ANTERIOR SEGMENT ASSESSMENT

Overview:
This course provides an overview of assessment of the anterior segment. Section I covers
the anatomy of anterior segment, introduction to slit lamp biomicroscopy. Common
disorders of the anterior segment are discussed in the second section (Section II). The use
of various imaging techniques to quantify the anterior segment disorders will be covered
in Section III.

Disclaimer: This course is not intended to market any instruments.

SECTION I
Anatomy of the anterior segment:
The external demarcation of the anterior segment lies at the limbus and extends till the
anterior hyaloid. Functionally, the anterior segment begins at the tear film and ends at the
posterior capsule of the lens. As can be seen from the figure 1.1 the anterior segment
comprises of the lids, conjunctiva, sclera, cornea, the anterior chamber, iris, posterior
chamber and the crystalline lens.

Figure 1.1: Anatomy of the anterior segment

Slit lamp biomicroscopy:

Slit lamp biomicroscope is a binocular optical microscope that typically has a
illumination system and a viewing system (Figure 1.2). A beam of light is projected on to
the structure that is to be examined and the structure is viewed through a series of
magnifying lenses. The anatomic structures are accentuated when the slit of light is
directed at a particular angle.

Figure 1.2: Slit lamp Biomicroscope

Using various accessories (Figure 1.3) and filters along with the slit lamp enables better
assessment of the anterior segment.

Figure 1.3: Slit lamp accessories

Slit lamp biomicroscopy is a scientific way of assessing the health of the ocular structures
using the slit lamp, both quantitatively and qualitatively.
Pictorial representation of various illumination types are given in figure 1.4 (a-d)

Figure 1.4a: Diffuse: Full slit height and width, direct illumination

Figure 1.4b: Focal illumination: Optic section-Slit height: Full; Width: <1 mm, direct
illumination, Parallelepiped-Slit height: Full; Width: 2-4 mm, direct illumination, Conical
section-Slit height: 2-3mm; Width: 1 mm, direct illumination

Figure 1.4c: Specular reflection: Parallelepiped beam, retro illumination, high

magnification

Figure 1.4d: Sclerotic scatter: Parallelepiped focused at the temporal limbus

The normal anterior segment:

The following section briefly explains the normal appearance of the structures in the
anterior segment and the technique of assessing these structures with slit lamp.

Lids: The lids are best assessed under diffuse illumination. The lids are further divided
into three parts: The lashes, lid margin and the puncta.
The lashes are more numerous in the upper lid than the lower lid. Normally, the lashes
are pigmented and are distributed with uniform density throughout the lids. Lid margin is
the junction between the skin of the lids and the palpebral conjunctiva. The lid margin is
a lubricated structure and contains various glands in addition to the lashes. A normal lid
margin is regularly thick and follows the structure of the globe. The puncta are small
openings present in the nasal aspect of both the upper and lower lids. The puncta are
small openings and the normal size of the punctum is 0.2mm. The punctum is well
apposed to the ocular surface.

Tear Film: The tear film consists three layers namely the lipid, aqueous and mucin
layers. The tear film spreads over the entire ocular surface. A normal tear film appears
clear on the ocular surface with a width of approximately 1mm at the surface and mm at

the lid margins. For assessment of tear quality diffuse illumination is used and for
assessing the thickness of the tear layer an optic section is used.

Sclera: is composed of collagen fibres arranged haphazardly. The sclera contains

numerous blood vessels. The normal color of sclera is whitish to yellowish white. The
sclera is covered by a layer of transparent structure called the episclera. Sclera is
examined with an optic section under direct illumination.

Conjunctiva: The conjunctiva is the outermost membrane between the tear film and
sclera. The conjunctiva is a transparent membrane with numerous fine blood vessels. The
interspace between the conjunctival membrane and the sclera regular, uniform and is
usually devoid of fluid. The conjunctiva ends anteriorly at the limbus and posteriorly
extends as tenons capsule. Conjunctiva can be assessed using both diffuse illumination
and optic section.

Cornea: The cornea is the convex transparent structure starting after the conjunctiva. The
cornea is a five layered structure: Epitheium, bowmans membrane, stroma, descemets
membrane and the endothelium. It is made of collagen fibers that are arranged in a
regular fashion. The cornea is devoid of any blood vessels.
The epithelium is lubricated by the tearfilm. It is best assessed with direct diffuse
illumination. In a parallelepiped section, the stroma represents the larger middle section.
The stroma appears regularly transparent. The endothelium is a monolayered structure.
Edothelium is best assessed with specular reflection. The bowmans and the descemets
membranes are not usually visible with a conventional slit lamp.
Anterior Chamber: Anterior chamber is the structure in front of the iris till the posterior
surface of the cornea. The aqueous humor is secreted in the posterior segment, flows
through the pupil and is circulated in the anterior chamber. The aqueous humor is a clear
fluid that circulates in the anterior chamber. Anterior chamber is assessed with an optic
section.

