Bio Microscopy Guide

Slit Lamp Biomicroscopy Part One
Slit Lamp Illumination Types

Associated Ocular Conditions And
Slit Lamp Examination Procedures
Direct Illuminations:
1.) Diffuse:
Diffuse illumination or "wide beam" illumination deserves a short
separate 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 independent racking microscopes. This allowed
each to be independently focus on different structures. Most of todays
slit lamp biomicroscopes have their light sources and microscope
coincident to one another 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 anterior segment of the eye. "Wide beam"
illumination is the only type that has the light source set wide open. Its
main purpose is to illuminate as much of the eye and its adnexia at
once for general observation.
A wide, un-narrowed, beam of light is directed at the cornea from an

angle of approximately 45 degrees. Position the microscope directly in
front of the patient's eye and focus on the anterior of the cornea. Low
to medium magnification
(7 - 16x) should be used which allows the observer to view as many of
the structures as possible. When viewing the eye with achromatic light
one should note, on gross inspection, any corneal scars, irregularities of
the lids, tear debris, irregularities of Descemet's membrane or
pigmentary changes found in the epithelial layer, etc. These findings
are investigated more thoroughly with other types of illumination.
With the aid of the cobalt blue filter and either fluorescein sodium or
Fluoresoft® permit the evaluation of bearing, movement, positioning of
contact lenses. Using the cobalt blue filter and fluorescein sodium this is
a reasonable illumination for assessing a patient's tear break up time
(TBUT), dark drying areas of the epithelium. Staining of the cornea and
conjunctiva can also be assessed. Fluorescein sodium dye will stain the
cornea and conjunctiva any time the epithelium is compromised.
Fluorescein dye does not stain epithelial cells themselves, but pools
within the intercellular defects thus highlighting the damaged area.
Fluorescein staining is relatively nonspecific, occurring with any
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condition affecting epithelial integrity. Do not confuse "negative

staining" for true TBUT. Negative staining, often seen when checking
TBUT or evaluating an area that has stained in the past. "Negative
staining" results because of irregularities in the corneal epithelium.
These dark areas are where the tears separate quickly rather than stain
tissue. Examples: Map and dot dystrophies, micro-cystic edema,
healing but still rough and not smoothly healed abrasions, etc. The
cobalt blue filter is also helpful in detecting Fleischer's Ring or Line in
keratoconus and Hudson Stahli's Line in older patients.
Using Rose Bengal and no filters will show a pink staining of epithelial
cell damaged tissue as in cases of keratoconjunctivitis Sicca, herpatic
lesions of the lids and cornea and other ulcer margins. Other types of
illumination are better for evaluating the degree and depth of any
staining. See color plates in Dr. Casser's book.
Diffuse, wide-beam, illumination together with the red free (green)

filter is helpful when viewing the bulbar conjunctiva, and episcleral
blood vessels. With the aid of the red free filter small hemorrhages,
aneurysms and engorged vessels stand out. It is not difficult to
differentiate between conjunctival, episcleral, and scleral injection.
Conjunctival vessels are obviously fairly superficial and are movable
upon friction from the eyelid, whereas less superficial and deep vessels
show minimal to no movement with the overlying conjunctiva. Deeper
episcleral injection may also appear somewhat darker and give an
overall purplish hue. (Abelson et al) proposed a standardized grading
system for judging the different types of injection.

A) Ciliary Injection B) Episcleral Injection C) Conjunctival Injection

Grade Severity
0 White and Quiet
1/2 Slight, Usually Normal
1 to 1+ Mild
2 to 2+ Moderate
3 to 3+ Severe
Adapted and modified from Abelson, M. et al.
2.)Direct Focal
a.) Optic Section: Optic section is used primarily to determining the
depth or elevation of a defect of the cornea, conjunctiva or locating
the depth of an opacity within the lens of the eye.
With the optic section as mentioned above, it is possible to detect

changes in corneal and conjunctival thicknesses, to assess depths of
foreign bodies, scars and opacities, to estimate the anterior chamber
depth and to identify the anatomical location of cataracts within the
crystalline lens. The biomicroscope should be directly in front of the
patient's eye, the illumination source at about 45 degrees and the
illumination mirror in "click" position. The slit width is almost closed
(0.5 - 1.0 mm wide by 7 - 9 mm high). Set the magnification on low
to medium (7 - 10 X) and focused on the patient's closed lid. The
thickness of the eye lid (about 1 mm) means focusing on the cornea
is accomplished with only slight movement of the joy stick. With eyes
open, give the patient a point of fixation such as the fixation light,
part of the biomicroscope, or the top of the examiner's opposite ear.
Once the cornea is in sharp focus, scan the cornea from temporal
limbus to nasal limbus. To maintain a clear, distortion-free view, the

illumination source is always moved to the opposite side when

crossing the mid-line of the cornea.
With a clearly focused optic section slightly temporal to the center of

the cornea, magnification increased to 16x then to 20x, and
brightness increased note the following:
1) The Front Surface Bright Zone Is The Surface Of The Tears

