Slit Lamp Bio Microscopy

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INTRODUCTION INTRODUCTION INTRODUCTION INTRODUCTION The slit lamp biomicroscope is a fundamental piece of optometric instrumentation, he slit lamp biomicroscope is a fundamental piece of optometric instrumentation, he slit lamp biomicroscope is a fundamental piece of optometric instrumentation, he slit lamp biomicroscope is a fundamental piece of optometric instrumentation, especially for fitting of contact lenses. especially for fitting of contact lenses. especially for fitting of contact lenses. especially for fitting of contact lenses. However, it is also vital for observing the health of the anterior eye, estimating the However, it is also vital for observing the health of the anterior eye, estimating the However, it is also vital for observing the health of the anterior eye, estimating the However, it is also vital for observing the health of the anterior eye, estimating the anterior chamber depth and performing Goldmann contact tonometry and Volk lens anterior chamber depth and performing Goldmann contact tonometry and Volk lens anterior chamber depth and performing Goldmann contact tonometry and Volk lens anterior chamber depth and performing Goldmann contact tonometry and Volk lens fundus examination. fundus examination. fundus examination. fundus examination. The slit lamp slit lamp slit lamp slit lamp is an instrument consisting of a high-intensity light source that can be focused to shine a thin sheet of light into the eye. It is used in conjunction with a biomicroscope. The lamp facilitates an examination of the anterior segment, or frontal structures and posterior segment, of the human eye, which includes the eyelid, sclera, conjunctiva, iris, natural crystalline lens, and cornea. The binocular slit-lamp examination provides stereoscopic magnified view of the eye structures in detail, enabling anatomical diagnoses to be made for a variety of eye conditions. BRIEF HISTORY BRIEF HISTORY BRIEF HISTORY BRIEF HISTORY Low Low Low Low–power clinical biomicroscopy power clinical biomicroscopy power clinical biomicroscopy power clinical biomicroscopy of the eye is an essential tool to diagnose ocular disease, and Optometrist routinely uses a slit lamp to examine almost all of their patients. At its root, the adjustable slit is simply a way to allow variable angles of illumination. However, this surprisingly simple concept has enabled the slit lamp microscope to become an indispensable instrument for every Optometrist. Slit lamps have evolved significantly since their advent in the early 1900s, and many of today’s slit lamp biomicroscopes are sophisticated instruments building on the discoveries of the past century. One of the first individuals to apply microscopy to the living eye was Purkinje, Purkinje, Purkinje, Purkinje, who in the 1820s in the 1820s in the 1820s in the 1820s studied the iris with an adjustable microscope by illuminating the field of view. The uniocular slit lamp was born years later when Louis de Wecker Louis de Wecker Louis de Wecker Louis de Wecker would combine an eyepiece, objective and adjustable condensing lens within a tube. Wecker’s Wecker’s Wecker’s Wecker’s invention was improved upon by Siegfried Czapski, Siegfried Czapski, Siegfried Czapski, Siegfried Czapski, who added binocularity to the microscope. However, none of the units constructed by these

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A Review Of Slit lamp biomicroscopy

Transcript of Slit Lamp Bio Microscopy

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INTRODUCTIONINTRODUCTIONINTRODUCTIONINTRODUCTION

TTTThe slit lamp biomicroscope is a fundamental piece of optometric instrumentation, he slit lamp biomicroscope is a fundamental piece of optometric instrumentation, he slit lamp biomicroscope is a fundamental piece of optometric instrumentation, he slit lamp biomicroscope is a fundamental piece of optometric instrumentation,

especially for fitting of contact lenses.especially for fitting of contact lenses.especially for fitting of contact lenses.especially for fitting of contact lenses.

However, it is also vital for observing the health of the anterior eye, estimating the However, it is also vital for observing the health of the anterior eye, estimating the However, it is also vital for observing the health of the anterior eye, estimating the However, it is also vital for observing the health of the anterior eye, estimating the

anterior chamber depth and performing Goldmann contact tonometry and Volk lens anterior chamber depth and performing Goldmann contact tonometry and Volk lens anterior chamber depth and performing Goldmann contact tonometry and Volk lens anterior chamber depth and performing Goldmann contact tonometry and Volk lens

fundus examination.fundus examination.fundus examination.fundus examination.

