Slit-lamp & Fundus Lenses

By Tolosa Tufa (MD)

Year-I resident

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 Outline
• Introduction
• Historical background
• Components of slit lamp
• Clinical uses
• Fundus lenses
• Summary

2
 Introduction
• Microscope provides a magnified view of a near object

• Telescope magnifies distant objects

• Compound microscope
– Contains multiple lenses

3
 …con’t
• The compound microscope consists of two convex
lenses, the objective and eyepiece lenses

4
 …con’t
• Objective lens forms
– A real, inverted, magnified image
– Falls close to the principal focal plane of the eye piece, which act
as a loupe & magnifies further
• The final image I is vertically and horizontally inverted
– Porro prisms are incorporated in clinical microscopes to obtain
an erect non-inverted image

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 Slit-lamp Bio-microscope
• Is a high-power binocular microscope with a slit-shaped
illumination source

• Equipped with a movable light source, variable beam

dimension

• Designed to give a magnified, three dimensional view of the

eye
• Specially designed for viewing the different optically
transparent layers of the eye

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 …con’t

• Is a compound microscope
– Its has multiple lenses & mirrors to
• Form upright image
• Provide variable magnification
• Deliver bright image than a single lens

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 History
• The first concept of a slit lamp dates back to 1911
• Allvar Gullstrand made his large reflection-free ophthalmoscope

• It consisted a special illuminator connected to a small stand base

through a vertical adjustable column.
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 …con’t
• By 1919 several improvements were made to the Gullstrand slit
lamp made by Vogt Henker

– Mechanical connection was made between lamp and

ophthalmoscopic lens
– Introduced Koehler illumination

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 …con’t
• In the year 1926, the slit lamp instrument was redesigned

– The axis through the patient’s eye was fixed along a common
rotating axis

– But it still lacked a coordinate cross-slide stage for instrument

adjustment
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 …con’t
• Following World War II the slit lamp was improved again,
modifying its parts

• From 1994 onwards, new slit lamps were introduced with new
technologies

• The last major dev’t was in 1996 in which included the advantages
of new slit lamp optics

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Basic parts of slit lamp

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16
 …con’t
• Basic Design :
– Mechanical system
– Illumination system
– Bio-microscope /Observation system

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18
 …con’t
• It concern with:
– Positioning & adjustment of patient and observer
– Maneuvering the illumination and microscope system
together with joystick
– Providing base to other parts

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 Observation system(microscope)
• Are compound microscopes composed of optical elements
providing enlarged stereoscopic image to observer
• Provides larger working distance in front of microscope for
manipulation on patient’s eye
• Magnification changer for detail view

• The eyepiece has a lens of +10D to + 14D towards the

examiner
• Most slit lamp provide a range of magnification from 6x to 40x

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 …con’t
• Each manufacturer has its own proprietary refinements
• The basic design includes the following components
 Astronomical telescope/eyepiece
 Inverting prism
 Galiliean telescope
 Objective lens
 Binocular viewing system

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 …con’t
• Astronomical telescope/ eyepiece
– Is a system of 2 convex lenses, one in front of the other
– The image is more magnified and free from optical aberrations
– Produces inverted image

• To overcome the problem of inverted image slit lamp microscope

uses a pair of prisms between the objective and eyepiece to
reinvert the image

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 …con’t
• Inverting prism
– Inverts it to produce an erect image

– Porro prism:- consists 2 triangular prisms

arranged to reflect light (TIR) resulting in
• Optically sharp
• Inverted image with no magnification
• Little loss of light

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• A Galilean telescope
– Has a single convex and a single concave lens, separated by
the distance of their focal lengths
– The image produced is upright with higher magnification
– When the object is in front of the convex lens, the image is
magnified & concave lens minifies it

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 …con’t
• The telescope system provide considerable distance between
the microscope and the patient’s eye
– foreign body removal from the cornea
– using extra lenses for fundus examination

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 …cont.
• Objective lens
– The astronomical and Galilean telescope systems are effective
at magnifying the image of a distant object

– Biomicroscope requires a working distance of a few cm

– Moves the working distance from infinity to ~10cm in front of

the microscope

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 …con’t
• Binocular viewing system
– There are 2 lens systems of identical design each focused on a
common point (13° or 14° to each other)