The depth of the anterior chamber is the space between the corneal endothelium and the
anterior iris. The anterior chamber depth (ACD) is deeper at the center and shallow
peripherally. The normal anterior chamber depth in the periphery is equal to at least half
the thickness of a normal cornea. The region where the iris meets the corneo-scleral
junction is called the anterior chamber angle. Anterior chamber angle is assessed using
gonioscope. A gonioscopic view of the anterior chamber looks as given in figure 1.6.

Figure 1.6
The angle is said to be opens or closed based on the furthest structure seen through a
gonioscope (Schaffers grading). The grading of anterior chamber angle is given in table
1.1
Table 1.1 Gonioscopic grading of anterior chamber angle
Structure seen

Angle

Grade

Iris

Closed

Schwalbes line

10o

1, Narrow

20o

2, Occludable

Scleral spur

30o

3, Open

Ciliary body band

40o

4, Widely open

Anterior trabecular
meshwork

IRIS: The pigmented diaphragm in front of the crystalline lens is called the iris. The iris
is a uniformly pigmented muscle that has cryptic appearance in the slit lamp. The iris is
the thicker at he pupillary margin compared to the center.

CRYSTALLINE LENS: The crystalline lens is a multilayered, biconvex structure with a

denser central nucleus surrounded by cortex on the anterior and the posterior sides. The
lens fibers are made of proteins. These proteins render the lens translucent and increases
in opaqueness with age.

Summary:
The key for successful slit lamp biomicroscopy are:

Using appropriate illumination and magnification (Table 1.2)

Proper angling of the illumination and viewing systems

Following a systematic approach

Table 1.2 Slit lamp illumination

Illumination

Structures

Diffuse

External overall view, lid, lashes, conjunctiva, cornea

Parallelepiped

Cornea, meniscus, iris, lens

Optical Section

Angle estimation, corneal layers, lenticular layers

Conical Beam

Anterior chamber (cells)

Retroillumination

Transillumination of the iris, lenticular opacities

Specular Reflection Tear Layer, endothelium

Sclerotic scatter

Corneal scars, central edema

SECTION II
Common disorders of the anterior segment
The objective of the following section is to list out the most common conditions and
disorders of the anterior segment seen in our population. The conditions are dealt with
respect to each anatomical structure.

Table 2.1: Lids

Condition

Image

Slit lamp Sign

Meibomitis: Inflammation

Small oil globules capping the

and obstruction of the

meibomian gland orifices.

meibomian glands

Oily and foamy tear film

Blepharitis: Eyelid

Hyperaemia, telangiectasia, hard

inflammation eye infection

and brittle scales at the bases

or dry eyes

Entropion: Inward folding

Inturned eye lashes, associated

of eyelids

with corneal ulceration

Ectropion: Outward folding

Abnormal lid globe apposition,

of eyelid

corneal exposure, tearing

Trichiasis: Misdirected

Traumatic punctate epithelial

eyelashes

erosions, corneal ulceration and

pannus

Phthiriasis palpebrarum:

Lice and nits gripping to the

Infestation of the lashes by

roots of the lashes at the base of

crab louse nit

the cilia.

Madarosis:

Decrease in number or complete

loss of lashes

Poliosis:

Whitening of the lashes and

eyebrows

Chalazion: Cyst in the

Non tender and painless swelling

eyelid that is caused by

on the eyelid asociated with

inflammation of a blocked

blepharitis

meibomian gland
Stye: Acute staphylococcal

Tender inflamed swelling on the

abscess of a lash follicle

lid margin, pointing anteriorly

through the skin

Lid edema: Due to allergic

Severely swollen lid, tenderness,

reaction or infection

redness or pain.

associated with itching,

redness or pain

Table 2.2: Conjunctiva and Sclera

Condition

Image

Slit lamp Sign

Follicles: Characterized by

Multiple, discrete, slightly

hyperplasia of lymphoid tissue

elevated lesions, encircled by

within the stroma

tiny blood vessel

Papillae: Composed of hyperplastic

conjunctival epithelium and a
diffuse infiltrate of chronic

A fine mosaic-like pattern of

elevated polygonal projections
with central blood vessels

inflammatory cells.
Conjunctivitis: Acute inflammation
due to an allergic reaction or an
infection

Red eyes (Difffuse congestion),

Dilated conjunctival vessels,
Puffy eyelids, Tearing (watery
eyes), Stringy eye discharge

Subconjunctival hemorrhage:

