sl exam pt ii

April 11, 2023April 11, 2023 Slit Lamp Examination - ICSlit Lamp Examination - IC 11

INSTRUCTION COURSE ON SLIT

LAMP EXAMINATIONPart II

M.P. STATE OPHTHALMIC CONFERENCE

UJJAIN

Presented by Presented by

Dr. Sanjay ShrivastavaDr. Sanjay Shrivastava

Dr. Nikhilesh Trivedi Dr. Nikhilesh Trivedi

Dr. Kavita KumarDr. Kavita Kumar

The science of examination with a slit lamp is called Biomicroscopy as it allows in vivo study of living tissues at high magnification.

SET UPSET UP

Prerequisites – Preferably a dark room and slit lamp biomicroscope

Position – Patient is seated comfortably on an adjustable stool, with chin resting against chin rest and forehead against head rest bar.

Examination of Various Ocular Structures

1. LIDS

Diffuse Illumination Direct Focal Illumination

1. Hyperaemia – Capillary engorgement and suffusion of superficial vessels

Individual hair follicle

2. Diffuse inflammation (Edema) Meibomian gland orifice

3. Hordeolum externum Cilium

4. Tumours and Naevi Papillae on lid margin

5. Punctal Occlusion

6. Regurgitation on Pressure over sac

7. Mites and Parasites

2. CONJUNCTIVA

- As the conjunctiva is transparent it is

mainly studied by light reflected from

sclera.

- Eversion of lid – Examination of upper

tarsal conjunctiva

- Double eversion of lid – Upper fornix

examination.

(a) Diffuse Illumination

Following things are noted - General status of ocular surface.- Conjunctival congestion- Inflammation - Presence of foreign body- Tear Film assessment – Marginal tear meniscus

Diffuse Illumination

- Cysts- Concretions- Tumours- Nodules- Conjunctival pigmentation- Staining of tear film.- Staining of any conjunctival defect.

(b) Direct Focal Illumination :- Detailed examination of all lesions - Depth of any lesion.- Papillae- Follicles- Blood Vessels over a tumour - Neovascularization - Extent of subconjunctival haemorrhage

(c) Specular Reflection - Zones of intensely brilliant reflexes - Conjunctival elevated zones - Mucus and Waxy meibomian gland secretions- Elevated papillae

(d) Indirect Illumination :- Vessels- Conjunctival scars.

(e) Sclerotic Scatter Technique : - Pannus in Trachoma

3. CORNEA Diffuse Illumination

- Generalised view of surface of cornea

- Size

- Shape

- Transperancy

- Foreign Body

- Opacity

- Staining of Cornea

Direct Focal Illumination

Integrity of corneal epitheliumThickness of corneaDepth of lesionVascularisation-superficial/deepFolds in Descemet's membraneRupture in Descemet's mvmebrane

Hypopyon Ulcer seen in Direct Hypopyon Ulcer seen in Direct Focal IlluminationFocal Illumination

Keratic precipitates can be seen in high powerOpacity in anterior part of cornea.DegenerationsDystrophies

Pigmentation KF ring Argyrosis Precorneal tear film

Specular Reflection

- Endothelial cell count (average 2800 cells/ Sq.mm)- Morphology of endothelium- Endothelial dystrophics- Hassall Henle bodies which are warts in descemet's membrane.- Bullae- Blood staining of endothelium

Sclerotic Scatter - Central nebular corneal opacity- Dystrophies- Corneal oedema- Rupture in descemet's membrane

Retro Illumination - Dystrophies of Descemet's membrane- Vacuoles- Keratic Precipitates (Stellate)- Oedema of epithelium- Bullae- Ghost Vessels

Corneal Staining

Fluorescein 2% Rose Bengal 1% Alcian Blue

Seen with cobalt blue filter Seen in red free filter Mucus

Corneal abrasion Mucus

Corneal erosion Keratin

Epithelial defect Abnormal and Devitalised epithelium

Ulcers Double staining

Siedel's test

Applanation tonometry

Break up time

Fit of contact lens

4. SCLERA AND EPISCLERA On Diffuse Illumination :- Deep, red, dusky congestion of episcleral vessels

On Direct Focal Illumination - Episcleritis – Raised congested nodule- Deep Scleritis – Conjunctival congestion associated with episcleral vessel congestion with peripheral keratitis and uveitis.

5. AQUEOUS HUMOUR Diffuse Illumination :- Depth of Anterior Chamber- Contents of Anterior Chamber- Foreign Body- Hypopyon- Hyphaema- Vitreous prolapse in AC- Traumatic Catractous material in AC- Micro Filareae- Cyst and Tumours

- Attachment of pupillary membrane - Cells- Flare- Foreign bodies- Depth of Anterior Chamber

AQUEOS FLARE

Flare is the ability to see the path of light when slit beam is obliquely aimed across the AC. It is due to light scattering by suspended colloid particles causing TYNDALL effect.

AQUEOS FLARE

It is seen in 2 mm x 1 mm slit beam with maximum light intensity.

- It is seen against the iris plane.

- It can be seen in conical beam by direct focal illumination technique.

Grading of flareGrading of flare

0 Absent

1+ Faint Barely detectable

2+ Moderate Iris and lens details clear

3+ Marked, iris and lens details hazy

4+ Intense fibrinous aqueous

Cells :Indication of active inflammation of iris

and ciliary body.Slit beam is directed across the AC and

beam is focused posterior to cornea. 2 x 1 mm slit beam is focused with

maximum light intensity.0 - 01+ - 5 – 10 2+ - 10 – 20 3+ - 20 – 504+ - > 50

ANTERIOR CHAMBERVan Herrick Method :

For assessment of peripheral anterior chamber depth using a slit lamp.