– Both eyes used together to get a 3D appreciation of the

magnified eye

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29
• Illumination system
– Provides a bright, evenly illuminated, finely focused, adjustable
slit of light at the eye
– The beam of light can be changed in intensity, height, width,
direction or angle and color

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Optical principle

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 …con’t
• 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

– It relies on the observation of light reflected from the

structures of the eye

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 Types
 There are 2 types of slit lamp biomicroscope
1)Zeiss slit lamp biomicroscope
2)Haag streit slit lamp biomicroscope

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• The coupling between the slit lamp and the biomicroscope
make the system “parfocal”
– i.e the focus of the slit and the focus of the microscope are
at the same point

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 Illumination techniques

• Diffuse illumination
• Direct focal illumination
• Parallilepiped
• Optic section
• Conical(pinpoint)
• Tangential
• Specular reflection
• Indirect focal illumination
• Retro-illumination
• Sclerotic scatter
• Transillumination
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Diffuse illumination
• The beam of light is thrown slightly out of focus across
the structure being examined
• General view of anterior of eye: lids, lashes, sclera,
conjunctiva, cornea, iris, pupil
• Gross pathology and media opacities
• Contact lens fitting

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• Direct focal illumination
– The slit beam is accurately focused upon that part of the
eye under inspection
– Slit width narrow to broad
– Illumination angle 45° to 60°
• Application
– Cornea in detail
– Anterior chamber
– Crystalline lens
– Anterior part of vitreous
– Grading cell and flare in anterior chamber
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 Direct focal illumination

• Parallelepiped
– Slit width 2-4 mm obliquely
focusing on the cornea so that a
quadrilateral block of light
illuminate the cornea

– To examine corneal surface,

stroma
– To ascertain depth (FB, abrasion)

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 Direct focal illumination
• Optical section
– Slit width 1mm or less
– Illumination angle 45-60° or more
– High illumination & magnification
– Uses :
• Corneal depth, layers, scars, vessels
• Lens opacity

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 Direct focal illumination
• Conical beam
– Small circular beam
– Assessment of particles floating in the A/C
– 45°-60° light source directed to pupil
– High magnification
– Uses
• Inflammatory cells, flare, pigmented cells,

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 Direct focal illumination
• 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
• Observe:
– Anterior and posterior cornea
– Iris is best viewed
– Anterior lens (especially useful for
viewing pseudoexfolation)
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 Direct focal illumination
• Specular reflection
– Angle of incidence = angle of reflection
– Observation and illumination system have same angle
with perpendicular axis to each other
– The light reflected from the anterior or posterior corneal
surface
– It is best seen monocularly
• Assessment of surfaces
– Corneal epithelium
– Corneal endothelium
– Lens surface
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 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

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 …con’t
• Retro-illumination :
– 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
• Two types: direct and indirect

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 …con’t
• Direct retro-illumination :
– Observed feature is viewed in direct pathway of reflected
light
– Infiltrations, small scars, corneal vessels, etc.

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 …con’t
• Indirect retro-illumination :
– Observer at right angle to the observed structures
– Feature on the cornea is viewed against a dark background

– Infiltrations, small scars, corneal vessels, micro cysts,

vacuoles

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 …con’t
• Sclerotic scatter
– 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

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 …con’t
– This technique will produce halo glow of light around the
limbus as the light is transmitted around the cornea

– Corneal changes or abnormalities can be visualized by

reflecting the scattered light

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 …con’t

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

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 Oscillation

• A back and forth sweep between the direct and indirect techniques

• The observation is positioned at some angle while the illumination

system is swept back and forth

• Helps to reveal fine corneal scars, opacities

• After observing an area the observation could be repositioned and the

illumination system sweeps the area again until the entire regions are
systematically investigatedbe repositioned and the illumination system
sweeps the area again until the entire regions are systematically
investigated
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 …cont.
• Filters :
– White filter
• Overview of ocular surface tissues
• Examining intraocular structures
– Cobalt blue filter
• Coneal abrasion, ulcer
• Applanation tonometry
• Tear film
– Red free filter
• Rose-bengal staining

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 Slit-Lamp Fundus Lenses
• With slit lamp only about 1/3 of the vitreous is visible
– High refractive power of the cornea and lens renders light from
retina parallel

– No image is formed within the focal range of the slit lamp

microscope

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 …con’t
• Special lenses can be used in front of the slit-lamp
objective lens to view the vitreous and posterior pole
of the eye

