INSTRUCTION COURSE ON SLIT LAMP EXAMINATION

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INSTRUCTION COURSE ON SLIT LAMP EXAMINATION Part
II
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M.P. STATE OPHTHALMIC CONFERENCEUJJAIN
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Presented by

• Dr. Sanjay Shrivastava
• Dr. Nikhilesh Trivedi
• Dr. Kavita Kumar

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

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Examination of Various Ocular Structures
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1. LIDS
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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.
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• Diffuse Illumination
• Following things are noted
• - General status of ocular surface.
• - Conjunctival congestion
• - Inflammation
• - Presence of foreign body
• - Tear Film assessment Marginal tear meniscus

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Diffuse Illumination

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

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(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
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(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
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3. CORNEA Diffuse Illumination - Generalised
view of surface of cornea - Size - Shape - Tran
sperancy - Foreign Body - Opacity - Staining
of Cornea
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Direct Focal Illumination Integrity of
corneal epithelium Thickness of cornea Depth
of lesion Vascularisation-superficial/deep Fol
ds in Descemet's membrane Rupture in Descemet's
mvmebrane
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Hypopyon Ulcer seen in Direct Focal Illumination
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Direct Focal Illumination

• Keratic precipitates can be seen in high power
• Opacity in anterior part of cornea.
• Degenerations
• Dystrophies
• Pigmentation
• KF ring
• Argyrosis
• Precorneal tear film

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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
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Sclerotic Scatter - Central nebular corneal
opacity - Dystrophies - Corneal
oedema - Rupture in descemet's membrane
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• Retro Illumination
• - Dystrophies of Descemet's membrane
• - Vacuoles
• - Keratic Precipitates (Stellate)
• - Oedema of epithelium
• - Bullae
• - Ghost Vessels

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Corneal Staining
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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.
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5. AQUEOUS HUMOUR Diffuse Illumination
- Depth of Anterior Chamber - Contents of
Anterior Chamber - Foreign Body - Hypopyon - Hy
phaema - Vitreous prolapse in AC - Traumatic
Catractous material in AC - Micro
Filareae - Cyst and Tumours
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Direct Focal Illumination - Attachment of
pupillary membrane - Cells - Flare - Foreign
bodies - Depth of Anterior Chamber
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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.
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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.

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Grading 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

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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 - 0 1 - 5 10
2 - 10 20 3 - 20 50 4 - gt 50
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ANTERIOR CHAMBER Van 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.
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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.

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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.
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6. IRIS Diffuse Illumination Carried under
low magnification - Colour of Iris
- Heterochromia iridium - Heterochromia
iridis - Gross structural abnormality - Iris
Motility
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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 Changes Optical Section
- Narrow beam is made to see details of crypts
and furrows.
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Retro Illumination - Visualization of iris is
via light reflected from the lens - Atrophic
patches in iris. - Holes - Tears and
dehiscences. - Patency of Peripheral iridectomy
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Indirect Illumination - Outline of
Crypts - Atrophic areas - Perforations
- Cysts and Tumours - Haemorrhages
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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

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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
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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.
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Lens under direct focal illumination
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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.
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Examination of Lens

• 3. Direct Retro Illumination Obstructive
  Lesion
• Indirect Retro Illumination Refractile and
  Respersive

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Posterior Sub Capsular Cataract Seen in Direct
Focal Illumination and Retro Illumination
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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.
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Post Operative Evaluation of IOL Surgery - IOL
Centration and Stability. - Position of
IOL - Pupillary Capture - Dislocated
IOL - Early Uveitis - PCO - Soemmerring
Ring - Elschnigs Pears.
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• PUPIL
• Diffuse Illumination
• Size
• Shape
• Contour
• Pupillary Membranes

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Examination of Pupil

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

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

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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.
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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.
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Hruby Lens Biomicroscopy - Planoconcave high
minus lens (55D) - Neutralises the optical
power of the eye. - Forms a virtual erect image
of fundus.
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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. BUT 5. Staining Procedures.
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Auxillary Devices

• 6. Corneal Thickness Pachymetry
• 7. AC Depth Van Hericks Method.
• 8. Ophthalmodynamometry Pulsations of blood
  vessels.
• Slit Lamp Photography
• Delivery of Argon, Diode and Nd YAG laser
• 11. Laser Interferometry
• 12. Potential Acuity Meter Test.

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Thanks