2) The Next Dark Line Is The Epithelium Layer
3) The Next Brighter Thin Line Is Bowman's Membrane
4) The Gray Wider Granular Area Is The Stroma Zone
5) The Last Bright Inner Zone Is The Endothelium
To attain an optic section of the crystalline lens, the angular

separation of the illumination source is reduced until the light beam
just grazes the edge of the pupil and the vertical height is reduced to
approximate the pupil size. This alignment can easily be
accomplished from outside the biomicroscope. When the beam cuts
just across the edge of the pupil, the crystalline lens will appear
sectioned. By focusing the biomicroscopes joy stick with one hand
and controlling the direction or angle of the light source with the
other hand, the different layers of the lens can be brought into focus,
hence, the anatomical location of any opacities can be determined.
Furthermore, the degree of nuclear opalescence and color can be
evaluated and graded via the, lens opacities classification system II
(LOCS II)[Chylack, 1989]. Different magnifications may be used, but
medium and high give the best detail.
Van Herick's technique for grading the anterior chamber angles uses
an optic section placed near the limbus with the light source always
at 60 degrees. The biomicroscope is placed directly before the
patient's eye. This technique only allows you to judge the temporal
and nasal angles.

Van Herick Angle Estimation Method
Angle
Risk of Angle Closure Cornea to Angle Ratio
Grades
Wide Open Angle; Incapable of Anterior Chamber Depth (Shadow) is
Closure. Iris to Cornea Angular Equal to or Greater Than Corneal
4 Separation Equals 35-450. Thickness
Moderately Open Angle; Incapable Anterior Chamber Depth (Shadow) is

of Closure. Iris to Corneal Angular Between 1/4 and 1/2 the Corneal
3 Separation Equals 20-350 Thickness
Moderately Narrow Angle; Closure

Anterior Chamber Depth (Shadow) is
Possible. Iris to Corneal Angular
2 Equal to 1/4 the Corneal Thickness
Separation Equals 200
Extremely Narrow Angle; Closure Anterior Chamber Depth (Shadow) is

Probable. Iris to Corneal Angular Equal to Less Than 1/4 the Corneal
1 Separation Equals 100 Thickness
Basically Closed Angle; Closure is Anterior Chamber Depth (Shadow) is Only

Most Emanate. Iris to Corneal a Very Narrow Slit; or no Anterior Chamber
0 Angular Separation Equals 00 Angle
Adapted from: Van Herick W, Shaffer RN, Schwartz A. Estimation of width of

angle of anterior chamber. Am J Ophthalmol 1969;68:626-9.

Optic section using the Van Herick Technique to grade the anterior
chamber depth. This is a grade 1 or narrow angle.
The "Split Limbal Technique" allows you to make an estimation of the

superior and inferior angles. The slit lamp and illumination system
are in click position aligned directly in front of the patient . The beam
width is that of an optic section which is focused on the limbal cornea
junction thus splitting the cornea and limbus. The doctor then views
the arc of light through the cornea and that falling on the iris without
the aid of the slit lamp. The angular separation seen at the limbus
corneal junction is an estimation of the anterior chamber angle depth
in degrees.
"Split Limbal Technique"

Which Is Observed With The Naked Eye
Grade Angle
+ 4 TO 4 - ( 45 - 350 )

+ 3 TO 3 - ( 35 - 200 )
+ 2 TO 2 - < 20 BUT > 100)
1-0 ( 100 OR LESS )
b.) Conical Beam: Examination of the anterior chamber for cells or

flare must be performed before either dilation or applanation
tonometry. Magnification
16 - 20x and illumination (high) or what the patient will tolerate.
Dilation often results in an increase in the number of cells and
fluorescein used in applanation tonometry causes an increase in flare
[Schlaegel, 1982]. This type of illumination is used to detect floating
aqueous cells and flare by the Tyndall effect (likened to dust floating
in the air of a sun filled window)
The traditional method of locating and grading cells and flare is to

reduce the beam to a small circular pattern with the light source 45
to 60 degrees temporally and directed into the pupil. Position the
biomicroscope directly in front of the patient's eye with as bright
illumination as the patient will permit and high magnification. The
examiner always allows themselves a period of time to dark adapt.
The conical beam is focused between the cornea and the anterior lens
surface and observation is concentrated on the dark zone between
the out of focus cornea and lens. This zone is normally optically
empty and appears totally black. Flare (protein escaping from dilated
vessels) makes the normally optic empty zone appear gray or milky
when compared to the uninvolved eye. Cells (white blood cells
escaping from dilated vessels) will reflect the light and be seen as
white dots. The techniques used may be either to oscillate the light
source with the joy stick from left to right while focused in the
anterior chamber or to focus from the posterior cornea to the anterior
lens while oscillating the light source.
The following is a less traditional technique, but one that works well
clinically and is superior when grading the severity of inflammation.
Use a parallelepiped approximately 2 mm wide and 4 mm high Focus
on the iris then the pulled back the focus into the anterior chamber.
The examiner waits and watches the zone between the out-of-focus
cornea and the light passing through the pupil. The convection
currents of the aqueous will move any protein or cells into this zone.
Grading Cells and Flare

Grade Aqueous Cells Grade Flare

Optically Empty Compared
None
0 0 Bilaterally
2-5 Cells Seen in 45 Faint: Haze or Not Equal

1 Seconds or One Minute 1 Bilaterally
Moderate: But Iris Detail Still

5-10 Cell Seen at Once Clear
2 2
Cells Scattered Through Out Marked: Iris Details Becoming

