Slit Lamp

Biomicroscopy
DR DISHA

MODERATOR-DR ANDREW

History
Liebreich- First to employ a monoocular microscope.
Aubert- Developed a truly stereoscopic microscope in
1891.
Czapski and Schatz- Developed the first true binocular
microscope mounted on a movable track in 1897
Gullstrand- designed the first slit lamp model
Henker- combined both Czapski and Gullstrand models
in 1916.

Gullstrand model

The term slit lamp biomicroscopy is accurate because they

identify the two basic components:
slit lamp with its focal narrow beam of light
And the microscope for stereoscopic magnified observation.
In 1925 Mawas to designate the examination of living eye with
this instrument coined the term biomicroscopy.

Hans Goldman developed the first successful

biomicroscope in 1933, in which both horizontal and
vertical adjustments of the lamp and slit beam were
placed on a single mechanical stage.
It was marketed as the Haag-Streit model 360 slit
lamp
In the 1950s ,first new optical principle for the
biomicroscope was introduced by Littmann .
The forerunner of the current Zeiss slit-lamp series

SLIT LAMP DESIGN

HAAGSTREIT

ZEISS

PRINCIPLE
A narrow "slit" beam of
very bright light produced by
a tungsten or halogen
lamp.
This beam is focused on to
the eye which is then
viewed under magnification
with a microscope

Components of the slit lamp

Observation system
Illumination system
Mechanical system

The biomicroscope based on the

optics of a compound microscope
Objective lenses- 22 dioptres
Eye piece- 10 diopters
Microscope is binocular with 2 eyepieces.
Prisms
Two basic types
1. The Grenough type
2. The Galilean changer type

The Grenough type

(Classical Haag
Streit)

Flip lever to change

magnification

The Galilean Magnification

changer
Knob to change
magnification (3
or 5step)

Magnification can be changed also by

rotating the knob

Adjusting the oculars for interpupillary

distance

ILLUMINATION SYSTEM
In both types of illumination system the
Kohler illumination principle is used

Koeller illumination principle

In the Zeiss type the illumination comes from below

In the Zeiss type the illumination comes from below

In the Haag Streit type the illumination comes from

above

Condenser

Illumination system comprises

following componentsHalogen bulb

Slit

1. LIGHT SOURCE-Halogen lamp provides a

illumination of 2x105 to 4x105 lux
2. CONDENSER LENS SYSTEM- Consists of
couple of planoconvex lenses with their
convex surfaces in apposition
3. SLIT AND OTHER DIAPHRAGMS- Height
and width of slit can be adjusted

Projection lens

Image of slit

 Slit and microscope angle

can be varied
Scale indicates number of
degrees off the center
Scale

4. FILTERS

Diffusing filter

Cobalt blue (fluorescein)

Red-free filter

5. PROJECTION LENS
Forms an image of the slit at the eye has two
advantages:
a)It keeps aberrations of the lens down which results in
better quality image.
b)It increases the depth of focus of the slit and thereby
produces a better optical section of the eye.
6. REFLECTING MIRROR OR PRISM

Mechanical system
Joy stick arrangement
Up and down arrangement
Patient support arrangement
Mechanical coupling

Joystick arrangement

Lock (4)

Joystick (2) and (3)

Brightness

The coupling between the slit lamp

and the biomicroscope
This is such as to make the system parafocal
The focus of the slit and the focus of the microscope
are at the same point
This parafocality may need to be occasionally
dissociated as for example in case of sclerotic scatter

Interaction of light with cornea

Transmission - Direct illumination
- Retroillumination
Reflection

- Sclerotic scatter
- Specular reflection
- Diffuse illumination

Absorption

Basic principles of slit lamp

illumination
Three specific types of illumination
Focal illumination : by narrowing the beam of light and preventing
extraneous light
Oblique illumination : view different layers
Optical section : view internal structure, Unique feature, hence the name
biomicroscopy.

Types of illumination- Berliner

Diffuse

Sclerotic
scatter

Focal slit

Broad
tangential

Proximal
Illumination

Retroiiluminat
ion from iris

Retroilluminat
ion from
fundus

Specular
reflection

1.Diffuse illumination
Angle between microscope and illumination system should
be 300 to 450
Slit width: widest
Filter: diffusing filter
Magnification: low to medium
Illumination: medium to high

Pterygium

Uses
1. Topography of pathological changes.
2. Surface of cornea, iris, lens can be viewed.
3. Folds of descemets membrane.
4. Corneal scar.
5. Whole configuration of lens.

