less likely to scatter and more likely
to obstruct and refract the reflected light.

 Observer looks for three optical phenomena

in retroillumination.
1) Obstruction of light by densely opaque
abnormalities appear black against the light
beam. e.g, pigment deposit.
2)Substructure of the droplets or refractile
material in retroillumination.
3)Distortion of light especially near the edge
of the abnormality by refractile lesions that
have different refractive index than the media in
which they are contained.

Technique:
Slit beam: narrow to medium, slit
height is reduced, area of corneal
pathology is positioned directly
over the slit beam light reflected
from the iris, either by moving the
instrument or by altering the
patients gaze.

Direct retroillumination

Indirect retroillumination.

Retroillumination from the

fundus:
Terminology : Light entering the
pupil is reflected from RPE and
choroid and emerges from the pupil
with orange red glow, commonly
called as red reflex.
When examiner views the cornea
against this reflex he/she is able to
detect lesions that are to subtle
for visualization by other
techniques.

 Principle: Same that of the

Retroillumination from iris.
Dense scars : Obstructs the
reflected and they appear as dark
silhouettes.
Translucent/transparent objects:
Corneal guttae, DM Folds, Lattice
corneal dystrophy, epithelial oedema
stands out as brightly refractile
contours.

 Technique: Slit lamp is aligned

coaxial with microscope. Then
decentered to the edge of the pupil.
Slit width: Medium and curved at
one edge to fit in pupil.
Slit height: Reduced to 1/3 .

Specular reflection
Terminology: The smooth surfaces
of cornea reflect incident light like a
plain mirror following SNELLS LAW.
When angle of incidence is equal
to angle of reflection as measured
from line drawn perpendicular to the
surface. THIS IS KNOWN AS
SPECULAR REFLECTION.

 Principle: Surface light reflex from the tear air

interface is brightest specular reflection
emanating from the cornea, but this does not
permit examination of individual epithelial cells,
because the light is reflected from tear film.
Intensity of anterior reflection is great because
the difference in refractive index between air and
tears is large.
Intensity of posterior reflection from endothelial
surface is much less because the difference in
index of refraction between aqueous humor and
endothelium is much less.

 Light Reflected from the endothelium is 0.22%

of total incident light.
Because cornea is curved , only a small part
of the incident light beam is reflected in a
specular manner which forces the observer
to narrow the slit beam in to eliminate the
surrounding glare.
Mirror smooth posterior surface of endothelium
is broken by the intercellular spaces,
which do not reflect the light, thus appears
dark boundaries outlining a regular mosaic.

 The regular endothelial mosaic pattern can be

disrupted by various pathologic entities.
1) large and small cells may form a
heterogeneous population.
2)Irregularities in Descemets membrane e.g.,
cornea guttata , ridges, folds may displace the
endothelial cells from the plane of reflected light so
that they can not be clearly visualised and
localised black area is viewed.
3)Pigment deposits/ keratic precipitates on the
posterior surface of the endothelium may reflect
light and may be seen as focal bright spots.

 Technique: It requires a more systematic,

stepwise, careful approach.
Patient is asked to look straight ahead.
Slit beam is projected on the central cornea from
the temporal side.
The height of beam : 3 to 4 mm
Width of beam: Moderately wide (0.5mm)
Angle of slit beam and microscope should be
same from the perpendicular to the corneal
surface.
With this settings observer sees three lights:

 1. Slit beam parallelepiped in the

cornea.
2) Beam reflected from the iris
nasal to the parallelepiped.
3) The corneal light reflex( First
Catoptric image) temporal to
parallelepiped.
Examiner focuses the slit beam at
the level of the endothelium and
slowly moves it temporally

 As this being done entire corneal

parallelepiped changes in appearance from
grey black to lighter and brighter
structure.
When the corneal parallelepiped passes in
front of the catoptric reflection, the bright
surface reflex from the tear air interface
dazzles the examiner and faint mosaic
pattern of the endothelium becomes
apparent, at this point magnification is
changed to high power.

Aqueous flare and cells

Conical beam: is a small circular beam used
to examine the presence of cells and flare.
Beam: Small circular pattern.
Light Source:45-60 Temporally and directed
in to the pupil.
Biomicroscope: Directly in front of the eye.
Magnification: High
Focusing: Beam is focused between cornea
and anterior lens surface.

Filters
Sodium fluorescein is applied gently to the bulbar conjunctiva.
The patient should blink once or twice for the dye to be
dispersed over the eye.
If the epithelium of the conjunctiva or the cornea is damaged,
the fluorescein stains the underlying tissue.
The remaining dye fluoresces a yellow green colour when
excited by the blue light.
Healthy epithelium does not stain.
Uses:
Contact lens fitting,
Marginal tear film height measurement,
Tear film break up time,
Jones dye disappearance test

Red free filter

The Red-free (green) filter to
differentiate vascular from
pigmented lesions.
Blood vessels and small
haemorrhages will take on a dark
appearance with the use of the redfree filter, whereas pigmented
lesions will remain dark.
It makes the detail better by
improving contrast.

Clinical Slit Lamp Microscopy

Examiner must integrate various types of illuminations in to
flowing examination of cornea that permits rapid and accurate
observations of corneal disease.
An example for sequence of illuminations in which the corneal
lesion is to be seen:
1)Flash light/ diffuse illumination: To locate the pathology.
2)Sclerotic scatter: To see the pattern of abnormality.
3)Focal slit: To know the depth at which the lesion is located.
4)Proximal illumination : For internal details of the lesion.
5)Tangential illumination: For surface characteristics of the
lesion.
6)Retroillumination from iris & fundus: For optical qualities of
the lesion.

Clinical Drawings of Corneal

Pathology
Colour coding:
Black:
Corneal limbus,
Scars ,
Degenerations,
Foreign Bodies,
Suture,
Contact lens.

 Blue: Designates oedema

1)Shading: Diffuse stromal oedema.
2)Small circles: Epithelial Oedema.
3)Wavy Lines: DM Folds.

 Brown: Indicates Melanin or Iron

Pigmentations
1)Pupil
2)Iris
3)Deposits of Melanocytes on
Posterior
cornea.
4)Sundry Iron lines on the
epithelium.

 Red
1) Blood vessels:
i) Wavy lines: Begin outside the limbus
indicates subepithelial vessels.
ii) Straight lines : Begin inside the
limbus indicates stromal vessels.
2) Rose bengal stain: RED DOTS indicates
area stained by rose bengal.
3)Solid red shades: Indicates
haemorrhage.

 Yellow: indicates presence of

white blood cells.
Hypopyon
Stromal infiltrate
Keratic precipitates

 Green: fluorescein staining of

the cornea
Green coloured dots: PEES
Small Lines: Filaments
Shaded Outlines: Epithelial
Defect.

Accessory Devices:

Gonioscopy.
Pachymetry.
Applanation tonometry.
Slit lamp photography.
Slit lamp as a delivery system for
argon, diode,and YAG laser.

Thank you!!