3 Beam 20 or More 3 Hazy
Dense Cells in Beam, More Dense Haze: With Obvious

4 Than You Can Count 4 Fibrin Collecting on Iris
READ VOL. 4 - CHAPTER 32 IN "DUANES' CLINICAL OPHTHALMOLOGY"
Cells and flare in the anterior chamber represent a condition of great

concern and are usually diagnostic of an inflammation. However, if
cells or flare is not seen but an inflammation is suspected, use the
"Consensual Pupillary Reflex" test "Henkind" test or "Consensual Pain
Reflex" test, all the same, to help confirming an inflammatory
diagnosis. The patient completely covers the eye in question so no
light can enter. They are to report any discomfort when the slit lamp
is focused on the "good eye" and the brightness is turned up. If he/
she reports discomfort, cells and flare may not be present, but there
most likely is a smoldering inflammation that has not resolved or is
about to develop [Au, 1981].
Grading the Consensual Pain Reflex

Grade Patient Response
1 To 1+ Definite Pain Without Acute Distress
2 To 2+ Causes Wincing or Complaint of Pain
3 To 3+ Causes Withdrawal From the Light
4 To 4+ Severe Allows No Light in the Eye

C.) Parallelepiped: A parallelepiped is one of most common types of

illumination used. It is used in combination with a number of different
types of illuminations. The biomicroscope should be directly in front
of the patient's eye, the illumination source at about 45 degrees and
the illumination mirror in "click," position. A parallelepiped is
essentially 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 distinguishable details within the crystalline
lenses "zones of discontinuity". As with the optic section, the angle
between the illumination source and biomicroscope may be varied to
expose more corneal epithelium, stroma and endothelium. The whole
cornea should be scanned using a parallelepiped. When scanning the
cornea, a clear undistorted view must be maintained by positioning
the light source to the opposite side when crossing the mid-line of the
cornea. Both normal and abnormal findings can be seen when
scanning the cornea with varied levels of magnifications and
brightness. Look for any of the following:
Tear debris is usually benign and related to allergies or sinus

conditions, but may correlate with bacterial infections.
Corneal nerves are white thread-like structures that bifurcate
and trifurcate and are located anywhere within the cornea.
Blood filled vessels extend from the limbus onto or into the
cornea, and are diagnostic of chronic or acute insult or
inflammation.
Ghost vessels extend from the limbus onto or into the cornea.
They are empty of blood and diagnostic of some type of past
corneal insult or inflammation.
Corneal scars are white in color and diagnostic of some past
corneal damage, ulcer, abrasion or foreign body.
Corneal striae are white usually vertical thread-like twisting
lines found in Descemet's membrane and posterior stroma.
They are diagnostic of poor soft contact lens fitting, diabetes or
metabolic changes as with the reduced number of endothelial
cells of the elderly. They are the result of overall thickening of
the entire cornea and buckling of the back surface.
Grades of Cornea Striae

Grade Observed Number
0 None
1 Less Than Five

2 Five To Ten
3 Ten To Twenty
4 More Than Twenty
Endothelial pigmentation when heavy and located vertically on

the endothelium is known as "Krukenberg's Spindle", it may be
diagnostic of iris atrophy and pigmentary glaucoma.
Transillumination of the iris should be performed and any
transillumination iris defects (TID's), holes in the iris, noted.
Scant, very fine deposits are commonly seen and not
pathological.
3.) Retro-Illumination: Usually uses a parallelepiped that bounces

unfocused light off one structure while observing the back lighting of
another. The alignment and angular separation of the biomicroscope
to the illumination source will vary. The light source beam is reflected
off another structure like the iris, crystalline lens or retina while the
biomicroscope is focused on a more anterior structure.
Retroillumination or transillumination the iris or crystalline lens uses
low to medium magnification
(7 - 10x). The slit width 1 - 2 mm wide and 4 - 5 mm high with the
biomicroscope and light source placed in direct alignment with each
other. They are both positioned directly in front of the eye to be
examined. Focus the slit just off the edge of the iris and on the front
of the lens. If there are defects or atrophy of the iris they will be seen
as a retinal "orange" glow coming back through each defect or hole.
Patients who have numerous endothelial pigment deposits must have
their iris transilluminated. Remember the term transillumination iris
defects or (TID's). See color plates in Dr. Casser's book.
Furthermore, retroillumination of the crystalline lens is required to
classify and grade both cortical and posterior subcapsular cataracts
using LOCS II.
The cornea is probably the most common structure viewed in retro-

illumination. Keratic precipitates (accumulation of white blood cells
and fibrin) will appear white in direct illumination but dark by retro-
illumination. This technique is valuable for observation of deposits on
the corneal endothelium and invading blood vessels. According to
some authors this is the only way by which tiny rod-like fibrin flecks
may be seen on the back of the cornea, warning the so-called "quiet
iritis" is still active. Retro-illumination is regarded by most
optometrist to be second in importance only to direct illumination.