Bright red or dark red patch on

Beeding underneath the conjunctiva

the sclera
Elevated, superficial, external

Pterygium: Benign fibrovascular

fibrovascular mass over the

growth of the conjunctiva

perilimbal conjunctiva to corneal

surface

Pinguecula: Non-cancerous growth

Yellowish white deposit on the

of conjunctiva

conjunctiva adjacent to the

limbus

Scleritis/Episcleritis: Inflammation
of the sclera associated with

Red or purplish sclera and

infection, chemical injuries, or

conjunctiva

autoimmune diseases

Table 2.3: Tear film

Condition

Image

Slit lamp Sign

A thin strip of tear fluid with

Tear film height

concave outer surfaces at the

upper and lower lid margins

Tear film debris: Associated

Dark specks in the tear film of

with blepharitis or a

the eye moving quickly with a

dysfunctional meibomian gland

blink
The tear film stained with
observed under cobalt-blue

Tear film break up: Faster tear

filtered light. Time elapsed

film break up in dry eyes

between last blink and

appearance of the first break is
TBUT

Table 2.4: Cornea

Condition

Image

Slit lamp Sign

Ectasia: Thinning and steepening of cornea

Keratoconus: Inferior

Munsons sign, Fleishers ring,

corneal steepening and

ectasia

thinning, with pigment line

Pellucid Marginal

Ectasia, Fleishers ring

Degeneration: Thinning
bellow the area of
steepening
Terriens Marginal

Mostly superior ectasia

Degeneration: Thinning of
peripheral cornea

Keratoglobus: Uniform

Global ectasia

thinning and steepening

Other Corneal Conditions

Arcus: Lipid deposition in

Diffuse, white band along limbal

stroma, usually seen in

margin

adults

Dendrite: Typically seen in

Branched opacities at stromal

viral keratitis

level

Guttata: Loss of endothelial

Warts/Shadow like gaps in

cells

endothelium

Ulcer: Wound resulting

Appearing as

from infection or injury

sore/opening/erosion

Opacity/Scar: Translucent

Can be minimally translucent

regions in cornea

(grey) to completely opaque

(white)

Infiltrate: Focal areas of

Granular opacities in stroma

active inflammation

Bullous Keratopathy:

Corneal edema with epithelial

Secondary to compromised

bullae

endothelial functions

Band Keratopathy:

Calcification with sharp margins

Deposition of calcium in

in band shape from limbus

anterior Bowmans
membrane

Punctate Keratitis:

Stained epithelial cells with

Granular, swollen epithelial

fluorescein

cells

Corneal Dystrophy
Lattice Dystrophy: Spidery

Ropy lines extending from

branching lines

limbus. Little/No haze. Best seen

in retroillumination

Macular dystrophy: Poorly

Superficial to deep opacities

delineated spots causing

involving limbus. Not well

haze

demarcated

Granular Dystrophy: Well

Sharply demarcated white

confined dots, does not

deposit like lesions

involve limbus

Fuchs Endothelial

Guttata, haze, edema, bullae in

Dystrophy: Associated with

later stages

vision loss, more in women

associated with open angle
glaucoma
Congenital Hereditary

Edema, ground glass appearance

Endothelial Dystrophy:
Focal or generalized
absence of stromal
endothelium

Corneal surgeries
Penetrating Keratoplasty:

Full thickness replacement of

opacified cormea

Lamellar Keratoplasy:

Replacement of selected corneal

layers

Descemet Stripping
Endothelial
Keratoplasty

Anterior Lamellar
Keratoplasty
LASIK:

Flap of corneal tissue over region

of ablated stroma

Table 2.5: Anterior Segment

Condition

Image

Flare:

Slit lamp Sign

Cells or particles moving in
anterior chamber

Flare
Hypopyon: Seen in

Sedimentation of collection

inflammatory conditions, or

of cells in anterior chamber

as response to infection
Hypopyon
Hyphema: Seen post trauma

Blood in anterior chamber

Hyphema
Shallow anterior chamber:

Narrow space between

cornea and iris

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Table 2.6: Iris

Condition

Image

Slit lamp Sign

Coloboma: Commonly

Absence of iris tissue,

associated with coloboma

typically called as key hole

of other ocular structures

appearance
Ectopic pupil-Iris
coloboma
Absence of iris

Aniridia: Commonly
associated with subluxated
lens
Aniridia
Synechiae: Anterior

Adherence of iris to cornea

synechiae is a risk factor for

(Anterior synechiae-AS) or

angle occlusion, posterior

lens (Posterior synechiae-

synechiae associated with

PS)

inflammatory conditions

AS

like uveitis

PS
Iridectomy: Induced

Hole in iris. A patent

surgically or by laser.

