Slit Lamp Training Tim Buckley Product Manager 1

Basics Definition and Applications Definition The purpose of a slit lamp is the biomicroscopy of the patient‘s eye under different lighting conditions. The slit lamp projects a bright and homogenously illuminated slit onto the eye which is variable in length, width, angle and light intensity. Fields of Application The primary field of application is the anterior eye segment (cornea, anterior chamber, lens, anterior vitreous). Using additional optics enables the user to also examine the posterior eye segment as well as the anterior chamber angle. 2

Basics Design Principles • • • components: microscope, slit projector, instrument base carrier arms for microscope and slit projector can be swiveled around a common axis swivelling axis is located in the focal plane of microscope and slit projector 3

Basics Design Principles - Biomicroscope • Zeiss slit lamps: Galilei type microscope – common front objective – parallel beam path – 3 or 5 magnification steps • other manufacturers also offer Greenough type microscopes – two separate, tilted beam paths – only 2 magnification steps – very few accessories 4

Basics Design Principles - Slit Projector • • purpose: to project a slit image focused on the patient‘s eye the slit image is variable in length, width and angle light source: usually halogen (high color temperature) filters: blue, green (redfree), diffusor, heat absorbing filter 5

Basics Design Principles - Instrument Base • functional coupling of carrier arms of microscope and slit projector • slit projector and stereo microscope can independantly be swiveled around a common axis • Axis is located below patient’s eye • both slit image and observation are in focus in the axial plane • three-dimensional positioning by joystick 6

Basic Functions of the Slit Lamp Slit Width narrow slit circle shaped, if fully opened slit width is adjusted continuously 7

Basic Functions of the Slit Lamp Slit Length short slit long slit length is adjusted in steps and continuously 8

Basic Functions of the Slit Lamp Slit Rotation vertical slit horizontal slit vertical slit rotation can be adjusted continuously by ± 90° 9

Basic Functions of the Slit Lamp Slit Decentration decentered slit can be decentered continuously by ± 4° 10

Basic Functions of the Slit Lamp Tilting Prism angle of incidence 0° angle of incidence 20° tilting prism can be tilted by 0° to 20° continuously positions 0°, 5°, 10°, 15°, 20° indexed 11

Types of Illumination Forms of direct Illumination 12

Types of Illumination Direct Diffuse Illumination Principle • illumination of the eye with a broad, unfocused light beam • usage of diffusor • microscope positioned at 0° • magnification 5 x. . . 12 x Applications • Overview • general assessment of anterior eye, eye lids • assessment of contact lenses 13

Types of Illumination Direct Diffuse Illumination IOL iris supported anterior chamber lens in diffuse illumination Bildquelle: Universitäts-Augenklinik Jena 14

Types of Illumination Direct Focal Illumination - Optic Section Principle • Illumination and observation are focused in the same plane • slit width ca. 0, 1 to 0, 3 mm Applications • mainly findings in the cornea and lens • opacities, scars, vessels • good perception of the depth of findings 15

Types of Illumination Direct Focal Illumination - Optic Section Cataract anterior cortical opacities, nucleosclerosis and posterior opacities Bildquelle: www. atlasophthalmology. com 16

Types of Illumination Direct Focal Illumination - Optic Disc Principle • Illumination and observation are focused in the same plane • slit width ca. 2 to 4 mm Applications • mainly findings in the cornea and lens • opacities, scars, vessels • good perception of shape and size of findings 17

Types of Illumination Direct Focal Illumination - Optic Disc Cyst on Pupillary Edge Cyst on pupillary edge stems from usage of too strong miotica Bildquelle: www. atlasophthalmology. com 18

Types of Illumination Direct Focal Illumination - Conical Beam Principle • assessment of particles floating in the anterior chamber by illuminating with a light beam • Tyndall‘s phenomenon • pinpoint illumination 0, 3 - 0, 5 mm Applications • assessment of particles in aqueaous humor • inflammation cells, pigmented cells, metabolic waste 19

Types of Illumination Direct Focal Illumination - Conical Beam cells in anterior chamber as a sign of uveitis Bildquelle: www. atlasophthalmology. com 20

Types of Illumination Tangential Illumination Principle • a narrow light beam is projected almost parallel along the structure to be observed • elevated structures are visible by shadowing Applications • elevated abnormities or changes in the iris • tumors, cysts 21

Types of Illumination Tangential Illumination Iris in tangential illumination 22

Types of Illumination Specular Illumination Principle • angle of incidence = angle of reflection • observation and illumination have same angle to perpendicular axis • slit width < 4 mm Applications • assessment of surfaces • assessment of tear film • endothelial cell layer α α 0° 24

Types of Illumination Specular Illumination α endothelial cells α 0° endothelial cell layer magnified ca. 192 x Bildquelle: Carl Zeiss Meditec 25

Types of Illumination Forms of indirect Illumination 26

Types of Illumination Indirect focal Illumination Principle • illumination by stray light • slit is slightly decentered so that stray light is created in direct neighbourhood of the finding • slit width ca. 2 to 4 mm Applications • mainly corneal lesions and scars 27

Types of Illumination Indirect focal Illumination no example 28

Types of Illumination Direct Retro-Illumination from the Iris Principle • Illumination of the finding with indirect light rflected from the iris • observation with light background • medium slit width, ca. 2 to 4 mm Applications • Infiltrations, small scars, corneal vessels, micro cysts, vacuoles • with this illumination findings are made visible with high contrast 29