The slit lampslit lampslit lampslit lamp is an instrument consisting of a high-intensity light source that can be

focused to shine a thin sheet of light into the eye. It is used in conjunction with a

biomicroscope. The lamp facilitates an examination of the anterior segment, or

frontal structures and posterior segment, of the human eye, which includes the

eyelid, sclera, conjunctiva, iris, natural crystalline lens, and cornea. The binocular

slit-lamp examination provides stereoscopic magnified view of the eye structures in

detail, enabling anatomical diagnoses to be made for a variety of eye conditions.

BRIEF HISTORYBRIEF HISTORYBRIEF HISTORYBRIEF HISTORY

LowLowLowLow––––power clinical biomicroscopypower clinical biomicroscopypower clinical biomicroscopypower clinical biomicroscopy of the eye is an essential tool to diagnose ocular

disease, and Optometrist routinely uses a slit lamp to examine almost all of their

patients. At its root, the adjustable slit is simply a way to allow variable angles of

illumination. However, this surprisingly simple concept has enabled the slit lamp

microscope to become an indispensable instrument for every Optometrist. Slit lamps

have evolved significantly since their advent in the early 1900s, and many of today’s

slit lamp biomicroscopes are sophisticated instruments building on the discoveries of

the past century.

One of the first individuals to apply microscopy to the living eye was Purkinje,Purkinje,Purkinje,Purkinje, who

in the 1820sin the 1820sin the 1820sin the 1820s studied the iris with an adjustable microscope by illuminating the field

of view. The uniocular slit lamp was born years later when Louis de WeckerLouis de WeckerLouis de WeckerLouis de Wecker would

combine an eyepiece, objective and adjustable condensing lens within a tube.

Wecker’sWecker’sWecker’sWecker’s invention was improved upon by Siegfried Czapski,Siegfried Czapski,Siegfried Czapski,Siegfried Czapski, who added

binocularity to the microscope. However, none of the units constructed by these

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individuals had sufficient and adjustable illumination to be of much clinical benefit.

Allvar Gullstrand, Allvar Gullstrand, Allvar Gullstrand, Allvar Gullstrand, an Ophthalmologist and 1911 Nobel laureate1911 Nobel laureate1911 Nobel laureate1911 Nobel laureate, developed a first

true slit lamp to illuminate the eye. Then, Henker and VogtHenker and VogtHenker and VogtHenker and Vogt improved upon

Gullstrand’s device in the 1910s1910s1910s1910s by creating an adjustable slit lamp and combining

Czapski’sCzapski’sCzapski’sCzapski’s microscope with Gullstrand’sGullstrand’sGullstrand’sGullstrand’s slit lamp illumination. The modern slit lamp

biomicroscope was born, a powerful diagnostic tool capable of stereoscopically

examining optical sections of the anterior segment in great detail. The instrument

was not only important as an essential diagnostic tool in the clinic, but also served to

greatly advance the scientific knowledge fueling Optometry. Alfred Vogt Alfred Vogt Alfred Vogt Alfred Vogt was

instrumental in driving this knowledge base through innovative and meticulous use

of the slit lamp. Vogt would use the slit lamp biomicroscope to study a vast array of

diseases and document his findings in the highly influential publication “Lehrbuch “Lehrbuch “Lehrbuch “Lehrbuch

und Atlas der Spaltlampenmikroskopie des Leibenden Auges”und Atlas der Spaltlampenmikroskopie des Leibenden Auges”und Atlas der Spaltlampenmikroskopie des Leibenden Auges”und Atlas der Spaltlampenmikroskopie des Leibenden Auges” inininin the 1930sthe 1930sthe 1930sthe 1930s. The slit

lamp microscope was thus accepted as an essential diagnostic tool by the accepted as an essential diagnostic tool by the accepted as an essential diagnostic tool by the accepted as an essential diagnostic tool by the

Ophthalmology community, and over time Eye MDsOphthalmology community, and over time Eye MDsOphthalmology community, and over time Eye MDsOphthalmology community, and over time Eye MDs invented new ways to reach

beyond the cornea and anterior segment. For example, the slit lamp, in conjunction

with certain contact lenses, could be used together to examine the anterior chamber

angle in great detail.