peripheral iridectomy

Usually as treatment for

passes light with

narrow angle glaucoma or

retroillumination

during cataract surgery

Patent PI

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Atrophy: Degeneration of

Appears white on direct

iris muscle

illumination, transmits light

on retro illumination
Iris atrophy
retroilluminated

Iris Nevus: Pigmentation in

Appears as patch of excess

iris. Indicative of tumor if

pigmentation

increases in size
Iris nevus
Rubeosis iridis: Seen

Blood vessels in iris

commonly in diabetes,
neovascular glaucoma
Rubeosis Iridis

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Table 2.7: Crystalline Lens

Condition

Image

Slit lamp Sign

Cataract: Clouding and opacification of the crystalline lens

Sutural Cataract: Mostly

Opacity in the shape of

congenital and non-

anterior or posterior Y suture

progressive
Sutural Cataract
Sub-capsular Cataract: Most

Yellowening of the lens in

common type of cataract.

the posterior or anterior sub

Associated with steroid use

capsular region
Posterior sub-capsular
cataract

Cortical Cataract: Opacities

Appears as water clefts/

located in cortical layer

vacuoles in early stages

Spoke-like or wedge-shaped
peripheral opacities in
advanced stages

Spokes in Cortical
cataract
Nuclear Cataract (Sclerosis):

Age related gradual

Shows myopic shift in

opacification of lens nucleus:

refraction
Nuclear cataract

13

Brunescent Cataract: A type

Nucleus appears brown to

of nuclear cataract

black

Brunescent cataract
Total Cataract: Completely

Appears whitish through

opacified crystalline lens

pupil (Leucocoria)

Total cataract
Other disorders of lens
Lenticonus: Protrusion of

Appears as sudden increase

lens at the center caused by

in central lenticular curvature

thin capsule. Can be

in the anterior or posterior

associated with keratoconus,

surface

polar cataract and retinal

Anterior Lenticonus

abnormalities.

Posterior Lenticonus

14

Dislocation: Absence lens

Lens seen in anterior or

from patellar fossa

posterior chamber

Dislocated cataractous
lens
Subluxation: Partial

Lens partially absent from

dislocation of lens. May be

visual axis. Lens edge and

associated with collagen

zonus visible

tissue disorders
Superior subluxation
Pseudophakia: Artificial lens,

Artificial lens in place of

usually as a substitute for

crystalline lens

crystalline lens after cataract

extraction
Pseudophakia
Posterior Capsular

Haze beyond pseudophakic

Opacification (PCO):

lens

Opacified posterior capsule

post cataract surgery
PCO with yag opening
Aphakia: Absence of

Void in pupillary zone

crystalline lens

Aphakia

15

Summary:

Diagnosis involves associating symptoms with signs

Right diagnosis leads to right management

Consider differential diagnoses for common slitlamp signs

16

SECTION III
Anterior segment imaging and diagnostics:
We have seen in previous sections that Slit lamp plays an important role in disease
diagnosis. However, it is to be understood that the slit lamp is useful to detect a
disease in its manifest stage. In many of the anterior segment disorders diagnosing the
disease at the sub-clinical stage would help in better management modalities and
thereby provides a better prognosis. Also, slit lamp biomicroscopy is more a
subjective technique and quantification of the disease stage. Thus, the role of a
diagnostic instrument becomes critical. A diagnostic instrument is important for the
following reasons:

Screening: Diagnosis of subclinical disease

Diagnosis: Confirmation of the clinical diagnosis

Progression: Quantitative improvement/worsening in follow up

When it comes to anterior segment, the disorders of the anterior segment can be
broadly classified into Diseases of the Anterior Chamber and Corneal Diseases.
The following section contains detailed description of the diagnostics specific to each
of the conditions.

Advanced imaging for the anterior chamber assessment

The anterior chamber, the region between the iris and posterior border of cornea, is
imaged by techniques that enhance the tomographic property of these structures. Such
diagnostics are

Ultrasound Biomicroscopy

Anterior Segment Optical Coherence Tomography

Scheimpflug technique

Unlike the anterior chamber diagnostics, the corneal diagnostics not only quantify the
volume of the cornea but also quantify the corneal shape. These include

Corneal topography

Corneal tomography
o Anterior Segment Optical Coherence Tomography
o Scheimpflug technique

Pachymetry
o Ultrasound and non contact techniques

Specular microscopy

Ultrasound Biomicroscopy (UBM)

Ultrasound biomicroscopy (Figure 3.1) is an imaging technique that uses high frequency
ultrasound to produce images of the eye a high, near microscopic resolution of the
structures. Though UBM is primarily a diagnostic tool for glaucoma, it can be used for a
comprehensive anterior segment assessment.

Principle: The ultrasound principle involves passing a sound wave through the tissue and
the delay in reflection and amount of absorption helps in imaging the tissue. A transducer
produces waves of 50 MHz frequency. At this frequency the tissue penetration is 4-5mm
and the resolution is approximately 50 microns.

