17/12/2021

Slit lamp techniques & CLs

complications

Wasim Sarwar & Shamina Asif

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Disclaimer

 Please do not rely solely on our suggestions and answers as we are here to guide you on how
to revise and understand topics
 What has been provided is a framework for you to develop and make your own
 Please do some further reading and independent learning around topics as we cannot cover
every single element in this short tutorial

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OSCE stations
 There are practical elements to the OSCE stations
 This includes carrying out Van Herick assessment, conical beam, specular reflection
 We will talk you through how to do the techniques, but you must practice on px’s yourself
 As you become more experienced over years – you will not have to think about how to set
up the slit lamp to do a particular technique – it will just flow, you will learn yourself that
to look at vessels you need to be using an indirect illumination.
What is the importance of techniques?
 If you use the wrong technique to look at a certain structure you will miss pathology – i.e.
a direct beam on a blood vessels will bleach the area of interest, you need to move to the
side.
 In order to pick up Fuchs endothelial dystrophy, you need to use high mag and specular
reflection to see that it is becoming grainy in appearance (as well as being proficient in
retro illumination)
 To examine the lids and surrounding areas you need low mag or diffuse illumination,
otherwise you may only view the cornea and miss lid lesions

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Techniques

Diffuse
Parallelepiped
Optic Section
Specular Reflection
Van Herrick
Sclerotic scatter
Conical Beam
Retro-illumination

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Slit lamp background

 Of all the procedures conducted by optometrists and ophthalmologists during a routine assessment, the
slit-lamp biomicroscope is one of the most important, due to the excellent stereoscopic view and range
of magnification available.
 The relatively simple instrument remains broadly similar to the original device dating from the start of the
20th century. The main change is the addition of video imaging on some models.
 Practitioners should develop a logical and consistent routine when performing a slit-lamp assessment.
It’s recommended you start anteriorly and observe structures gradually working from front to back, each
eye in turn
 There are a number of different designs of slit lamp, most commonly the Haag-Streit and Zeiss styles.
 Disinfect the eyepiece cups, and joystick controller.
 The slit lamp table should be positioned so the practitioner has a straight back and good posture.
 Set a bright narrow beam of light to shine on a focusing rod.
 Set each eye piece individually to maximum plus, then while viewing, reduce the eyepiece plus dial until
the beam appears clear and sharply in focus.
 Do this with a low/medium magnification for each eye.

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Slit lamp background

 This ensures that the practitioner’s accommodation is relaxed whilst using the instrument.
 Adjust the binocular microscope to the correct interpupillary distance. With both eyes open, a binocular
stereoscopic view of the focusing rod should be achieved. Fine tuning of the microscope position and
angle may be required.
 Ask your patient to remove any glasses. Explain the procedure.
 “I am going to use this microscope to examine the front of your eyes.”
 If the patient is happy to proceed, implied consent may be given by the patient voluntarily placing their
chin onto the chin rest.
 Dim the room lights and ask the patient to fixate on an object such as your ear.

Avoid cleaning the actual eyepiece lenses because

then the coating is removed

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Direct techniques
3.1.2 Uses a slit lamp to examine the external eye and related
structures
Technique Use
Diffuse General eye view for lumps
6-10 x magnification or diffuser and bumps
Wide and tall beam
45o angle between observation & illumination
Parallelepiped Approximation of the depth of
2-3mm wide beam, maximum height any abnormalities, 3D view
10-16 x magnification
45-60o angle
Optic section Locates the layer of a defect
Thin slit (1mm), maximum height once detected with
16-25x magnification parallelepided
45-60o angle
Specular reflection (monocular view) Assesses the integrity of the
30-450 angle corneal and lenticular
16-40x magnification surfaces
Tall slit beam

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Direct techniques

Parallelepiped Indirect illumination

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Specular reflection

Corneal reflex /
Purkinje Image I
Corneal reflex Endothelium
(Purkinje II)

Corneal section

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Specular reflection – Fuchs endothelial dystrophy

