Slit lamp Biomicroscopy

(Instrumentation,Principle, Illumination and Uses)

optomet
rist

MANOJ ARYAL
B . Optometry
IOM,MMC

Introduction
Biomicroscope derives its name from

the fact that it enables the

practitioner to observe the living
tissue of eye under magnification.
It not only provides magnified view of

every part of eye but also allows

quantitative measurements and
photography of every part for
documentation.

 The lamp facilitates an examination

which looks at anterior segment, or

frontal structures, of the human
eye, which includes the
Eyelid
Cornea
Sclera
Conjunctiva
Iris
Aqueous
Natural crystalline lens and
Anterior vitreous.

Important historical landmarks

De Wecker 1863 devised a
portable ophthalmomicroscope .
Albert and Greenough
1891,developed a binocular
microscope which provided
stereoscopic view.
Gullstrand ,1911 introduced the
illumination system which had for
the first time a slit diapharm in it
Therefore Gullstrand is credited

Large Gullstrand
Ophthalmomicrosc
ope (1911)

TYPES
There are 2 types of slit lamp

biomicroscope
1)Zeiss slit lamp biomicroscope
2)Haag streit slit lamp biomicroscope

In Zeiss type light source is at the base

of the instrument while in Haag streit

type it is at the top of the instrument.

Zeiss slit lamp biomicroscope

Haag streit slit lamp biomicroscope

PRINCIPLE
A "slit" beam of very bright light

produced by lamp. This beam is

focused on to the eye which is then
viewed under magnification with a
microscope

Instrumentation
Operational components of slit

lamp biomicroscope essentially

consist of:
Illumination system
Observation system
Mechanical system

Illumination system
It consist of:
A bright ,focal source of light with a slit

mechanism
Provides an illumination of 2*10^5 to
4*10^5 lux.
The beam of light can be changed in
intensity,height,width,direction or angle
and color during the examination with
the flick of lever.

Condensing lens system:

Consist of a couple of planoconvex

lenses with their convex surface in

apposition.
Slit and other diapharm:
Height and width of slit can be
varied by using knobs.

Projection lens:
Form

an image of slit at eye.

Advantages,
1.keeps the aberration of lens
down.
2.increase the depth of focus of
slit.

Reflecting mirrors and prisms

Filters
Yellow barrier filter
Red free filter
Neutral density filter
Cobalt blue filter
diffuser

Observation system(microscope)
Observation system is essentially a

compound microscope composed of two

optical elements
1.an objective ,2.an eyepiece
It presents to the observer an enlarged
image of a near object.
The objective lens consists of two

planoconvex lenses with their convexities

put together
providing a composite power of +22D.
Microscope is binocular i.e. it has two

The eye piece has a lens of +10D.

To overcome the problem of

inverted image produced by

compound microscope ,slit lamp
microscope uses a pair of prisms
b/w the objective and eyepiece to
reinvert the image.
Most slit lamp provide a range of
magnification from 6x to 40x

Mechanical system
Joystick arrangement
Movement of microscope and

illumination system towards and

away from the eye and from side
and side is achieved via joystick
arrangement.
Up and down movement
arrangement
Obtained via some sort or screw
devices.

Fixation target:
A movable fixation target greatly faciliates

the examination under some conditions.

Mechanical coupling :
Provides a coupling of microscope and the
illumination system along a common axis of
rotation that coincides their focal planes.
This ensures that light falls on the point
where the microscope is focused
Has advantages when using the slit lamp
for routine examination of anterior
segment of eye.

Magnification control :
Including two or pair of readily

changeable objective lenses and

two sets of eyepieces.
An on and off switch and
illumination control .

biomicroscope
Illumination
control
Reflecting mirror
Chin rest
Light beam is controlled by
knobs
Joy stick arrangement

Topcon slit lamp model SL-3E

Magnification
may be
changed by
flipping a
lever...

Changing filters.

Alignme
nt mark

Patient

biomicroscope

Microscope
and light
source
rotate
indepedent
ly

Filters used in slit lamp biomicroscopy

Cobalt blue filter
Used in conjunction with fluorescein stain
Dye pods in area where the corneal

epithelium is broken or absent.

The dye absorbs blue light and emits
green.
Uses:
Ocular staining
RGP lenses fitting
Tear layer

Red free(green)filter:
Obscure any thing that is red

hence the red free light , thus

blood vessels or haemorrhages
appears black.
This increases contrast ,revealing
the path and pattern of
inflammed blood vessels.
Fleischer ring can also be viewed

Illumination techniques
Includes
Diffuse illumination
Direct illumination
Parallilepiped
Optic section
Conical(pinpoint)
Tangential
Specular reflection

Indirect illumination
Retro-illumination
Sclerotic scatter
Transillumination
Proximal illumination

Diffuse illumination
Angle between microscope and

illumination system should be 30-45

degree.
Slit width should be widest.
Filter to be used is diffusing filter.
Magnification: low to medium
Illumination: medium to high.