Procedure: The procedure is done with patient lying in supine position (Figure 3.2).
After instilling the topical anesthetic a 20mm eye cup filled methyl cellulose solution is
placed between the lids. The transducer probe is placed close to the corneal surface
perpendicular to the structure of interest. The probe is moved radially to visualize the
structures. In vivo, cross-sectional or transverse images can then be obtained detailing the

cornea, iris, ciliary body, anterior chamber angle, and peripheral sclera to demonstrate
structural relationships.

Figure 3.1 Ultrasound Biomicroscope

Figure 3.2 Ultrasound Biomicroscopy

Quantitative assessment: Table 3.1 given below has the list of quantifiers that helps in
quantification of the anterior chamber.
Table 3.1: Anterior Segment Quantifiers
Parameter

Description

Angle Opening Distance (AOD) Distance between trabecular meshwork and iris at 500
m anterior to scleral spur
TrabecularIris angle (TIA)

Angle of angle recess

TrabecularCiliary process
distance (TCPD)

Distance between trabecular meshwork and ciliary

process at 500 m anterior to scleral spur

Iris thickness (IT)

Iris thickness at: 500 m anterior to scleral spur, at 2

mm from iris root, maximum iris thickness near
pupillary edge

IrisCiliary process distance

(ICPD)

Distance between iris and ciliary process along TCPD

line

IrisZonule distance (IZD)

Distance between iris and zonule along TCPD line

IrisLens contact distance

(ILCD)

Contact distance between iris and lens

IrisLens angle

Angle between iris and lens near pupillary edge

Normal Anterior segment and UBM:

The structures that can be visualized using the UBM include the cornea, Schwalbe's line,
sclera and scleral spur, anterior chamber, iris, anterior lens capsule, posterior chamber,
and ciliary body (Figure 3.3). Morphologic relationships among the anterior segment
structures alter in response to a variety of physiologic stimuli (ie, accommodative targets
and light); therefore, maintaining a constant testing environment is critical for crosssectional and longitudinal comparison.

Figure3.3: Normal Angle: Cornea (C), Sclera (S), Anterior Chamber (AC), Posterior
chamber (PC), Iris (I), Ciliary body (CB), Lens capsule (LC), Lens (L) and Scleral spur
(black arrow)

In the normal eye, the iris has a roughly planar configuration with slight anterior bowing,
and the anterior chamber angle is wide and clear. The scleral spur is the key landmark to
interpret UBM images in terms of the morphologic status of the anterior chamber angle
and is the key for analyzing angle pathology. The scleral spur is located at the junction of
the trabecular meshwork and the interface line between the sclera and ciliary body.

Glaucoma and UBM:

Angle-closure: Angle closure is caused by iris apposition to the trabecular meshwork. It
can be caused change in sizes, positions of anterior segment structures or by abnormal
forces in the posterior segment that can cause pupillary block and plateau iris
configuration. Differentiating the affected sites is the important in deciding the mode of
treatment.
Occludable angle: Narrow angles closing on provocative environment like dim
illumination.

Figure 3.4a: Narrow angle, Figure 3.4b: Closed angle (in dim illumination)

Pupillary block: Pupillary block is caused by the iridolenticular contact resisting

aqueous flow from the posterior to the anterior chamber and anterior bowing of iris.

Figure 3.5: Pupillary block (indicated by arrows)

Plateau iris: A plateau iris configuration can be caused by large/anteriorly positioned

ciliary body or short iris root.

Figure 3.6: Plateau iris: T sign (best observed by indentation technique)

Open-angle glaucoma: Pigment dispersion syndrome is a type of open angle glaucoma

caused by mechanical friction of posterior iris surface on zonules causing reverse
pupillary block. UBM typically shows concave iris and increased iridolenticular contact.
Other open angle types may not be typically seen in a UBM.

Figure 3.7: Pigment dispersion syndrome

Abnormalities of iris and ciliary body and UBM: UBM is helpful in differentiating solid
and cystic lesions of the iris and ciliary body in addition to quantifying the size.

Figure 3.8a: Iris cyst; Figure 3.8b: Ciliary body cyst

Lens and UBM:

The intactness of the zonules, the optic and haptic locations of an intraocular lens can be
assessed accurately by UBM.

Figure 3.9: Haptic location in IOL (Arrow)

Anterior Segment Optical Coherence Tomography(ASOCT)

The anterior segment OCT (Figure 3.10) is non-contact, non-invasive imaging technique
that acquires and analyzes cross-sectional tomograms of the anterior eye segment
(cornea, anterior chamber, iris and the central portion of the lens) in vivo.

Figure 3.10: Anterior Segment OCT

Principle: It works on low-coherence interferometry to obtain high-resolution images.