Information taken from the College CMG’s
 The most common posterior corneal dystrophy
 Slowly progressive dysfunction of the corneal endothelium that eventually results in corneal oedema
and reduced vision; resultant stromal and epithelial oedema leads to epithelial bullae
 Can have genetic element to it
 Most cases begin in the fourth decade or later
 Females are more likely to get it
Corneal reflex /
 Another risk factor is smoking
Purkinje Image I
Corneal reflex Endothelium
 Symptoms – none at the beginning but then glare at night and blurred vision especially on waking
(Purkinje II)
(this is due to overnight corneal oedema)
Diurnal changes in refraction (relatively myopic on waking)
Corneal section
 Usually bilateral and you see on posterior surface (guttata) - ‘beaten metal’ appearance, this results
in not having a clear specular reflection

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Fuchs endothelial dystrophy

Corneal reflex /
Purkinje Image I
Endothelium
(Purkinje II)

Corneal section

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Direct techniques
Technique Use
Van Herick Anterior chamber angle
Optic section (1mm) beam, very close to the limbus
60o angle
10-16x magnification
Temporal/nasal examination

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Direct techniques

Grade Ratio of optical space to Classification

corneal section (and management)
4 1:1 Open (none)
3 1:2 Open (none)
2 1:4 Narrow (routine referral)

1 <1:4 Closure likely (same day

referral if has sx, impending
closure)

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Direct techniques

Technique Use
Conical beam Checking for cells/flare in the anterior
Parallelepiped – reduce the beam chamber such as in the investigation of
until the height and the width of Anterior uveitis
the illuminating beam are equal
(square shaped)
45-60o angle, 16-25x magnification
Dark room
Focus onto the front surface of
the cornea
Direct all the light through the
pupil illuminating a small area of
the lens
Pupil is used as a dark background

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Direct techniques

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Conical Beam

Questions:

1) Why dim the room?

2) What is the difference between cells and flare in

terms of appearance?

3) What is the difference in terms of biological origin?

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Direct techniques

Technique Use
Sclerotic scatter Assesses corneal clarity & transparency
45o illumination at the temporal limbus, Light scattering
low magnification Total Internal Reflection
Decouple or look to the side with naked
eye
2mm slit beam
4-5mm in height
Dark room
Retro-illumination Area of interest is illuminated by light
Moderately wide beam reflected back from the iris or retina
Medium-high magnification Iris – FB and vascularisation
Coupled or decoupled Retina – cataract and iris
transillumination

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Direct techniques

Sclerotic Scatter - uncouple Retroillumination

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Common Problems
 Not having the correct focus with the eyepieces

 Bleaching your view with direct bright light on area of interest

 Clumsy use of controls, one hand on joystick and the other to move the illumination system and touch
eyelids - it take practice.

 Room lights to bright, resulting in missing pathology when using retro illumination and conical beam.

Top tips
 Do slit lamp on every single person and check their angles

 Make sure the light is bright enough when examining structures

 Must get px to look up and down when examining the cornea

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Slit lamp assessment

 Diffuse illumination: Provides an overall assessment under low magnification (~10 × ). Adjust the
illumination to a wide beam and place a diffusing filter in front of it to systematically examine the
components of the anterior segment and adnexa

 Direct illumination using a parallelepiped: Use low to moderate magnification ~10 ×. Set the
illumination system at approximately 45° from the microscope position on the temporal side and use a
beam width of approximately 2mm

 Move the slit lamp laterally across the tissue until the centre is reached, maintaining good focus at all
times. Then sweep the illumination system across to the nasal side, taking care not to bump into the
patient’s nose, and examine the nasal tissue. This scanning procedure may be repeated several
times to examine all areas of the tissue concerned and may require more than one level of
magnification. Ask the patient to look up and down to ensure all of the cornea is examined Being able
to keep a parallelepiped sharply in focus as you scan from temporal limbus to central cornea and then
nasal limbus to central cornea, is the foundation for a good slit-lamp technique.