4.) Sclerotic Scatter: This illumination uses a parallelepiped at the

limbus to scatter light internally throughout the cornea. Use low 6 -
10x magnification. In the case of central corneal clouding (CCC) the
biomicroscope is not used. The pupil is observed with the naked eye
from an angle directly opposite from the light source.
5.) Indirect-Lateral-Proximal: Place the biomicroscope directly in

front of the patient's eye and the illumination light source at about 45
degrees. Make sure 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 lateral 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 biomicroscope. This type of
illumination is widely used for observation of the corneal epithelium
and tears. Most helpful in detection of mycrocystic edema, faint
corneal infiltrates and other types of irregularities of the epithelium
and tears. Because it utilizes direct, indirect and retroillumination
simultaneously, one should consider it to be as important as any
other type of illumination.
Keratic precipitates on the endothelium of the cornea as seen in

direct, indirect, and retroillumination using a parallelepiped.

6.) Specular Refection: Again a parallelepiped is used. This is the

only means by which one is able to view the endothelial cells of the
cornea or the epithelial cells on the back of lens. The cells are seen
only by one eye and they appear in the ocular opposite from the
direction of the illumination light source.
The basic requirements for specular reflection are as follows:
1) The angle between the illumination source and

biomicroscope is approximately 60 degrees.
2) High magnification must be used.
3) High illumination is needed.
4) A parallelepiped beam of light is used.
Place he biomicroscope directly in front of the patient's eye and the

illumination light source at 45 - 60 degrees. Just off the limbus,
obtain a sharply focused parallelepiped of the cornea. Slowly
advanced it across the cornea until a dazzling reflection of the
filament is seen within the biomicroscope. This reflection is only seen
by one eye the other eye is not bothered. Keeping the reflected light
within the biomicroscopes field of view, the focus is moved back
toward the endothelial cells. There will be a point where two images
of the filament are seen, one bright, and the other ghostlike or
copper-yellow in color. Critically focus the biomicroscope on the latter
until a mosaic of hexagonal cells are seen. It should be noted that
even with 40x magnification the endothelial cells do not look as large
as most texts show. They resemble the appearance of the dimpled
surface of an orange peel or basketball. When the slit lamp's
illumination system and the biomicroscope are at equal angles of
incidence and reflection the cornea's endothelium is viewable. Both
front and back surfaces of the crystalline lens can also be viewed
using specular refection.
Positioning The Patient In The Slit Lamp

1.) Procedure:
Inform the patient what you are going to do and why. For Example:
This is a slit lamp biomicroscope and I'll be examining the general
health of your eye. I'll be checking for any signs of past or present
infections that you may or may not be aware and any signs of
cataracts.
2.) Head Position:
A.) Tell the patient what you want them to do: chin in the chin rest
and forehead up against the head rest. For professional and hygienic
reasons always place a facial tissue on the slit lamp's chin rest. You
should have already cleaned the head and chin rest with an alcohol
swab. This is always done between every patient. This not only helps
keep things more antiseptic, but also makes the slit lamp smell clean
and more professional.
B.) Make sure the patient not only looks comfortable but is
comfortable. Their forehead tight against the head rest, chin firmly
down on the chin rest and their outer canthus aligned with the black
marker on the slit lamp post. At this point it is a good idea to reach
around and gently pull their head slightly forward against the
headrest.
3.) Fixation Instructions:
The patient must be given fixation instructions, where you want them
to look. This might be the fixation light, part of the slit lamp or just
past your ear.
4.) Pre-Alignment And Focusing:
Tell your patient to close their eyes and relax while you get things
aligned. Turn the biomicroscope on and focus the light source on the
patient's lid. The eye lid is only about 1 mm thick, therefore, when
you instructed the patient to open their eyes you should almost be in
focus on the tear film of the cornea.
Suggested Slit Lamp Examination Procedure

(1) (2)

Use Broad Beam or a 2 To 3 mm wide Have The Patient Look To Their Left,
Parallelepiped Type Illumination, Light Source To Your Left At
Magnification 10-16x, Illumination On Approximately 45 Degrees , The
Low @ 45 Degrees, Examine Both The Microscope Is Set Straight Ahead. Scan
Upper And Lower Lids And Lashes In A And Examine The Temporal Bulbar
Arching Motion. The Patient's Eyes Are Conjunctiva
Open And The Illumination Source Is
Moved At The Midline Of The Lid.
(3) (4)
Have The Patient Look To Their Right, Have The Patient Look UP, Retract The
Light Source To The Left At 45 Degrees Lower Lid, Examine The Lower Bulbar,
The Microscope Is Set Straight Ahead. Lower Palpebral Conjunctiva and Inferior
Scan And Examine The Nasal Bulbar Cornea. The Light Source Should Be
Conjunctiva. Moved Across To The Opposite Side At
The Midline Of The Eye. Microscope Is
Set Straight Ahead.
(5) (6)
Have The Patient Look Down, Retract The Use A Parallelepiped, 16X Magnification,
Upper Lid, Examine The Upper Bulbar Light Source At 45 Degrees And The
Conjunctiva and Superior Cornea. The Microscope Set Straight Ahead. Scan And
Light Source Should Be Moved Across To Examine The Cornea. The Light Source
The Opposite Side At The Midline Of The Should Be Moved Across At The Midline
Eye. Microscope Is Set Straight Ahead. Of The Cornea.
(7) (8)