Low-coherence interferometry involves measuring the interference between the reference
and the reflected beams of infrared light. This wavelength, limits the penetration depth to
the anterior segment. Multiple A Scans are reconstructed to form a B-Scan like image.
Procedure: Appropriate anterior segment protocol is selected and the patient fixates at
the fixation target. After aligning the instrument at the X, Y and Z axis the instrument
acquires tomographic images of the anterior segment on click of joystick. It is important
to review the scan for reliability.

Glaucoma and ASOCT: For assessing the eye for glaucoma high resolution and quadrant
scan protocols of the ASOCT is selected. The anterior segment metrics can be
quantitatively assessed and an indirect estimate for risk of glaucoma can be obtained
using ASOCT.

The quantitative parameters (figure 3.11) that help in diagnosis of glaucoma are the
anterior chamber depth (ACD), the angle to angle distance (ATA) and the anterior
chamber angle (Figure 3.12). The anterior segment parameters can be compared on
subsequent visits which help in analysis of progression.

Figure 3.11: Horizontal line indicates ATA and vertical line indicates ACD

Figure 3.12: Anterior chamber angle

Structural changes in the anterior chamber like iris cyst (Figure 3.13) and the patency of
the peripheral iridectomy (Figure 3.14) can also be assessed with ASOCT.

Figure 3.13: Iris cyst

10

Figure 3.14 Peripheral Iridectomy

Cornea and ASOCT: Tomography of various corneal disorders can be assessed with
ASOCT. The high resolution corneal image and pachymetry protocol is chosen.
Following are the disease groups that can be assessed effectively using the ASOCT.

Corneal ectasia: The differential pachymetry map (Figure 3.15) provides a

quantitative estimation of the zone of thinning. However, the tracing of the
corneal contour should also be considered to check for reliability.

Figure 3.15: Pachymetry - ASOCT

Post refractive/lamellar surgery: The ASOCT has a flap tool that helps in
assessing the thickness of the LASIK flap or partial lamellar surgeries. The flap
11

tool can be placed at various points in cornea and the flap/lamellar thickness,
bed/host tissue thickness, pachymetry at the point and the location can be
obtained (Figure 3.16).

Figure 3.16: Flap tool analysis

Corneal haze/scar: A hazy cornea appears as hyper-reflective zone in ASOCT.

The depth and extent of the scar can be measured using a caliper (Figure 3.17
a&b)

Figure 3.17 a: Corneal haze

12

Figure 3.17b: Center Corneal Scar-Hyperreflective in OCT color

Lens and ASOCT: The anterior segment OCT can be used to find the location of the
haptics and optics like the UBM. ASOCT can also be used to find the tilt of the intra
ocular lenses (Figure 3.18). While, the live image of the posterior lens capsule can be the
same cannot be acquired hence, ASOCT is not useful in assessing the posterior lens
surface.

Figure 3.18: Tilted IOL

13

Scheimpflug technique
Like the ASOCT, scheimpflug technique is a non invasive technique to measure and
image the anterior segment in vivo. The resolution of a scheimpflug technique is lower
compared to the ASOCT. Oculus Pentacam (Figure 3.19) is a diagnostic based on
scheimpflug technique.

Figure 3.19 Pentacam

Principle: The scheimpflug uses two rotating camera to image the anterior segment in
three planes. These images cut at one point and are reconstructed to obtain a three
dimensional image of greater depth of focus.
Procedure: Appropriate scan protocol is chosen and the patient is instructed to fixate at
the red dot (fixation target). On aligning the camera with the center of the cornea in the
three dimensional axes, the scan process starts automatically.

Glaucoma and Scheimpflug technique: For assessing the characteristics of the anterior
chamber, 50 scans are taken per second. In addition to ACD, anterior chamber angle,
angle to angle measurements are possible with pentacam, volume of the anterior chamber
(Figure 3.20) from the posterior corneal surface can be obtained. A decreased anterior
chamber volume is indicative of a shallow anterior chamber. It is also possible to obtain a
corrective factor for measured IOP based on corneal contour and thickness.

14

Figure 3.20 Anterior chamber parameters

Cornea and Scheimpflug technique: Using scheimpflug technique a variety of corneal

parameters can be obtained. The most important are: Corneal topography, corneal height
data or elevations for the anterior and posterior corneal surface from a refernce sphere
(Figure 3.21a&b), pachymetry and B Scan like images for densitometric assessment.

Figure 3.21a: Anterior corneal elevation

Figure 3.21b: Posterior corneal elevation

For corneal analysis, 25 images are acquired per second. Comparison of the acquired
images between various follow ups is also possible with this instrumentation. Various
corneal conditions that can be assessed with scheimpflug technique are

Corneal ectasia: Steepened corneal curvature, less pachymetry and high positive
elevations (Figure 3.21) are features of corneal ectasia in Pentacam. Depending
on the type of ectasia, the relationship in location of the three parameters change.
Keratoconus has a thinning, steepening and increased elevation in the same zone.