• There are 2 approaches

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 …con’t
1. To nullify the optical power of the eye using a contact lens or a high
power minus lens
• The Hruby lens:-
– Is a powerful plano-concave lens, –58.6 D
– Forms a virtual, erect & diminished image of the illuminated
retina within the focal range of the slit-lamp

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 …con’t

• Goldmann fundus contact lens:-

 The lens is a plano-concave contact lens

 Moves the retinal image to a point near the pupillary

plane, within the focal range of the slit-lamp

 It is used during vitrectomy to allow visualisation of

the fundus

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…con’t

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 …con’t
• Goldman 3-mirror contact lens

 Central contact lens (1)

 Midperipheral fundus mirror (2)
 Peripheral fundus mirror (3) and
 Iridocorneal angle mirror (4)

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 …con’t
– Zone 1 = Examination the ocular fundus in the 30° zone

– Zone 2 = Mirror with a declination of 73°

• Zone outside 30° range

– Zone 3 = Mirror with a declination of 66°

• Peripheral sections of the ocular fundus
• The ora serrata
– Zone 4 = Mirror with a declination of 59°
• vitreous body
• ora serrata
• gonioscopic examination
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 …con’t
• The Zeiss 4-mirror goniolens

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 …cont.
2. Is to use the power of the cornea as a component of an
astronomical telescope

• Lenses used in this approach include the

– 60 D, 78 D, and 90 D funduscopic lenses

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 …cont.
• The 60 D, 78 D and 90 D funduscopic lenses
– High power condensing lenses
• Shorten the light path and bring the retinal image within the
focal range of the slit lamp

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 …cont.
– There is loss of image size through using these
lenses

– The 90 D lens gives a wider field of view but less

magnification

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 …cont.
• Panfunduscope contact Lens
– Use a combination of both approaches to avoid high corneal
refractive power

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 …cont.

– Employs a corneal contact lens & also a high-power spherical

condensing lens, within which is created a real, inverted
image

– Because the condensing lens is so close to the eye, the field

of view is very wide

– The image formed is correspondingly smaller, and the slit

lamp adjusted to give high magnification

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 CLINICAL USES
• A slit-lamp with its supplementary devices allows
• Magnified views of every part of the eye
• Quantitative measurements
– IOP
– Endothelial cell count
– Pupil size
– Corneal thickness
– AC depth

• Photography of every part of eye for documentation

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• Van Herick grading

– Use to evaluate AC angle

without gonioscopy
– Medium magnification
– Angle 60 degrees
– Narrow beam close to limbus

– Depth of AC is evaluated in to
the thickness of cornea:

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…cont.

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 Attachments for the slit lamp
• Goldman tonometer - IOP measurement

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 …cont.
• Pachymetry - measures corneal thickness.

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 …cont.
• Gonioscope - used to assess anterior angle

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 …cont.
• Camera attachments - Can be used to photograph and
record the external eye of a patient

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 Summary
• The slit lamp is essential for a detailed examination of the
anterior segment

• It utilises reflections from various optical interfaces to

visualise different structures

• Illumination may be varied in height, intensity, angle, colour

and concentricity

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 Summary
SLIT LAMP EXAMINATION

Suggested Power

6X or 10X external ( lids, tear film, conjunctiva), contact lenses

16X angles, cornea, iris, lens, foreign bodies, corneal abrasions

25x aqueous flare, corneal endothelium

40X corneal endothelium

Beam Width
1. narrowest angles, cornea, anterior chamber
2. a bit wider cornea, lens, etc
3. a bit wider yet external, contact lenses
4. full width external, applanation tonomery
Beam Height

Full most areas and structures

short checking anterior chamber for cells & flare

Color/Filter

White most areas and structures

Blue (use fluorescein dye) applanation tensions, corneal staining, tear

film, staining patterns of rigid contact lenses

Green (red-free) evaluating blood vessels

 Summary
• Accessory Devices
– Gonioscopy
– Fundus examination
– Pachymetry
– Applanation tonometry
– As delivery system for argon, diode and YAG laser
– Slit lamp photography
– Slit lamp videography

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 References
• Clinical optics 3rd edition Andrew R.elkington ,Helena J.
Frank and Michael J. Greaney

• American Academy of Ophthalmology BCSC, sec3, optics

• Ophthalmology investigation and examination technique,

Bruce James

• A manual for beginning residents 4th edition

• http://eyewiki.aao.org/

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THANK YOU!

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