Types of Illumination Direct Retro-Illumination from the Iris Keratitis Superficialis Punctata finding after moderate cauterization by acid, defects of epithelium and conjunctiva have been stained with bengal rose Bildquelle: www. atlasophthalmology. com 30

Types of Illumination Indirect Retro-Illumination from the Iris Principle • Illumination of the finding with indirect light reflected from the iris • observation with dark background • medium slit width, ca. 2 to 4 mm Applications • Infiltrations, small scars, corneal vessels, micro cysts, vacuoles 31

Types of Illumination Indirect Retro-Illumination from the Iris Keratitis Punctata, contact lens wearer multiple erosions of the central cornea due to inappropriate contact lens fitting Bildquelle: www. atlasophthalmology. com 32

Types of Illumination Retro-Illumination from the Lens Principle • Illumination of the finding with indirect light reflected from the lens • observation with light background • medium slit width, ca. 2 to 4 mm Applications • corneal defects, foreign bodies, scars • (type of illumination not frequently used) 33

Types of Illumination Retro-Illumination from the Lens no example 34

Types of Illumination Retro-Illumination from the Fundus Principle • Illumination of the finding with indirect light reflected from the fundus • observation with red/yellowish background • dilated pupil Applications • abnormities in the anterior vitreous, lens, anterior chamber, cornea • findings are visible like silhouettes 35

Types of Illumination Retro-Illumination from the Fundus Aniridia missing iris and zonular cataract made visible by retro-ilumination Bildquelle: www. atlasophthalmology. com 36

Types of Illumination Iris-Transillumination Principle • transillumination of the iris by indirect light reflected from the fundus • half dilated pupil (3 to 4 mm) • Illumination and observation at ca. 0° Applications • Visualization of defects of the pigment layer of the iris 37

Types of Illumination Iris-Transillumination Albinism Iris-Transillumination shows the light transmission of the iris Bildquelle: www. atlasophthalmology. com 38

Types of Illumination Sclerotic Scatters Principle • Illumination of the limbus region with a broad light beam at an angle of 45° - 60°, decentered slit • total reflection of the incoming light at inner corneal boundaries (endothelium and epithelium) Applications • scars, foreign bodies, corneal defects • irregularities in the cornea cause straylight 39

Types of Illumination Sclerotic Scatters corneal scarring after infection Bildquelle: www. atlasophthalmology. com 40

Fundus Observation and Gonioscopy 41

Fundus Observation and Gonioscopy Contact Glasses Fundus Image Contact Glasses • • • additional tool for fundus observation with the slit lamp mostly direct: erect and non mirrored image of the fundus required: dilated pupil, use of gliding liquid Microscope Bildquelle: www. ocular-instruments. com 42

Fundus Observation and Gonioscopy Lenses Inverted fundus image Lenses • • additional tool for fundus observation with the slit lamp mostly indirect: upside-down and mirrored image of the fundus (convex optics) non contact required: dilated pupil microscope Bildquelle: www. ocular-instruments. com 43

Fundus Observation and Gonioscopy central lens Three mirror contact glass • • • Goldmann contact glass central lens: posterior pole 73° mirror: equator 67° mirror: ora serrata 59° mirror: anterior chamber angle Bildquelle: www. ocular-instruments. com 44

Fundus Observation and Gonioscopy 73° mirror Three mirror contact glass • • • Goldmann contact glass central lens: posterior pole 73° mirror: equator 67° mirror: ora serrata 59° mirror: anterior chamber angle Bildquelle: www. ocular-instruments. com 45

Fundus Observation and Gonioscopy 67° mirror Three mirror contact glass • • • Goldmann contact glass central lens: posterior pole 73° mirror: equator 67° mirror: ora serrata 59° mirror: anterior chamber angle Bildquelle: www. ocular-instruments. com 46

Fundus Observation and Gonioscopy 59° mirror Three mirror contact glass • • • Goldmann contact glass central lens: posterior pole 73° mirror: equator 67° mirror: ora serrata 59° mirror: anterior chamber angle Bildquelle: www. ocular-instruments. com 47

Fundus Observation and Gonioscopy Example: Fundus microscope retinal scar Bildquelle: UAK Jena / Carl Zeiss 48

Fundus Observation and Gonioscopy Example: Anterior Chamber Angle blood in chamber angle vessels in chamber angle 49

Examination using Fluorescein 50

Examination using Fluorescein Principle • Fluorescein is inserted into the conjunctival sac and fills, for example, intracellular spaces • dye is excited with blue light (λ 450. . . 500 nm) • contrast reducing straylight is blocked with barrier filter (yellow filter λ > 530 nm) Applications • corneal lesions / defects • contact lens fitting 51

Applanation Tonometry 52

Applanation Tonometry Principle (according to Prof. Goldmann) • diameter of the applanated area: 3, 06 mm • counteracting forces of corneal rigidity and capillary attraction cancel each other out • applanated force (AF) equals the intraocular pressure (IOP) Applications • measurement of intraocular pressure IOP AF 53

Applanation Tonometry measuring figures a: applanation force too low b: correct setting c: applanation force too high 54

Length and Angle Measurement 55

Längen- und Winkelmessung Length and Angle Measurement • Diameter of cornea and pupil • height of conjunctival folds • anterior chamber depth • toric contact lenses 56

Redfree Examination 57

Redfree Examination • • Objects with high portion of red (e. g. fundus, vessels) contrast enhancement through green filter 58