A comparison of depth of peripheral anterior chamber to the peripheral corneal thickness is used to determined the degree of shallowness of the anterior chamber.

ANTERIOR CHAMBER

An optical section of peripheral cornea and anterior chamber is made on slit lamp with illumination and viewing arms at 60° to each other.

Viewing arm is perpendicular to cornea. Magnification is 15 X.

GONIOSCOPY It is done to see the structures in the

recess of angle of anterior chamber.It is important in - Glaucoma- Foreign bodies entangled in angle of AC- Tumours arising in angle of AC.- Narrowing of angle can be identified by

a steep configuration of iris and angulation of slit light reflex as it passes into the angle recess.

6. IRIS Diffuse Illumination:

Carried under low magnification :

- Colour of Iris :

- Heterochromia iridium

- Heterochromia iridis

- Gross structural abnormality

- Iris Motility

Direct Focal Illumination - High Illumination- Light beam focused from temporal side- First periphery is inspected then pupillary zone to avoid dazzling.Observation :- Exudates- Vascular changes- Atrophic Changes- Neoplastic ChangesOptical Section :- Narrow beam is made to see details of crypts and furrows.

Retro Illumination

- Visualization of iris is via light

reflected from the lens

- Atrophic patches in iris.

- Holes

- Tears and dehiscences.

- Patency of Peripheral iridectomy

Indirect Illumination - Outline of Crypts- Atrophic areas - Perforations - Cysts and Tumours- Haemorrhages

Iris Scatter

- Beam is focused on corneoscleral junction.

- Magnification is kept low or medium.- Used to see –- Iris contour, depression, discontinuities- Any tumour- Holes and other defects

7. LENS

Diffuse Illumination :

- To visualize anterior lens surface with

part of its anterior capsule.

- Surface and suture system of adult

nucleus in older patients.

- Embryonic Y suture.

- Posterior Capsule when altered

pathologically

Direct Focal Illumination :

- Enables to see zone of discontinuity

- Finer details of tissue stratification

- Exact localization of minute changes.

- Differentiate between congenital and

developmental opacities, senile changes,

traumatic opacities, complicated opacities.

Lens under direct focal illuminationLens under direct focal illumination

Retro Illumination :1. Used to observe whether the opacity is –

- Obstructive – Opaque to light- Respersive – Scatters light- Refractile – Refracts, minimizes or

distorts the views of background.2. Observe anterior capsular changes

- Deposits, Foreign bodies, Opacities Below Capsule.

Examination of LensExamination of Lens

3. Direct Retro Illumination – Obstructive Lesion Indirect Retro Illumination – Refractile

and Respersive

Posterior Sub Capsular Cataract Seen in Direct Focal Illumination and Retro Illumination

Specular Reflection :-

Mirror reflexes of anterior and posterior

capsule can be seen as bright reflex, when

the beam is moved from side to side across

the surface of lens. It is due to irregular

reflection caused by small irregularities of

capsular surface known as SHAGREEN

reflex. Any capsular opacity can be seen by

this method.

Post Operative Evaluation of IOL Surgery :

- IOL Centration and Stability.

- Position of IOL

- Pupillary Capture

- Dislocated IOL

- Early Uveitis

- PCO :

- Soemmerring Ring

- Elschnigs Pears.

8.PUPIL Diffuse Illumination

SizeShapeContourPupillary Membranes

Examination of PupilExamination of Pupil

Direct Focal Illumination - Direct Reflex - Consensual reflex- Accomodation reflex- Neovascularisation at pupillary margin - Exfoliative changes.

9. VITREOUS

- Examination of Anterior 1/3rd vitreous can be made using direct focal illumination.

- Illumination is kept maximum

- Slit very narrow.

- Illumination is brought from largest angle possible, without disturbing the slit.

- It is seen as optically clear space with delicate undulating fibrils and membrane like structures.

Direct Focal Illumination :- Shape- Rigidity- Vitreo retinal attachments- Vitreous opacities- Vitreous Bands and Membranes- Any pigmented Debris.- Foreign bodies in vitreous- Haemorrhages in vitreous

Slit lamp biomicroscopy can be used is combination with various lenses and mirrors for a magnified stereoscopic evaluation of retina and vitreous by vertical tilting of a slit 10° - 20°.

Goldmann Three Mirror Lens Examination :

- Central planoconcave lens – 64 D.

- It has 3 mirrors at 59°, 67° & 73°.

- Central lens allows a magnified stereoscopic examination of central 30° of retina giving an erect image.

- Oblong mirror gives a view of posterior retina.

- Rectangular and anterior retinal mirrors examine corresponding retinal areas respectively.

Indirect Slit Lamp Biomicroscopy :- Carried out by hand held high plus condensing lenses.- + 90 D, + 78 D.- An inverted, stereo magnified image is formed between lens and slit lamp.- Lens is held 5 – 10 mm from patient's cornea. - Magnification is 10 X or 16 X.- Coaxial illumination for fundus examination.- Slit beam is angled 10° – 20° from axis of observation for vitreous examination.

Hruby Lens Biomicroscopy :

- Planoconcave – high minus lens (–55D)

- Neutralises the optical power of the eye.

- Forms a virtual erect image of fundus.

Auxillary Devices :These can be used along with slit lamp.

1. Gonioscope for angle structure examination.2. Applanation tonometer for IOP.3. Endothelial cell counts using Eisner grid.4. BUT5. Staining Procedures.

Auxillary Devices

6. Corneal Thickness – Pachymetry7. AC Depth – Van Hericks Method.8. Ophthalmodynamometry – Pulsations of

blood vessels. 9. Slit Lamp Photography10. Delivery of Argon, Diode and Nd YAG laser 11. Laser Interferometry12. Potential Acuity Meter Test.

Thanks

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