Applications:
General view of anterior of eye:

lids,lashes,sclera,cornea ,iris,
pupil,
Gross pathology and media
opacities
Contact lens fitting.
Assessment of lachrymal reflex.

Optics of diffuse illumination

Diffuse illumination with slit

beam and background
illumination

Direct illumination

Involves placing the light source at

an angle of about 40-50 degree from

microscope.
This arrangement permits both light
beam and microscope to be sharply
focused on the ocular tissue being
observed.
Wide beam direct illumination is
commonly used as a preliminary
technique to evaluate large area.

it is particularly suitable for

assessment of
cataracts,scars,nerves,vessels etc.
It is also of great importance for
the determination of stabilization of
axis of toric contact lens.

Parallelepiped:
Constructed by narrowing the beam

to 1-2mm in width to illuminate a

rectangular area of cornea.
Microscope is placed directly in
front of patients cornea.
Light source is approximately 45
degree from straight ahead position.

Applications:
Used to detect and examine

corneal structures and defects.

Used to detect corneal striae that
develop when corneal edema
occurs with hydrogel lens wear and
in keratoconus.
Higher magnification than that
used with wide beam illumination
is preferred to evaluate both depth
and extent of corneal ,scarring or

Conical beam(pinpoint)
Produced by narrowing the vertical

height of a parallelepiped to produce a

small circular or square spot of light.
Light source is 45-60 degree temporally
and directed into pupil.
Biomicroscope: directly in front of eye.
Magnification: high(16-25x)
Intensity of light source to heighest
setting.

Focusing:
Beam is focused between cornea

and anterior lens surface and dark

zone between cornea and anterior
lens observed.
Principle is same as that of beam of
sun light streaming through a
room ,illuminating airborne dust
particles.
This occurance is called tyndall
phenomenon.

Tyndall phenomenon

Cells, pigment or proteins in the aqueous

humour reflect the light like a faint fog.

To visualise this the slit illuminator is
adjusted to the smallest circular beam
and is projected through the anterior
chamber from a 42 to 90 angle.
The strongest reflection is possible at
90.

Optic section
Optic section is a very thin parallelepiped

and optically cuts a very thin slice of the

cornea.
Axes of illuminating and viewing path
intersect in the area of anterior eye media
to be examined e.g. the individual corneal
layers.
Angle between illuminating and viewing
path is 45 degree.
Slit length should be kept small to minimize
dazzling the patient.

With narrow slit the depth and

portion of different
objects(penetration depth of foreign
bodies, shape of lens etc) can be
resolved more easily.
With wider slit their extension and
shape are visible more clearly.
Magnification: maximum.
Examination of AC depth is
performed by wider slit width .

Used to localize:
Nerve fibers
Blood vessels
Infiltrates
Cataracts
AC depth.

Optical section of lens

1.Corneal scar with wide beam illumination 2.optical section through

scar indicating scar is with in superficial layer of cornea.

Tangential illumination
Requires that the illumination arm

and the viewing arm be separated by

90 degree.
Medium wide beam of moderate
height is used.
Microscope is pointing straight
ahead.
Magnification of 10x,16x,or 25x are
used.

Observe:
Anterior and posterior cornea
Iris is best viewed without

dilation by this method.

Anterior lens (especially useful
for viewing pseudoexfolation).

Example of tangential illumination

(iris).

Specular reflection
Established by separating the microscope and

slit beam by equal angles from normal to

cornea.
Position of illuminator about 30 degree to one
side and the microscope 30 degree to otherside.
Angle of illuminator to microscope must be
equal and opposite.
Angle of light should be moved until a very
bright reflex obtained from corneal surface
which is called zone of specular reflection.

Irregularities ,deposits ,or excavasation in

these smooth surface will fail to reflect light

and these appears darker than surrounding.
Under specular reflection anterior corneal
surface appears as white uniform surface
and corneal endothelium takes on a mosaic
pattern.
Used to observe:
Evaluate general appearance of corneal
endothelium
Lens surfaces
Corneal epithelium

Schematic of specular
reflection.
Reflection from
front surface

endothelium

Indirect illumination
The beam is focused in an area adjacent to

ocular tissue to be observed.

Main application:
Examination of objects in direct vicinity
of corneal areas of reduced transparency
e,g, infiltrates,corneal
scars,deposits,epithelial and stromal
defects
Illumination:
Narrow to medium slit beam
Decentred beam
Magnification: approx. m=12x (depending

Retroillumination
Formed by reflecting light of slit

beam from a structure more posterior

than the structure under observation.
A vertical slit beam 1-4mm wide can
be used.
Purpose:
Place object of regard against a
bright background allowing object to
appear dark or black.

Used most often in searching for

keratic precipitates and other

debris on corneal endothelium.
The crystalline lens can also be
retroilluminated for viewing of
water clefts and vacuoles of
anterior lens and posterior
subcapsular cataract

Direct retroillumination from iris:

Used to view corneal pathology.
A moderately wide slit beam is aimed

towards the iris directly behind the

corneal anomaly.
Use magnification of 16x to 25x and
direct the light from 45 degree.
Microscope is directed straight ahead .