Today, the two main components of the modern slit lamp microscope are the

illumination system and observation system. The illumination system on most slit

lamps consists of two different designs. The first designfirst designfirst designfirst design, the HaagHaagHaagHaag----Streit type Streit type Streit type Streit type

illuminationilluminationilluminationillumination, allows de-coupling in the vertical meridian. Such vertical de-coupling

is particularly useful when performing gonioscopy to minimize reflections and for

indirect funduscopy to gain increased peripheral views. The second designsecond designsecond designsecond design, the Zeiss Zeiss Zeiss Zeiss

type illumination systemtype illumination systemtype illumination systemtype illumination system, does not allow de-coupling in the vertical meridian. Many

optometrist argue that the Zeiss illumination’sZeiss illumination’sZeiss illumination’sZeiss illumination’s advantage is that it confers lightness

and compactness onto the slit lamp to make it somewhat easier to use. In either case,

the illumination systems of today are both capable of producing a homogenous,

aberration-free beam of white light. Most slit lamps use halogen bulbshalogen bulbshalogen bulbshalogen bulbs to yield

shorter wavelengths of light, which allow better visualization of smaller structures

compared with longer wavelengths of light (i.e. tungsten bulbs).(i.e. tungsten bulbs).(i.e. tungsten bulbs).(i.e. tungsten bulbs).

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PROCEDURES FOR CARRYING OUT SLIT LAMP BIOMICROSCOPYPROCEDURES FOR CARRYING OUT SLIT LAMP BIOMICROSCOPYPROCEDURES FOR CARRYING OUT SLIT LAMP BIOMICROSCOPYPROCEDURES FOR CARRYING OUT SLIT LAMP BIOMICROSCOPY

While a patient is seated in the examination chair, he rests his chin and forehead on

a support to steady the head. Using the biomicroscope, the ophthalmologist or

optometrist then proceeds to examine the patient's eye. A fine strip of paper, stained

with fluorescein, a fluorescent dye, may be touched to the side of the eye; this stains

the tear film on the surface of the eye to aid examination. The dye is naturally rinsed

out of the eye by tears.

A subsequent test may involve placing drops in the eye in order to dilate the pupils.

The drops take about 15 to 20 minutes to work, after which the examination is

repeated, allowing the back of the eye to be examined. Patients will experience some

light sensitivity for a few hours after this exam, and the dilating drops may also

cause increased pressure in the eye, leading to nausea and pain. Patients who

experience serious symptoms are advised to seek medical attention immediately.

Adults need no special preparation for the test; however children may need some

preparation, depending on age, previous experiences, and level of trust.

The slit lamp exam may detect many diseases of the eye, includingThe slit lamp exam may detect many diseases of the eye, includingThe slit lamp exam may detect many diseases of the eye, includingThe slit lamp exam may detect many diseases of the eye, including:

• Cataract

• Conjunctivitis

• Corneal injury such as corneal ulcer or corneal swelling

• Diabetic retinopathy

• Fuchs' dystrophy

• Keratoconus (Fleischer ring)

• Macular degeneration

• Presbyopia

• Retinal detachment

• Retinal vessel occlusion

• Retinitis pigmentosa

• Sjögren's syndrome

• Uveitis

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• Wilson's disease (Kayser-Fleischer ring)

Slit Lamp lighting Types Slit Lamp lighting Types Slit Lamp lighting Types Slit Lamp lighting Types

1.1.1.1.Diffuse:Diffuse:Diffuse:Diffuse:

Spread illumination or wide beam illumination deserves a short part discussion from

the other types of illuminations. The term diffuse has been carried over from earlier

writings when slit lamps had either diffusing filters or free racking microscopes.

This permitted each to be independently focus on different structures. Most of todays

slit lamp microscopes have their light sources and microscope coincident to one an

additional and are focused on the same structure at the same time. Diffusing filters

are still found in some slit lamps and are used in photographing the frontal segment

of the eye. Wide beam illumination is the only type that has the light source set wide

open. Its main function is to illuminate as much of the eye and its adnexa at once for

general observation.

2.Direct 2.Direct 2.Direct 2.Direct FocalFocalFocalFocal

a. Optic Section:a. Optic Section:a. Optic Section:a. Optic Section: Optic section is used primarily to shaping the depth or elevation of

a defect of the cornea, conjunctiva or locating the depth of a cloudiness within the

lens of the eye. The optic section as mentioned above, it is likely to detect changes in

corneal and conjunctival thicknesses, to assess depths of foreign bodies, scars and

cloudiness, to approximation the frontal chamber depth and to identify the

anatomical location of cataracts within the crystalline lenation source at about 45

degrees and S.

The slit lamp microscope should be straight in front of the patients eye, the

illuminthe illumination mirror in click position. The slit width is almost closed, about

0.25 mm wide and 7 to 9 mm high. First place the enlargement on low to medium 7

- 10 X and focused on the patients closed lid. The thickness of the eyelid is about 1

mm thick, which means focusing on the cornea is accomplished by only to some

extent moving the joystick ahead.