Use A Full Length Optic Section, Use A Narrow Parallelepiped, 16X

Magnification 16X, Light Source At 60 Magnification, Light Source At 45 Degrees
Degrees And The Microscope Set Straight And The Microscope Set Straight Ahead.
Ahead. Evaluate And Grade The Temporal Examine The Iris, Crystalline Lens And
And Nasal Angles Using The Van Herick The Anterior Vitreous Body.
Technique
Important: Always, pull the slit lamp back, shut off the instrument,
and lock it down at the end of any procedure.
The above is only intended as a schematic and students are
encouraged to develop any order with which they feel comfortable. It
should be pointed out that all steps in the schematic are relevant and
should be part of the procedure.
To View Part Two
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Slit Lamp Biomicroscopy Part Two
Slit Lamp Examination

Associated Ocular Conditions
Part Two
Things You Must Know

Tear Make Up
1.) Lipid: Meibomian Glands ( Outermost )

2.) Serous: Lacrimal Gland
3.) Mucin: Goblet Cells ( Innermost, Nearest The Cornea)
Tear Break Up Time And Contact Lens Success
1.) Equal To Or > 15 Sec.----Very Acceptable

2.) 10 - 14 Sec.-------------Is Questionable --Must Be Selective
3.) < 10 Sec.----------------Not Acceptable --"Dry Eye"
Types Of Corneal Opacities (Scars)
Scar Types---------------------To Be Seen---------------Vision

1.) Nebular }(No) ----------Need Slit Lamp--------Vision Usually
Okay
2.) Macular }(More) -------Need Slit Lamp--------Vision Can Be
Affected
3.) Leukoma }(Light) -----Just Light------------Vision Greatly
Reduced
Anterior Uveitis
"Signs And Symptoms"
1.) PAIN: Moderate To Severe

2.) PHOTOPHOBIA: Pain From Most Any Type Of Light, Consensual Pain
Reflex Present
3.) INJECTION: Conjunctival And Or Limbal
4.) SMALL PUPIL: On The Affected Side
5.) MUDDY IRIS: Due To Swollen Vessels An Cellular & Protein Debris
6.) REDUCED VISION: Due To Tearing Or What Precipitated The
Inflammation
7.) FLARE: Smoky-Appearing Precipitate Of Protein "Flare"
8.) CELLS: White Blood Cells
9.) POSTERIOR SYNECHIAE: Resulting From The Cells And Flare
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10.) LOWERED INTRAOCULAR PRESSURE: Reduced Aqueous Production

Secondary To The Inflammation. This is True in the Initial Stage of the
Inflammation. In The Later Stages The Intraocular Pressure Will Rise If
Treatment And Control Has Not Been Established.
Homatropine (5%) is the drug of choice for dilation a patient with a

anterior uveitis. Place one drop in the affected eye every 5 minutes
(i gtt q 5 minutes) or until the pupil starts to dilate. It is very important
to know the pupil is dilating before patching a patient.
When prescribing homatropine for use at home, instruct the patient to

place one drop in the affected eye, once in the morning and again
before going to sleep until told to do otherwise. Every morning and at
bedtime is abbreviated (qam & hs).
Unique Properties of Homatropine and Why It Is Used
1.) PRODUCES CYCLOPLEGIA: Paralyzes The Ciliary Body Which

Increases Patient Comfort and Reduces Pain.
2.) RESTORES NORMAL IRIS VASCULATURE: Reduces Release Of Cells
And Protein
3.) PREVENTS POSTERIOR SYNECHIAE: Dilates the pupil Averting
Secondary Glaucoma
Upper Lid Eversion
You must to be able to evert both the right and left upper lids with the
patient behind the slit lamp. The technique described in Dr. Casser's
book leaves out one very important step. Regardless, if a Q' tip or just
fingers are used to evert the upper lid the lid must be totally everted.
Evert the lid from the temporal side completely to the most nasal side.

ONLY GRASP THE THE INDEX FINGER

LASHES AND NOT THE MUST BE FREE TO
SKIN OF THE UPPER REACH OVER AND
LID BETWEEN THE EVERT THE INNER
THUMB AND INDEX MOST PART OF THEIR
FINGER. LID.
The technique is to have the patient look down so your thumb is just
under the upper lashes. Grasp only the lashes between your thumb and
index finger. Pull down and out breaking the suction and forming a
slight air pocket between lid and globe. Once the upper lid is everted
use the thumb to firmly pin the outer lid margin and lashes against the
temporal orbit. Freeing the index finger, reach it across and evert the
nasal part of the lid too.
It is important to give your patient good instructions. Do not overly

alarm them just explain what you are going to do and why. The patient
is told the procedure is slightly uncomfortable but not painful. Tell the
patient to keep looking down at all times. This helps keep the cornea
partly covered by the lower lid reducing tearing and drying. If the
patient looks up most likely the lid will flip back down and the procedure
will have to be started all over again. This will only add to the patient's
anxiety and unwillingness to cooperate. "Be sure to check for false
eyelashes before your start." There are many reasons for everting the
upper lids, the following are just some of those reasons:
1.) All Prospective Contact Lens Patients
2.) Patients With Irritation And Seasonal Allergies
3.) Removal Of A Lost Or Possible Lost Contact Lens
4.) Searching For A Foreign Body
5.) Removal Of A Foreign Body From The Upper Lid
6.) Evaluating The Apex Of Internal And External Hordeolums
7.) Evaluating The Internal Apex Of Chalazions
8.) Grading And Evaluating The Presence Of Giant Papillary
Conjunctivitis (GPC)
9.) Evaluate GPC With Fluorescein Sodium And Cobalt Blue Light
10.) Checking For Scaring Of The Lid Secondary To Previous GPC
Clinical Stages of Giant Papillary Conjunctivitis