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Whereas in PMD the thinning and increased elevation is noted below the region
of thinning.

Corneal haze/scar: In addition to measuring the depth and size of the scar,
objective measurement of the density of the scar can be analyzed using this
technique (Figure 3.22).

Figure 3.22: Corneal Densitometry

Lens and Scheimpflug technique: Objective assessment of cataract density change with
subsequent visits is possible with Pentacam. Figure 3.23 shows densitometric analysis of
a cataractous lens.

Figure 3.23: Cataract densitometry

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Corneal topography
Corneal topography is the technique of imaging the corneal shape contour. This
technique is otherwise called as videokeratography or photokeratoscopy.
Principle: The widely used principle for imaging the corneal contour is the Placidos
principle. The cornea is treated as a reflective mirror and a series of concentric rings are
projected. The deviation in size between the projected image and the reflected image
helps in calculation of the corneal curvature at each point.
Procedure: The patient is instructed to fixate at the fixation target (green dot). The
instrument center and the center of the central mires are aligned and focused in the X, Y
and Z axes. On click of the joystick the CCD camera acquires the image for processing.

Qualitative topographic assessment: The color coding of the topography is an

important qualitative factor. A steeper zone is given by warm colors (reddish) and flatter
zones are given by cool colors (bluish). Also, quantitative parameters displayed in green
represent a normal range; yellow indicates suspect and red indicates abnormal values.
The shape of the placido-mires is also important qualitative factor. The mires in a
kertaoconic cornea are crowded in the paracentral zone (Figure 3.26b). In PMD the mires
are oval/egg shaped (Figure 3.26c). In post refractive surgery the mires are far spaced
(Figure 3.26e) and any corneal irregularity distorts the regularity of the mires also.
Quantitative topographic parameters:

Simulated Keratometry (SimK): Corneal curvature in central 3mm (Figure 3.24).

Surface regularity index (SRI) and surface asymmetry index (SAI): Quantifiers of
local abnormalities in corneal shape contour (Figure 3.24).

Figure3.24 Indices

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Keratoconus screening: Based on parameters that quantify the asymmetry in

corneal contour, the probability of the given topographic pattern to be keratoconic
is given (Figure 3.25)

Figure 3.25: Keratoconus screening

Some typical topographic patterns:

Figure 3.26a: Astigmatism: The mires are elongated along the axis of steepening. Shows
symmetric bow tie corresponding to the type of astigmatism.

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Figure 3.26b: Keratoconus: Shows asymmetric paracentral or infero temporal steepening

in early stages. Increased area of steepening noted with progression

Figure 3.26c: Pellucid Marginal degeneration: Typical PMD shows a Butterfly or Bird
Peck pattern of steepening

Figure 3.26d: Terriens marginal degeneration: Shows T shaped pattern of steepening

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Figure 3.26e: Post myopic refractive surgery: Amount of flattening corresponds to the
refractive error corrected; should always be interpreted with pre operative topographic
pattern. It is important to look for centartion and extent of ablation.

Slit Scanning
Corneal tomographic and topographic information can also be obtained with Orbscan
which works on the principle of slit scanning. In this method the anterior corneal
topography is obtained with a placidos principle and the tomographic information like
the pachymetry and elevations are simulated. Figure 3.27 shows a typical Orbscan report
that contains topographic and tomographic information.

Figure 3.27: Orbscan analysis

However, the anterior segment OCT and the scheimpflug technique are the reliable
methods of obtaining corneal tomographic information.

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Pachymetry
Corneal pachymetry is the technique of measuring corneal thickness (Figure 3.28).
Principle: Ultrasound pachymetry uses high-frequency sound waves of 1640m/s to
detect the epithelial and endothelial layers, both of which are highly reflective surfaces.
Knowing the velocity of sound in corneal tissue, the distance between the two reflecting
surfaces can be calculated by detecting the time lapse between reflected sound waves
from the 2 surfaces.
Procedure: The patient is comfortably seated and topical anaesthetic is instilled.
The probe tip is now placed perpendicular on the cornea (Figure 3.29).
Measurement is initiated on indentation. The measurement is repeated and the
average of the ten measurements is considered.