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Slit lamp assessment

 Eyelids and lashes: Examine the superior eyelid and lashes first using the scanning procedure described
above.
 Conjunctiva: Ask the patient to look upwards while you pull the lower eyelid gently downward to expose the
lower fornix for examination. Examine both the bulbar and palpebral conjunctiva using a scanning process.
Next ask the patient to look downwards and gently pull up the upper eyelid, thereby exposing the superior
bulbar conjunctiva for examination. Finally ask the patient to look in right and then left gaze to allow
examination of the entire conjunctiva
 Cornea and tear film: Use the scanning process to examine the cornea in three sweeps: inferior, central
and superior
 Assessment of the tear meniscus: The height of the tear meniscus can be estimated by decreasing the
height of the slit-lamp beam to one millimetre and then judging the relative height of the meniscus at the
lower lid margin as a proportion of the beam height.
 Iris: Examine the iris with direct illumination by moving the joystick towards the patient. Take note of the
depth of the anterior chamber and the shape of the pupil

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Slit lamp assessment

 Lens: Examine the lens, using an optic section. The Y sutures may be visible, as will cataract
 Anterior vitreous: Moving the joystick further towards the patient allows viewing of the anterior
vitreous with a parallelepiped. Completing a dynamic assessment is most useful and this is best
performed when dilated. This is probably the most difficult structure to view and may take many years
before it becomes confident to view pathology.
 Dynamic vitreous assessment – used to look at the vitreous to pick up Schaffer’s signs as well as
Vitreous haemorrhage

https://imagebank.asrs.org/discover-new/files/
1/25?q=detached%20vitreous

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Volk and slit beam

 Cases like Cystoid macula oedema you would put the slit beam on the macula and see if the slit
beam is straight – if there is elevation the beam will move to the side and then after elevation it
would come back again – with both eyes binocularly though you would see elevation of the macula
Note: this is different to a Watzke-Allen slit beam
test
Cystoid Macula Oedema The WASBT is a good low-tech tool to help
distinguish between full-thickness macular holes
looking through a slit lamp
and pseudo-holes. Patients can describe one of
these slit beam options after testing

https://www.reviewofoptometry.com/article/mac
ula-exam-tips-and-tricks

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Cystoid Macula Oedema

 Irvine-Gass syndrome: a complication following cataract surgery – can happen 8 weeks after
surgery usually but can happen even up to 6 months later (swelling/fluid at the macula)
 Can occur after CRVO or BRVO
 Vision is affected, CMO normally affects near vision more
 Usually some scotoma or distortion in the eye and epiretinal membrane
 More likely to happen if had CMO before
 More likely to happen if complications during surgery
 More common in Diabetics
 Factors that increase risk of this are: Uveitis, previous vein occlusion, previous episodes of CMO,
px’s using beta blockers or prostaglandins for glaucoma and epiretinal membrane
 Urgent referral – one week
 Treatment – usually gets better but maybe prescribe NSAID – if recurrent given steroid injection
in the eye
 Prognosis – very good 90% cases resolve
 For the non resolving cases – intravitreal steroid injections are given

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Cystoid Macula Oedema

https://www.semanticscholar.org/paper/Cyst
oid-macular-edema-induced-by-nab-
paclitaxel-Tanaka-
Bando/e7271beb9bc773d482ca49fbfc78d096f3
273b62/figure/0

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Dry eye complications

Lid Wiper Epitheliopathy (LWE)

This is a clinical condition observed as vital staining of the upper and lower lid margin regions
that are in contact with the globe of CL

It is believed to result from an increase in friction between the palpebral lid and the opposing
bulbar conjunctiva cornea or CL
You would check this with lissamine
green.
GOC issued in March 2020
based on the evidence available and
practice and clinical opinion, lissamine
green is clinically safe to use and that
optometrists and contact lens opticians in
the UK may, within their scope of
practice, use a CE marked lissamine green
impregnated ophthalmic strip for clinical
investigations of the ocular surface until
further notice.19

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Dry eye complications

Step by Step guide to use of Lissamine Green

LG has been shown to have a similar staining pattern to rose Bengal, but it is much better tolerated by
patients. Its best efficacy is in the examination of conjunctival staining, while sodium fluorescein remains
the most suitable dye for the visualisation of corneal staining.
The Tear Film and Ocular surface Society guidelines for LG instillation should
also be followed, namely:

• For instillation, wet the LG strip with saline, with the whole drop retained on
the strip for at least 5 seconds to elute the dye

•10 µL, or ¼–½ drop, appears optimal volume if pipetting a specific

concentration

• The drop is instilled inside the lower temporal lid on upgaze with the eyelid
pulled temporally to avoid damage to the conjunctiva or lid wiper tissue

• Observation should occur between 1 and 4 minutes post-instillation, with use of

a red filter to potentially aid visualisation

•For lid wiper epitheliopathy, assessment involves repeat instillation of LG using

two separate strips, wetting with two saline drops, with viewing recommended
after 3–6 minutes 1. Optometry in Practice
2. Volume 21, Issue 2
3. Lissamine green – where have we been and where are
we now?