Preclinical - Baseline Stage Early Developmental Stage
Little Fluorescein Pooling Increased Fluorescein Pooling
Clinically Significant Stage Severe Clinical Stage
Marked Fluorescein Pooling Extreme Fluorescein Pooling
Grading Giant Papillary Conjunctivitis

Morning Itching on Lens Method of
Stage Size of Papillae
Discharge Removal Diagnosis
1 Minimal Increase Mild Baseline Symptoms Only
Small Red Dot Slit Lamp Cobalt
Papillae Areas Filter and
Extending to Lid Fluorescein Dye
2 Moderate Increase Increased Margin that Pools Around
Beginning
Elevations

Increased Slit Lamp and

Moderate to Number and Size Occasionally the
3 Moderate Heavy of Elevations Naked Eye
Severe
Heavy: Lids Stick Flattening of the

Together and Elevations and With the Naked
May Have to be Moderate to Progression of Eye
4
Separated Severe Stage Three
Adapted and Modified from Allansmith et al.

Cataracts Types
1.) Developmental: Usually Congenital

2.) Pre-Senile & Senile: Age Related Cataracts
3.) Complicated: Secondary To Intraocular Inflammations
4.) Traumatic: Secondary To Eye Trauma
Examples
I.) Congenital Cataract Types

Coronary (Club Or Crown):-- Found in the far periphery of the lens
and are seen only with dilation. They have a ball bat or bowling pin
shape and may be single or numerous. They are found in about 25%
of the population in some shape or form.
B. "Y" Suture (Stellate):-- Are opacities located in the fetal nucleus

and can involve either the anterior or posterior "y" sutures or both
and many times are bilateral. They do not cause a reduction in vision
nor will they get any larger.

C. Anterior Polar (Pyramidal): -- Usually round, well defined, dense

opacity on the anterior surface of the lens. Because of its shape,
which might look similar to a pyramid, the name anterior pyramidal
cataract is sometimes used. This opacity may have an effect on vision
depending on its size and location, though this is rare.
D. Posterior Polar (Pyramidal): -- Again, this is usually a round, well

defined, dense opacity, but located on the posterior surface of the
lens. Because of its shape it may, also, be referred to as a posterior
pyramidal cataract. Because this opacity is located on the posterior
surface of the lens, closer to the retina, there is a greater chance that
it will have an effect on vision depending on its size and location.
E. Zonular (Lamellar): -- Some authors feel these are among the

most frequent types of congenital cataracts. They may vary in size
which is dependent upon what time during the intrauterine stage of
development the disruption occurred. They are oval in shape when
viewed with an optic section and round when viewed in reto-
illumination through a dilated pupil. They surround a clear or almost
clear central zone of the embryonic and fetal nucleus and contain a
varying number of small grayish to white punctate shaped opacities.
These opacities have a tendency to increase in density rather than
size, becoming stationary in mid-life "35 to 55" years of age. Because
they do increase in density, vision may become reduce to varying
degrees.

F. Mittendorf`s Dot: -- This is a remnant of the hyaloid artery that

has failed to dissolve and usually remains partly attached to the back
surface of the lens or may be free floating just behind the lens. There
may be a part of the hyaloid artery that trails off into the vitreous in
a corkscrew-shape. Though many may think this is a relatively
benign finding, "I can assure you vision can be reduced to 20/200 or
worse."
G. Reduplicating Cataract: -- This is a anterior lens opacity. This

condition shows that there has been an intrauterine or, more rarely,
postnatal injury or defect of the anterior capsule. This process results
in a localized opacity of the anterior capsule with similar opacities
behind it, but separated from each other by normal lens tissue.
II. Pre-Senile & Senile Cataracts (Age Related)

A. Cortical (Spoke - Cuneiform): -- These start in the periphery of
the lens and progress toward the pupillary area. They may start in
any quadrant, however, the inferior nasal area seems to be more
prevalent. They start out as lamellar separations as the lens takes on
water and progress to waterclefts as the lamellar fibers are torn
apart. These areas rapidly fill with fluid and appear as optically empty
spaces when viewed with an optic section. These fluid filled spaces

progressively become more opaque until they finally form a fully

developed cuneiform cataract.
Using Retroillumination Of The Lens And Locs II
If the spoke opacities do not invade the pupil and are only seen
during dilation you should only grade them as grade 1/2. It is
conceivable that one might have one sector extending into the pupil
while another sector is only seen when the pupil is dilated, this
should be graded as 1 and 1/2 or better yet as a (1+) cortical
cataract. It should be kept in mind that these opacities may occur in
either the anterior or posterior part of the lens and a cross section
drawing should be made to indicate their true location. They are
usually slow progressing opacities, however, like any cataract one
cannot predict how fast they will progress.
B. Posterior Subcapsular ( Cupuliform - PSC ): -- The typical
appearance of this opacity is vacuolated and granular in nature. It is
a thin area of dense opacification located in the most posterior layers
of the lens cortex and usually along visual axis region. Patients past
forty (40) it may take on a yellow hue secondary to nuclear sclerosis.
Because of its position and granular nature it may cause marked
reduction in vision while the remainder of the lens may be very clear.
Causative factors may be, age - related, secondary to steroid
therapy, trauma, or secondary to a long standing chronic uveitis. The
last of these may take on a notable color play for it is a form of
complicated cataract. Posterior subcapsular cataracts (PSC) are one
of the fastest progressing age-related lens changes and need to be
closely monitored.