90o
t

Figure 3.28: Ultrasound pachymeter

Figure 3.29: Probe placed perpendicularly

Corneal thickness is an important criterion for assessing the risk of postoperative

corneal decompression and for determining the appropriate surgical approach.
Sequential corneal pachymetry is used to document the resolution of corneal
disease or surgery affecting corneal thickness. The conditions in which
pachymetry is indicated are:

Corneal ectasia: Ectatic cornea has reduced corneal thickness. However, the
zone of thinnest pachy changes with each condition In keratoconus, there is
central or paracentral corneal thinning (Figure 3.30a) while keratoglobus has

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overall corneal thinning (Figure 3.30b). In conditions like Pellucid marginal

degeneration and Terreins marginal degeneration, inferior (Figure 3.30c) and
superior corneal thinning (Figure 3.30d) may be noticed respectively.

Figure 3.30a: Keratoconus

Figure 3.30b: Keratoglobus

Figure 3.30c: PMD

Figure 3.30d: TMD

Corneal dystrophies: Corneal dystrophies usually have increased corneal

thickness corresponding to compromised endothelial function. In Fuchs
endothelial dystrophy associated with epithelial edema, the corneal thickness
measure is higher than in cases of Macular corneal dystrophy, wherein the
thickness is reduced.

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Corneal decompensation: In cases of Bullous keratopathy, resulting in

decompensation of the cornea, the thickness is generally increased, as a result of
corneal edema.

Glaucoma and Pachymetry:

The intraocular pressure (IOP) measurements are highly influenced by corneal thickness.
IOP is overestimated in thicker cornea and actual IOP may be underestimated in patients
with low pachymetry. The measurement of the central corneal thickness and
correspondingly correcting the measured IOP value is an important step in managing a
patient with high IOP.

Corneal Thickness-Contact Vs Non-Contact:

The corneal thickness measured using a contact technique like ultrasound pachymetry is
usually lesser than that obtained with non contact pachymetry given by the scheimpflug
and ASOCT by 10 to 20 microns. It is therefore important that in follow-ups, the
thickness be assessed with techniques using similar principle.

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Specular microscopy
The corneal specular microscope is a reflected-light microscope that projects light onto
the cornea and images the light reflected from an optical interface of the corneal tissue,
most typically the interface between the corneal endothelium and the aqueous humor. A
normal corneal endothelium is a single layer of uniform hexagonal cells.
Principle: When the angle of incidence and the angle of reflection is equal, the incident
light is partially reflected onto the photomicroscope which captures the magnified image
of the endothelium. It is therefore, difficult to image the endothelium of an edematous
cornea which causes scattering of the reflected light.
Procedure: The patient is seated comfortably and is instructed to look at the green
fixation light. The region of cornea that is to me imaged is selected and the image is
captured after appropriate focusing. The acquired image is analyzed by clicking at the
center of 100 subsequent cells.
Qualitative Morphometric Analysis of Specular Images: Qualitative cellular analysis
identifies abnormal endothelial structures and grades the endothelium either according to
the number or size of the abnormal structures present or on the basis of an overall visual
assessment of endothelial appearance. Guttata is a gap between cells (Figure 3.31a),
polymegathic cells (Figure 3.31b) appear larger and pleomorphic cells are not
hexagonal(Figure 3.31c).

Figure 3.31a Guttata

Figure 3.31b: Polymegathism

Figure 3.31c: Pleomorphism

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Quantitative Morphometric Analysis of Specular Images: Cell size (cell area or cell
density along with standard deviation), coefficient of variation of mean cell area, percent
of hexagonal cells. The normal ranges of the above parameters in an adult are given in
table 3.2.
Table 3.2: Quantitative parameters of Specular rmicroscopy
Parameter

Normal Value

Cell Density (sq mm)

1500-2000

Percent of hexagonal cells

>60

Coefficient of variation

<40

Standard deviation

<100

There are few conditions where in specular microscopy is indicated:

Endothelial dystrophies: In Fuchs endothelial dystrophy the specular

microscopy is highly variable. However, it provides a quantitative estimation of
the number of guttata in a region in addition to the cell count.

Pre/post intraocular surgeries: The health of the corneal endothelium in an

elderly should be necessarily assessed prior to intraocular surgeries. The
estimation of corneal cell count and anticipated loss of endothelial cells during the
surgery provides an estimation of risk of corneal decompensation post
operatively. The risk of decompensation is high when the pre operative cell
density is less than 1000mm2 or the post operative cell count is < 700mm2.

Graft surgeries: The health and compactness of a full thickness graft or a

lamellar graft can be assessed by specular microscopy, which in turn indicates the
risk of the tissue rejection.

Corneal decompensation: The prognosis in an eye with decompensation can be

speculated by obtaining the endothelial cell count. A better count indicates a
faster recovery and better prognosis. However, it is to be noted that it is unreliable
to analyze a hazy specular image resulting from a decompensated cornea.
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Summary:

Diagnostics help in screening of sub-clinical disease, quantification and

confirmation of the disease and for assessing progression in follow up

Variability of parameters to be considered while assessing progression

Slit lamp biomicroscopy is better than a bad imaging

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