Schematic of
direct retroillumination
from
the iris.

direct retroillumination from the

iris.

Indirect retroillumination from iris:

Performed as with direct

retroillumination but the beam is

directed to an area of the iris bordering
the portion of iris behind pathology.
It provides dark background allowing
corneal opacities to be viewed with
more contrast.
Observe:
Cornea, angles.

Retroillumination from
fundus(red reflex photography)

The slit illuminator is positioned in an

almost coaxial position with the

biomicroscope.
A wide slit beam is decentered and
adjusted to a half circle by using the slit
width and
The decentred slit beam is projected
near the pupil margin through a dilated
pupil.

Schematic of
retroillumination from
the retina.

Example of retroillumination from the re

Sclerotic scatter
It is formed by focusing a bright but

narrow slit beam on the limbus and

using microscope on low magnification.
Such an illumination technique causes
cornea to take on total internal
reflection.
The slit beam should be placed
approximately 40-60 degree from the
microscope.
When properly positioned this technique
will produce halo glow of light around
the limbus as the light is transmitted

Used to observe:
Central corneal epithelial edema
Corneal abrasions
Corneal nebulae and maculae.

Schematic of
sclerotic scatter.

Example of
sclerotic
scatter.

Proximal illumination

This illumination technique is used

to observe internal detail, depth,

and density.
Use a short,fairly narrow slit beam.
Place the beam at the border of
the structure or pathology.
The light will be scattered into the
surrounding tissue, creating a light
background that highlights the

Depending on the density of the

abnormality, the light from behind

may reflect through, allowing
detailed examination of the internal
structure of the pathology.
Observe: corneal opacities
(edema, infiltrates, vessels, foreign
bodies), lens, iris

Transillumination
In transillumination, a structure (in

the eye, the iris) is evaluated by

how light passes through it.
Iris transillumination:
This technique also takes
advantage of the red reflex.
The pupil must be at mid
mydriasis (3to 4 mm when light
stimulated).
Place the light source coaxial

Use a full circle beam of light equal to

the size of the pupil.

Project the light through the pupil and
into the eye .
Focus the microscope on the iris.
Magnification of 10X to 16X is adequate
Normally the iris pigment absorbs the
light, but pigmentation defects let the
red fundus light pass through..
Observe: iris defects (they will glow
with the orange light reflected from the
fundus)

Basic slit lamp examination

Patient positioning:
Head support unit
Adjust height of table or chair
Adjust height of chin rest such

that patients lateral canthus is

aligned with the mark.
Adjust ocular eyepieces.

Power up
Fixation
Magnification : begin with 6x -10x

magnification
Focusing
Special procedures
Protocol and documentation

Uses of slit lamp biomicroscopy

Diagnostic:
OCT
FFA
Anterior segment and posterior

segment diseases
Dry eye

 Procedures:
Applanation
Tear evaluation
Pachymetry
Gonioscopy
Contact lens fitting
Therapeutic:
Laser
FB

removal
epilation

Anterior and posterior segment disease evaluation

Lids and lashes

Conjunctiva and cornea
Instillation of fluorescein and BUT

measurement
Eversion of the lids
Anterior chamber and angle
measurement
Iris
Crystalline lens
Anterior vitreous

Meibomian gland openingsInjected conjunctiva

pinquecula,

INSTILLATION OF FLUORESCEIN

PALPEBRAL CONJUNCTIVA
EXAMINATION

Evertion of lids

This technique is used to examine

the inferior and superior palpebral

conjunctiva, particularly in contact
lens wear and when looking for
allergic conjunctival changes,
papillae, and foreign bodies.
1. Ask the patient to look down

and grasp the superior eyelashes.

2. Press gently on the superior

margin of the tarsal plate using a

cotton swab (or the index finger of
the other hand), and at the same
time pull the eyelashes upwards.
3. To evert the lower eyelid, pull

the eyelid down and press under

the eyelid margin while moving
finger upwards. The eyelid will

Meibomian gland evaluation

With the patient at the biomicroscope,

use white light and medium

magnification to inspect the lower eyelid
margins.
Look for capping of the meibomian

gland orifices (yellow mounds), notching

of the eyelid margins (indentations) and
frothing of the tears on the eyelid
margins.
Pull the lower eyelid down and look for

With mild pressure, press on the

eyelid margins near the eyelashes

and watch the meibomian gland
orifices.
Clear fluid should be expressed.
Capping of the orifices, a cheesy

secretion on expression and

frothing of the eyelid margins
indicates meibomian gland

CENTRAL RETINA PHOTOGRAPHS

WITH A 90-DIOPTER LENS

A moderate

slit beam in
the almost
coaxial
position gives
the best
results.

References
Clinical procedure in optometry
Primary care optometry
Borishs clinical refraction
Theory and practice of optics and

refraction:AK Khurana
internet

Thank You