Using Retroillumination Of The Lens
C. Nuclear Sclerosis ( NS ): -- It begins soon after the age of 40, as a

simple sclerosis of the older central part of the lens. There is
ultimately a change in the refractive index of the lens over time in
the direction of myopia sometimes referred to as "second sight". In
the advancing stages the nucleus will take on a round "oil droplet"
like shadow appearance. This is very noticeable when viewed in retro-
illumination with the direct ophthalmoscope at a distal distance or
reto-illumination with the slit lamp, both with the pupil dilated.
Using An Optic Section

The Color Change, "Yellowing" Of The Lens, Plus The Overall Central
Haziness Is What Determines The Stage Or Grade.
Grading Based On Lens Color

Grade Color
1/2 Slight-Yellowing
1 Definitely-Yellowing
2 Very-Very-Yellow
3 Yellow-Orange
Orange-Brown
4
(Brunescent)
There have been attempts to correlate the different and varying

grades of color change with visual acuity. This in my opinion does not
work out very consistently. It is not uncommon to have all types of
these age related cataracts present at the same time and they will
have an additive reduction on vision. Their location within the
undilated pupil is the most important factor related to reduced vision.
III.) Complicated Cataracts: -- This type of cataract is usually

reserved for opacities developing within the lens secondary to an
ocular disease or some other atypical type of ocular condition.
Causative factors may include, high myopia, retinal detachment,
chronic uveitis, retinitis pigmentosa, ocular tumor, etc. Complicated
cataracts begin with a change in the posterior lens capsule, notably
the lens shagreen, taking on a play of colors "not" seen in senile (age-

related) lens changes. In the later stages the posterior subcapsular

part of the cortex becomes involved. There are two main features
that help distinguish it from other forms of cataracts.
1.) Definite multicolored luster appearance, in the early stages, of the
posterior lens capsule.
2.) The opacities are not clearly separated from the other lens
structures, but rather are surrounded by a cloudy haze.
IV.) Traumatic Cataracts

A. Vossius Ring: -- There is an ongoing controversy over whether or
not the anterior subepithelium of the lens tissue is effected. It is
agreed that it only occurs in the young and is a pigment ring
corresponding to the pupil margin of the iris following a contusion to
the eye. Also, that the pigment is brown and in many cases the
pigment may disappear completely. The controversy may be link to
other lens findings following a contusion which may be related to
hyphema (blood) in the anterior chamber. The hemosiderin (iron)
from the blood is deposited within the lens surface epithelium.
Questionable theory, but one that has been proposed.
B.) Rosette Cataract: -- This opacity may occur under the anterior or
posterior capsule or both and may be complete or sectored with a
flower peddle or feather shape. One can get a very close estimation
as to when the injury occurred by viewing the lens with an optic
section and determining at which nucleus it appears. Like any other
cataract the effect that it has on vision depends on its location and
density.
There are a great number of other forms of cataracts that have not
been discussed and you should review. DR. FREDERICK C. CORDES'
MANUAL CATARACT TYPES: ON RESERVE IN THE LIBRARY.
Cataract Patient Referrals
Doctors must decided when to refer a patient for cataract surgery. It

is most important that the patient's retina can still be evaluated by

the surgeon. "The general rule of thumb for referring is as follows:
when the patient's visual acuity has dropped to 20/80 in dim
illumination or when the cataract starts to have an effect on their
ability to perform their normal daily tasks". You cannot predict how
fast a patient's cataracts will progress, however, patients are going to
ask you how soon it will be before they will need surgery. The best
policy is to monitor these patients on a four (4) to six (6) month
bases or sooner if the patient becomes concerned because of a
noticeable visual change.
Vitreous Evaluation
A.) Normal Vitreous: -- The anterior vitreous is adhered to the back

of the lens in an area approximately 9mm in circular diameter and is
known as the "Ligament Of Wieger." Within this area is an optically
empty retrolental space known as "Berger's Space." The anterior
vitreous of the young individual is grayish in color with optically
empty spaces between the collagen fibers. Small white dots
(nodosities ) may be seen where fibers cross one another and this is
normal.
B.) Aging Vitreous: -- With increasing maturity (aging) the collagen
fibers lose their fluid binding ability and the fibers and fluid start to
separate. The collagen fibers start to clump together forming an
increase in the so-called vitreous floaters, noticed by the patient and
the doctor. Further aging plus shirking and liquefaction of the
vitreous the fluid may escape through the hyaloid membrane causing
the vitreous body to pull and separate from its posterior attachment
to the optic nerve. The posterior vitreous detachment (PVD) may be
seen, at a distal distance with the direct ophthalmoscope, as a
annular ring in retro-illumination and dilated pupil. Other reasons for
floaters are vessels that fill the eye in the fetal state do not totally
dissolve and remnants remain in the vitreous body. Also, myopic
individual's cystoidal areas near the ora rupture easier allowing their
fluid to be released into the vitreous causing somewhat of a earlier
aging effect.