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b. Conical Beam:b. Conical Beam:b. Conical Beam:b. Conical Beam: Examination of the frontal chamber for cells or flare must be

performed earlier than dilation . Magnification 16 - 20x and illumination high or

what the patient will tolerate. Dilation frequently results in add to in the number of

cells causes an enlarge in flare . This type of illumination is used to notice floating

aqueous cells and flare by the, Tyndall effect, much like seeing dust floating in the

air of a sun filled window.

C. Parallelepiped:C. Parallelepiped:C. Parallelepiped:C. Parallelepiped: A parallelepiped is one of the majority common types of

illumination used. It is used in blend with a number of different types of

illuminations. The slit lamp microscope should be directly in front of the patients

eye, the illumination starting place at about 45 degrees and the illumination mirror

in click, position. A parallelepiped is basically an optic section, except the slit width

is greater 2.0 - 4.0 mm and the height may vary, providing a more three

dimensional view of the cornea or crystalline lens.

The three-dimensional view permits observation of obvious details within the

crystalline lenses zones of discontinuity. As with the optic section, the angle between

the illumination source and slit lamp microscope may be varied to expose more

corneal epithelium, and endothelium.

3. Retro3. Retro3. Retro3. Retro----Illumination:Illumination:Illumination:Illumination:

typically uses a parallelepiped that bounces unfocused light off one structure while

observing the back lighting of another. The arrangement and angular separation of

the slit lamp microscope to the illumination source will vary. The light source beam

is reflected off another structure like the iris, crystalline lens or retina while the slit

lamp microscope is focused on a more anterior structure.

4. Sclerotic Scatter:4. Sclerotic Scatter:4. Sclerotic Scatter:4. Sclerotic Scatter:

for this illumination uses a parallelepiped at the limbus to spread out light internally

throughout the cornea. Use low 6 - 10x magnification. In the case of innermost

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corneal clouding CCC the slit lamp microscope is not used. The pupil is observed

with the naked eye from an angle directly opposite from the light starting place.

5. Indirect5. Indirect5. Indirect5. Indirect----LateralLateralLateralLateral----Proximal:Proximal:Proximal:Proximal:

Place the slit lamp microscope directly in front of the patients eye and the

illumination light source at about 45 degrees. Make certain the illumination mirror

is in click position. Use a parallelepiped beam sharply focused on a given structure

like the cornea. The light passes through the cornea and falls out of focus on the iris.

The dark area just sideways or proximal to the parallelepiped is the indirect or

proximal zone of illumination. This is the area of the cornea which one surveys

through the slit lamp microscope.

6. Specular Refection:6. Specular Refection:6. Specular Refection:6. Specular Refection:

Once more a parallelepiped is used. This is the only means by which one is capable

to view the endothelial cells of the cornea or the epithelial cells on the backside of

lens. The cells are seen only by one eye and they come out in the ocular opposite

from the direction of the illumination light source.

CONSTRUCTION OF SLIT LAMP BIOMICROSCOPECONSTRUCTION OF SLIT LAMP BIOMICROSCOPECONSTRUCTION OF SLIT LAMP BIOMICROSCOPECONSTRUCTION OF SLIT LAMP BIOMICROSCOPE

The 2 basic parts of the slit lamp biomicroscope are:

• The slit lamp (illumination system)

• The biomicroscope

The illumination system can be

1. Of the Zeiss type

2. Of the Haag Streit type

The slitlamp biomicroscope in its most basic form consists of an illumination source

with a range of light intensity setting (i.e. the illumination system) and a microscope

with a series of magnification setting (i.e. the observation system). Other important

considerations are the mechanical and support and controls.

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Illumination systemIllumination systemIllumination systemIllumination system;

The illumination systems of most slitlamp biomicroscope consist of a Tungsten-

halogen lamp with a condenser system to gather all light emitted into the projection

system in turn consists of a focusing lens and an objective lens at its output point.

Because of the shape of the illumination tube, reflection surfaces are provided to

direct the light path in the desired direction.

Along the path of light are various filters. Some are used for safety reasons, while the

others are used to change the colour of the working light. Notably is the infrared

absorption filter for heat absorption together with cobalt blue and red-green filters

for redfree and green lights respectively. Also, variable slit apertures are used to vary

the shape of light output.