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Dry eye complications

Lid Parallel conjunctival folds (LIPCOF)
These are conjunctival folds
You assess the area that is directly below the limbus – nasal and temporal. Then you make the
beam horizontal and you look for the conjunctival folds

No conjunctival Folds = 0
One permanent and clear parallel fold = 1
2 folds = 2
3 folds = 3
Dry eye threshold is that it should be less than 2

Treatment? Lubricating drops and better

CL e.g. hydrogel instead of SiH and more
lubricious lens surface

https://www.semanticscholar.org/paper/The-relationship-between-lid-parallel-conjunctival-
Bandlitz-Purslow/9afd201122cb6b5f973d3012c72f3cfedde88089

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Constituents of ocular lubricants – what might you

find in dry eye drops?
Aqueous Supplementation: common in all dry eye drops is aqueous base
Viscosity enhancing agents: e.g. Hyaluronic acid (HA). It occurs naturally in tears and is part
of vitreous humour. HA has been shown to bind to ocular surface cells and promote water
retention. It stimulates corneal healing by inducing fibronectin production. Some products
contain cross-linked HA which gives longer retention so drops only have to be used once or
twice a day

Carboxy Methyl Cellulose (CMC) – viscosity enhancing agent that binds to corneal epithelial
cells to promote healing.

Osmotic Agents: Increased osmolarity is a feature of dry eye disease. Some drops have low
osmolarity in an attempt to reduce the osmolarity of the tear film.

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Constituents of ocular lubricants – what might you

find in dry eye drops?
Antioxidants: Px’s with dry eye have higher levels of reactive oxygen free radicals. Antioxidants
such as vitamin E and co-enzyme Q10 may help to reduce this and thus less inflammation
Preservatives: Preservative – free drops help to limit the likelihood of allergic reaction in long
term use but many multi-dose drops still contain preservatives such as benzalkonium chloride,
polyhexanide or polyquad to prevent microbial growth. If using drops with CL wear make sure it
is compatible – read the box

Buffers: Citrate, phosphate and borate buffers are used to control the pH of eye drops to
maintain the stability of the active ingredients and to improve comfort on insertion

Electrolytes: Dry eye drops profile of electrolytes matches that of a healthy tear film. This
includes sodium, potassium and magnesium salts

Cell protectants: Q10 and substances like this have been shown to reduce cell damage and
promote wound healing.

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Constituents of CL solutions (generic)

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Constituents of CL solutions (generic)

Alcohols: e.g. 20% isopropyl alcohol. Dissolve lipids and efficient antimicrobial performance. High
cytotoxicity – must rinse carefully, may not be compatible with certain RGP materials

Chelating agents: e.g. EDTA and citric acid (opti-free solution)

Bacterial growth inhibited, do not bind within the hydrogel lens matrix, so no reports of irritation.
EDTA is not effective alone it needs to be used synergistically with other antimicrobials
Chlorine releasing compounds e.g. Halane and Halazone – (Softab by Alcon). Marketed in tablet
form requires saline as diluent. It’s not very effective at microbe killing and chlorine inactivated
by mucus so must clean before using.

Hydrogen Peroxide 3%: H202 e.g AOSept. Either one step – automatic neutralisation however
reduced antimicrobial power. 2 step – must neutralise properly before putting into eye. Use on
those wear lenses will definitely be exposed to more bacteria due to job?
Organic mercury compounds e.g. phenylmercuric nitrate PMN and Thimersol THI
Poor antimicrobial properties but very good anti-fungal properties. The mercurial ions enter cell
inactivate respiratory enzymes. THI is anionic = low cytotoxicity however notorious for giving px’s
allergic responses

Sorbic acid: e.g. sensitive eyes saline by Bausch and Lomb. Sorbic acid is an effective
bacteriostatic agent for saline and surfactant cleaners however not powerful enough for
disinfection and storage of lenses.