C.) Asteroid Hyalosis: -- This condition was once thought to be

secondary to an ocular inflammation, which it is not. It is usually
diagnosed in patients in their sixties or later and is considered to be
an aging vitreous condition of unknown etiology. It is thought to
occur more frequently in males than females. The condition is usually
unilateral, but may be bilateral. These round spherical opacities
(containing calcium soaps) within the vitreous are attached to the
vitreous collagen fibers and will move with the vitreous like floaters
which always return to their original position. They are disturbing to
patients like floaters, but to a much greater degree for they have a
disorientating effect. When viewed in direct illumination with either
the slit lamp or direct ophthalmoscope they appear as bright yellow
opacities. This is secondary to the nuclear sclerosis of the lens. These
opacities are really white in color.
D. ) Synchisis Scintillans: -- Is a condition of a younger vitreous and

is either secondary to an injury or inflammation that has involved the
vitreous cavity. This is considered to be a rather rare condition which
is usually bilateral. Unlike asteroid hyalosis the opacities are free
floating in the vitreous, not attached to the collagen fibers, controlled
by gravity and seeking the lowest point within the vitreous cavity.
The opacities are cholesterol crystals and are truly yellow in color in
direct illumination.
E.) Shafer's Sign: -- The presence of pigment granules suspended in

the anterior vitreous or floating in Berger's space, sometimes termed
"tobacco dust," can be very significant clues to a retinal break or
detachment. Hamilton and Taylor found that 98% of patients in their

clinical review with this sign had retinal detachments and 60% had
flat retinal holes. The source of the pigment granules is not known,
though is suspected to arise from the retinal pigment epithelium
(RPE). There are a large number of patients with retinal detachments
that are totally asymptomatic an simply checking the retrolental
(Berger's Space) & anterior vitreous for cells is important. The failure
to check for this sign on a symptomatic patient could be considered
gross negligence
( symptoms being flashes of lights in their peripheral fields and or an
increase in the number of floaters). Red blood cells, secondary to a
vitreous hemorrhage, may be difficult to differentiate from the
pigment granules. However, when a red free filter (green) is
introduced the red blood cells will appear black and not be seen while
the pigment granules will. The pigment granules will not absorb the
red-free light and will still be seen. If the vitreous cells are white in
color, they are most likely inflammatory white blood cells. Their
presence usually indicates a posterior segment inflammation;
although, an anterior uveitis may cause cells in the anterior vitreous
also.
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Slit Lamp Biomicroscopy Part One

Slit Lamp Illumination Types

A wide, un-narrowed, beam of light is directed at the cornea from an

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condition affecting epithelial integrity. Do not confuse "negative

Diffuse, wide-beam, illumination together with the red free (green)

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A) Ciliary Injection B) Episcleral Injection C) Conjunctival Injection

With the optic section as mentioned above, it is possible to detect

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illumination source is always moved to the opposite side when

With a clearly focused optic section slightly temporal to the center of

1) The Front Surface Bright Zone Is The Surface Of The Tears

To attain an optic section of the crystalline lens, the angular

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Van Herick Angle Estimation Method

Moderately Open Angle; Incapable Anterior Chamber Depth (Shadow) is

Moderately Narrow Angle; Closure

Extremely Narrow Angle; Closure Anterior Chamber Depth (Shadow) is

Basically Closed Angle; Closure is Anterior Chamber Depth (Shadow) is Only

Adapted from: Van Herick W, Shaffer RN, Schwartz A. Estimation of width of

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The "Split Limbal Technique" allows you to make an estimation of the

"Split Limbal Technique"

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b.) Conical Beam: Examination of the anterior chamber for cells or

The traditional method of locating and grading cells and flare is to

Grading Cells and Flare

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Grade Aqueous Cells Grade Flare

2-5 Cells Seen in 45 Faint: Haze or Not Equal

Moderate: But Iris Detail Still

Cells Scattered Through Out Marked: Iris Details Becoming

Dense Cells in Beam, More Dense Haze: With Obvious

READ VOL. 4 - CHAPTER 32 IN "DUANES' CLINICAL OPHTHALMOLOGY"

Cells and flare in the anterior chamber represent a condition of great

Grading the Consensual Pain Reflex

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C.) Parallelepiped: A parallelepiped is one of most common types of

Tear debris is usually benign and related to allergies or sinus

Grades of Cornea Striae

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Endothelial pigmentation when heavy and located vertically on

3.) Retro-Illumination: Usually uses a parallelepiped that bounces

The cornea is probably the most common structure viewed in retro-

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4.) Sclerotic Scatter: This illumination uses a parallelepiped at the

5.) Indirect-Lateral-Proximal: Place the biomicroscope directly in

Keratic precipitates on the endothelium of the cornea as seen in

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6.) Specular Refection: Again a parallelepiped is used. This is the

1) The angle between the illumination source and

Place he biomicroscope directly in front of the patient's eye and the

Positioning The Patient In The Slit Lamp

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Suggested Slit Lamp Examination Procedure

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Use A Full Length Optic Section, Use A Narrow Parallelepiped, 16X

To View Part Two

Return To Home Page

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Slit Lamp Examination

Things You Must Know