Observation systemObservation systemObservation systemObservation system;

The second main component of slit lamps is the observation system. Modern slit

lamp microscopes can magnify images between 5X and 25X, with some microscopes

allowing magnification to 40X and even 100X. Magnification is generally achieved

by three methods, namely a flip-type, a Galilean rotating barrel, and a continuous

zoom system. However, magnification of the slit lamp is less important than its

resolution. A slit lamp’s resolution is dependent on the wavelength of light used, the

refractive index between the eye and objective, the working distance, and the

diameter of the objective lens. In practicality, the first three of these factors are not

easily modifiable, but the objective lens diameter can be modified to increase

resolution. However, a very large diameter lens will also introduce optical

aberrations. The observation system is also influenced by the proximity of the

patient’s eye to the examiner’s eyes. This necessitates a convergence system for

binocular viewing, and most modern slit lamp biomicroscopes are designed with 10

to 15 degrees of convergence to minimize eye strain for the examiner. These features

in the illumination and observation systems must be considered when deciding on

the best slit lamp to match a particular clinic.

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In the Zeiss type the illumination comes from below;

In the Haag Streit type the illumination comes from above as shown below;

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In both types of illumination system the Kohler Kohler Kohler Kohler illumination principleillumination principleillumination principleillumination principle is

used:

The filament is imaged on to the objective lens but theThe filament is imaged on to the objective lens but theThe filament is imaged on to the objective lens but theThe filament is imaged on to the objective lens but the mechanical slit is imaged on mechanical slit is imaged on mechanical slit is imaged on mechanical slit is imaged on

to the patient’s eyeto the patient’s eyeto the patient’s eyeto the patient’s eye....

The biomicroscope: based on the optics of a compound microscope

Two basic types:Two basic types:Two basic types:Two basic types:

– The Grenough typeThe Grenough typeThe Grenough typeThe Grenough type

– The The The The Galilean changer typeGalilean changer typeGalilean changer typeGalilean changer type

The Grenough type(Classical Haag Streit)The Grenough type(Classical Haag Streit)The Grenough type(Classical Haag Streit)The Grenough type(Classical Haag Streit)

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The Galilean Magnification changerThe Galilean Magnification changerThe Galilean Magnification changerThe Galilean Magnification changer

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Magnification can also be changedMagnification can also be changedMagnification can also be changedMagnification can also be changed by changing the eyepiece powerby changing the eyepiece powerby changing the eyepiece powerby changing the eyepiece power

The slit lamp and the biomicroscope

are maneouvred together on a cross

slide by means of a joysticka joysticka joysticka joystick

The coupling between the slit lamp and the biomicroscope

• This is such as to make the system “parfocal”

• i.e the focus of the slit and the focus of the microscope are at the same point.

• This parfocality may occasionally need to be dissociated as for example in the

technique of sclerotic scatter

The coupling between the slit lamp and the biomicroscope

This allows both the slit and the microscope to rotate about the point of

focus(i.e the eye) as shown below;

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Dissociation of parfocality can be done in

“Haag Streit” type slit lamps by loosening

the sclerotic scatter knobscatter knobscatter knobscatter knob

This dissociation of parfocality is useful for indirect illumination, sclerotic scatter

and retroillumination as shown below.

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The key to successful examination of the anterior segment is

knowledge of the various methods of lighting which can be achieved by the slit lamp

Diffuse illuminationDiffuse illuminationDiffuse illuminationDiffuse illumination

• Not all slit lamps have this option

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Diffuse illumination for surfaceDiffuse illumination for surfaceDiffuse illumination for surfaceDiffuse illumination for surface DetailsDetailsDetailsDetails

FOCAL BROAD BEAM ILLUMINATION

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BROAD BEAM BROAD BEAM BROAD BEAM BROAD BEAM NARROW BEAMNARROW BEAMNARROW BEAMNARROW BEAM

FOCAL BROAD BEAM

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FOCAL SLIT ILLUMINATION

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RETRILLUMINATION AGAINST RED GLOW

Indirect Indirect Indirect Indirect illumination(similar to sclerotic scatter)illumination(similar to sclerotic scatter)illumination(similar to sclerotic scatter)illumination(similar to sclerotic scatter) Sclerotic scatterSclerotic scatterSclerotic scatterSclerotic scatter

Knob for sclerotic scatterKnob for sclerotic scatterKnob for sclerotic scatterKnob for sclerotic scatter

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Sclerotic scatterSclerotic scatterSclerotic scatterSclerotic scatter

Specular illuminationSpecular illuminationSpecular illuminationSpecular illumination

FILTER TURRET

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COLLAGE

LENS PRECIPITATE

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SPKS,a Collage

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