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Constituents of CL solutions (generic)

Quaternary ammonium compounds: e.g. Alkyl triethanol ammonium chloride ATAC and
Benzalkonuim chloride BAK: Has surfactant properties so good for cleaning and disinfecting used
with THwidespread. However BAK used more for therapeutic than contact lens solutions as toxicity
issues as it binds to certain hydrogels

Polymeric nitrogen containing agents: PABP,- Renu multipurpose solution, PHMB – Complete by
Allergan, Polyquad – Opti-free express. Synthetic long chain polymers, large molecule so will not
penetrate hydrogel lens matrix. Very good disinfectant.
PHMB is effective in treatment of Acanthamoeba keratitis at 0.02% concentration
Polyquad has good antimicrobial properties but poor anti-fungal agent, that is why used in addition
with other agents.

Pancreatin – Opti free enzymatic cleaner. It removes proteins and lipids, contains extract from the
hog pancreas.

Subtilisin A – sensitive eyes protein removal tablets – the best in terms of efficacy and removing
protein

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Constituents of CL solutions (generic)

Other solution components

Wetting agents PVA AND PVP Improves hydrophilic nature of lens and acts as a buffer between lens
and eye. Note 15-30 mins later mucus does same role so this is just for initial contact

Viscosity agents e.g. Methyl cellulose or hydroxyethyl cellulose

Viscosity agents increase residence time of a solution on the lens or ocular surface. They act as
lubricating and cushioning agent and give solution a thick and slippery feel

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Superior Limbic Keratoconjunctivitis (SLK)

Inflammatory reaction of cornea in superior limbic region. Px experiences Foreign Body sensation and
photophobia and pain when inserts lenses

May occur due to solutions containing Thimerosal in response to hypoxia or as an allergic reaction
Bilateral
Occurs in soft toric CLs
Superior cornea shows superficial punctate keratitis which can lead to subepithelial opacities
Pannus may develop to involve the whole cornea

Rare in terms if incidence

Management:
 Use non preserved solutions,
 Reduce wearing time and increase Dk/t of lens

https://webeye.ophth.uiowa.edu/eyeforum/cases/245-superior-
limbic-keratitis.htm

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Foreign Body tracking

Epithelial abrasion due to presence of foreign body under a lens
More commonly with hard and RGP lenses
Typically unilateral

Signs: characteristic superficial linear disruption to corneal epithelium

Symptoms: Pain relieved by elimination of the foreign body

Occasional in terms of incidence

Management:
 Avoid predisposing environments,
 Remove lens, and leave till healed with lubricants

https://rebelem.com/topical-anesthetic-use-corneal-abrasions/

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Superior arcuate epithelial lesions (SEALs)

Tight lid staining
Signs: superior arcuate staining of superior cornea – occurs in superior region of cornea normally covered by
the upper eyelid.
Symptoms: mild discomfort or none
Incidence: common
Associated with silicone hydrogel CLs

Management:
 Discontinuation of lens wear until resolved
 Lubrication with artificial tears
 Closely monitor for resolution if associated with EW lenses
 Refit into a CLs with a lower modulus or different design, esp if persistent

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Deposits – Jelly bump

Focal deposits on lens, particularly with high water soft contact lenses
Usually occurs after weeks or months of wear, care regime may be implicated

Signs – Focal gelatinous lump on lens surface

No real symptoms
Found occasionally

Management:
 New lens of different material (low water)
 Alter lens care regime
 Advise on compliance with cleaning procedures
 Maybe refit with dailies or high DK EW lenses

http://www.bausch.com.my/ecp/-/m/BL/Malaysia/Images/ECP/For%20Your%20Practice/Clinical%20Photos/Soft%20Contact%20Lenses/Jelly-
bump-on-high-water-content-lens.jpg