6. Skin disorders like acne rosacea

7. Eyelid lesions such as molluscum contagiosum
8. Eyelid dysfunction like floppy lid syndrome
9. Scleritis

2.SCLEROTIC SCATTER
Slit beam directed at scleral limbus and illumination
transmitted into cornea by internal reflection .
Principle- Total internal reflection of light
Defines pattern of the abnormality.
Settings- Slit lamp is about 15 degrees from
microscope
Slit height: full
Slit width: moderate

Should be used early in the examination because,

1) The patient acclimates to bright light of the slit lamp
before it is directed in to the pupil.
2) It accurately reveals the presence and pattern of
corneal opacities.
3) It helps to identify faint opacities that are difficult to
see in direct illumination.

Schematic of Sclerotic scatter

Sclerotic scatter

Corneal ulcer

Uses of sclerotic scatter

Corneal opacity pattern
Sub epithelial infiltrates
Corneal stromal edema
Perforating scars
Dystrophy

3.DIRECT FOCAL SLIT

ILLUMINATION

Direct focal slit illumination

Terminology : Projection , of a narrow slit beam at an angle, to the
corneal surface, producing an optical section that slices through
the cornea and eye.
Principle: A direct narrow slit beam optically cuts through the cornea ,
providing a cross sectional view that reveals its contour and its
internal structure.
It forms two parallel curved surface, one that follows anterior
corneal surface and one that posterior corneal surface.
Two surfaces are joined by a block of light scattered in the stroma
to create a geometric figure that resembles an elongated ice cube.
This is known as parallelepiped/ optical block/optical section.

The angle between microscope and illumination system is

approximately 30 degrees.
Heterogeneous tissues like cornea and lens disperse light and
become visible as bright objects against a dark background
The direct illumination examination is carried out utilizing
three slit beam effects
1.Optical section
2.Parallelepiped of the cornea
3.Conical beam

Hypopyon ulcer seen in direct focal

slit illumination

1.OPTICAL SECTION
Produced by a very narrow slit beam focused
obliquely
Resembles a knife like histological section of the tissue
focused
(a) Corneal optical section consists of a segment of
an arc with following concentric zones:

i) Tear layer is seen as bright anterior most zone

i)Epithelium is seen as dark line immediately behind the
tear layer
iii)Bowmans membrane is seen as bright line
iv)Stroma is focused as a wider granular and greyer
zone
v)Descemets membrane and endothelial layers are
seen as a posterior most bright zone

Examination of the optical section of the cornea

gives useful information about
Changes in corneal curvature
Changes in corneal thicknessSwelling of stromal edema
Generalised thinning of keratocnus
Focal thinning of rheumatoid keratolysis
Focal posterior thinning of Peters
anomaly

Depth of corneal pathologies

b)Optical section of the lens layers seen from

front to backwards
Anterior capsule

Sub capsular clear zone

A bright narrow scattering zone of discontinuity
Second cortical clear zone
Light scattering zone of deep Cortex
Clear zone of deep cortex
Nucleus

c)Optical section of the anterior 1/ 3 rd of the vitreous

2.PARALLELEPIPED OF THE CORNEA

Observed using a 2-3 mm wide focused slit
Pathologies of the epithelium and stroma are better
studied
Corneal scars or infiltrates appear brighter than
surroundings
Water clefts appear black in optical block

3.CONICAL BEAM
Used to examine the presence of aqueous flare

4.Broad tangential
illumination
Wide beam oriented at an extremely oblique illumination
angle causing it to project tangentially across corneal surface.
The slit beam is swung to the side so that it creates a 70-80
degree angle with the microscope.
Principle- Extreme angle of incidence of slit beam results in
decrease of light reflected and scattered by cornea.
Reduces background glare causing surface details to stand
out.

Schematic of tangential illumination

Uses
1. Corneal intraepithelial neoplasia
2. Stromal ulcers
3. Calcific band keratopathy with holes
4. Diffuse punctate epithelial keratopathy
5. Highlights Descemets membrane folds

5.PROXIMAL (INDIRECT)
ILLUMINATION
Slit beam is focused on a position just beside the area
to be examined
Set up required is
Angle between slit lamp and microscope should be >45 0
Beam width is moderate (0.2mm)
Illumination used is low, medium or high

Schematic of indirect
illumination

Uses
To observe the details within the corneal opacities.
1.Corneal infiltrates
2.Corneal microcysts
3.Corneal vacuoles
4.Epithelial cells
5.Corneal foreign body

6.Retroillumination from iris

Refers to illuminating an area of the cornea using light
reflected from the iris.
It can be direct or indirect retroillumination from the
iris.
Determine the optical qualities of the abnormality

Direct Retroillumination
Observer in direct pathway of light
Light is reflected from structures so pathology seen
against illuminated background.

Indirect Retroillumination
Observer is right angle to observed structures, not in
line so pathology seen against dark non illuminated
area.

Retroillumination from iris

Pathologies can be
Obstructive- Seen as dark against light background.
E.g. Pigment or blood filled vessels
Respersive- These scatter light but do not obstruct
completely. Seen as bright against dark background.
E.g. Epithelial edema, precipitates
Refractile- They distort the view of junction of
illuminated and dark area because the refractive index
is different from that of the surrounding tissue. E.g.
vacuoles

Retroillumination from the

fundus
Terminology- Light entering dilated pupil is reflected from
retinal pigment epithelium and choroid and emerges from
the pupil with orange red glow called red reflex. Examining
the cornea with light reflecting from the fundus.
Determines optical qualities of the abnormality.
Settings- slit beam is placed co-axial with the microscope,
then decentered to the edge of the pupil
Slit width- medium and curved at one edge to fit in the pupil.
Slit height- reduced to one third to avoid striking the iris.

Posterior subcapsular catarct seen in direct

focal illumination and retroillumination

7.Specular Reflection
Smooth surface of the cornea reflect incident light like a
plain mirror following Snells law. This is known as specular
reflection.
Relies on the use of the reflective properties of the anterior
and posterior corneal surfaces .
The magnification of the microscope must be 200x view
through one eye piece
Observe: corneal epithelium and endothelium, lens surfaces.

Schematic of specular reflection

Endothelial cells on specular

reflection

Endothelial guttata
Guttata

Oscillatory illumination of
Koeppe
The slit beam is given an oscillatory movement by
which it is possible to see minute objects or filaments
especially in aqueous.

Examination requiring accessory

devices
Gonioscopy
Fundus examination with focal illumination
Tonometer
Pachymetry
Slit lamp photography
Potential acuity meter test
Laser interferometry
As a delivery system for argon diode and Nd Yag laser

Normally the angle of the anterior chamber cannot be seen as light from it
cannot exit from the eye due to total internal reflection at the cornea.

A gonioscopy lens allows light from the angle to

exit the eye by eliminating the cornea air
interface

Direct Gonioscopy

Fundus Examination
An accessory lens is necessary in order to image the
fundus in a position where it can be reimaged by the
slit lamp.
It can be either contact or noncontact variety of
accessory lens.

Some contact fundus slitlamp

lenses

Goldmann three mirror lens

examination
Central planoconcave lens -64 D
It has three mirrors at 59 degree, 67 degree and 73
degree.
Central lens allows a magnified stereoscopic examination
of central 30 degree 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.
Done with +90D and +78D.
An inverted stereo magnified image formed between
lens and slit lamp.
Lens is held 5-10 mm away from patients cornea.
Magnification is 10x or 16x
Co axial illumination for fundus examination

Hruby lens biomicroscopy

Planoconcave High minus lens (-58.6 D )
Neutralises the optical power of the eye
Forms a virtual erect image of the fundus
Disadvantage:small field, low magnification cannot visualize beyond the
equator

Posterior segment examination

with +78 D lens

Fundus view with slit lamp and

mainster contact lens

Tonometer
Modern slit lamp tonometers use the applanation
principle.
The goldmann applanation tonometer measures the
force necessary to flatten an area of given size.

Goldmanns applanation tonometer

Systematic sequence of Slit- Lamp microscopy of the cornea

Thank you