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Deposits – Protein
Sheets of denatured tear protein on the lens surface, occurs in, predisposed individuals, very common, may
initiate immune reaction such as GPC

Signs : uneven haziness on lens surface

Symptoms: increased lens awareness and itchiness

Management:
 Enzymatic cleaner
 Alter lens care regime
 Replace lenses if necessary
 Switch to frequent replacement daily disposable or RGPs

http://www.bausch.com.my/ecp/-
/m/BL/Malaysia/Images/ECP/For%20Your%20Practice/Clinical%20Photos/Soft%20Contact%20L
enses/Deposits-on-high-water-content-soft-lens.jpg

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Dellen
This is desiccation or focal corneal dehydration
You see a saucer like depression in the cornea, caused by local dryness and desiccation
Loss of stromal hydration causes compaction of lamellae
Occasionally occurs with 3 and 9 o clock staining in RGP lens wear

Signs: Depression in the peripheral cornea

Maybe scarring and vascularisation
Epithelium is intact

No real symptoms maybe dryness

Rare incidence

Management:
 Eliminate the causes of 3 and 9 o clock staining,
 Depression will resolve within days, scarring may not
 Persistent dellen may require reducing lens wearing time
or refitting with hydrogel lenses

https://eyewiki.aao.org/Corneal_Dellen

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Other CLs complications

Please see our soft and RGP CLs tutorials for more detailed information
Name Giant Papillary CLs Peripheral Microbial keratitis Acanthamoeba
Conjunctivitis (GPC) Ulcer (CLPU) keratitis
Causes Poor fitting CLs EW lenses Poor hygiene Showering or swimming in
CLs material Localised inflammation EW lenses CLs
Deposits Blepharitis Poor hygiene

Symptoms Variable vision Discomfort Red Pain>signs

Discomfort Redness Painful Redness
Itching on removal of CLs Mucus discharge Reduced VA
Stringy discharge Reduced VA

Signs Giant papillary conjunctivitis
Scarring on tarsal conjunctiva
Peripheral or mid Irregular and large corneal Epithelial or subepithelial
peripheral round stromal ulcer – central or mid infiltrates
infiltrate peripheral Pseudodendrites
Varying size: from 0.1mm AC cells and flare Radial Keratoneuritis
to 2mm
Redness in area of ulcer
esp if peripheral

Management Stop CLs wear Stop CLs wear Emergency referral to HES Stop CLs wear
NaCr drops Dailies Take CLs and case with them Emergency referral
Dailies Lid hygiene
Change material
Reduce wear time
Enhanced cleaning

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Quiz

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Quiz

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References

 College of Optometrists:
 Clinical management guidelines
 Cases I have facilitated
 Recording slit lamp video for College of Optometrists – Daniel Hardiman notes
 Diagrams – from Clinical Procedures in Primary Eye Care by David B. Elliott
 A guide to Clinical CL management – Adrian S Bruce and Noel A. Brennan Ciba Vision

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Upcoming courses

 Peer discussion: Real life cases – Tuesday 21st December 7pm

 3 interactive CET points: please let all your friends and colleagues know
 Online 1:1 mock OSCE course – booked on a mutually convenient time and date
 Visit 3a – Sunday 30th January 715pm
 Sight test (including practical demonstrations) – Monday 31st January 730pm
 Visit 3b – Sunday 6th February 715pm

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Eyecare Conference,
 Sunday 16th January 2022 Glasgow
 Full day pre-reg course
 In addition and different to our online courses
 Slit lamp tutorial with practical demonstrations
 Practical workshops (VOLK, focimetry, low vision etc)
 Stage 2 case scenarios walk-through
 Taster group mock OSCEs
 Access to the Eyecare exhibition and lectures
 Light refreshments and lunch provided
 Great value
 £99 early bird discount until 26th December, £125 otherwise
 Discount for package students
Booking link available online or via Instagram

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OA Optomise Learning portal

 Release date: early January 2021

 All our completed tutorials will be added onto here along with handouts
 Can watch any of these at your own convenience and will be available to be watched
for a period of weeks
 Each tutorial will have it’s own price
 You are welcome to ask any questions on these
 This is a different service to our live tutorial package offer
 Package students will receive a discount

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