Ophthalmic instruments part I
MODERATOR –MEKETE (MSC OPTOMETRIST)
PRESENTED BY- DR. MINTESNOT A (R1)
SEP,2019
HU-CHS
Outline
Slit lamp biomicroscopy
Direct ophthalmoscope
Indirect ophthalmoscope
Retinsoscope
SLIT LAMP BIOMICROSCOPE
Introduction
Slit lamp biomicroscope is a high-power binocular microscope with a
slit-shaped illumination source
Speciallydesigned for viewing the different optically transparent or
translucent tissues of the eye and adnexa
Slit
Lamp: It is a misnomer since slit is only one of the various other
diaphragmatic opening present in the instrument
Cont…
Allvar Gullstrand: An ophthalmologist and 1911 Nobel laureate
introduced the illumination system which had for the first time a slit
diaphragm, therefore Gullstrand is credited with the invention of the slit
lamp.
Basic design of slit lamp biomicroscope – 3 parts
illumination unit
Observation
unit
Mechanical
unit
Koehler illumination principle
It create an even illumination of sample and ensures the image of the
illumination source isn’t visible in the resulting image
The light filament (F) is imaged on to the objective lens (O) but the
mechanical slit (MS) is imaged on to the patient’s eye (S
Types – based on - how illumination unit aim light?
Zeiss type the illumination comes Haag Streit type the illumination
from below comes from above
Illumination unit – consist of :
Light source ( the halogen bulb)
Condensing lens system
Consist of 2 planconvex lenses with
their convexities in apposition
Slit and other diaphragm
Slit
width and diameter can be
changed
Filters
Reflective mirror or prisms
Filters
Cobalt
blue filter - enhances fluorescein
observations
Tear film assessment
Cornea staining to exclude abnormality
Goldmann applanation tonometry
Green or Red free filter
Increase visibility of rose Bengal staining
Normal density – ND filter
Decrease beam brightness
Observation or stereomicroscope unit
Eye piece
complex
Inverting prism
Magnification
changer
Objective lens
Binocular
viewing system
Eye piece lens complex
Astronomical telescope
a system of 2 convex lenses
Result in image which is
More magnified and inverted
Freer from optical aberrations than
a single convex lens
Cont.…
Inverting prism - Porro-Abbe prism The objective lens
2 triangular prisms arranged to
reflect light several times Object is located in the
Resulting in an optically sharp, objective lens focal point
inverted image with no
magnification and little loss of light Magnifies the object image
projecting it virtually to infinity
Compensate for the inverted image
produced by eyepiece Move the working distance
Shorten tube length from infinity to approximately
10 cm in front of the
microscope
Magnification changer-
Galilean telescope type
Positioned between objective
lens and tube
Single convex lens and a single
concave lens, separated by
the difference of their focal
lengths
The image produced is upright,
virtual image and at infinity
Most commonly used are 10×,
16×, and 25×
The Grenough type magnification changer
Flip lever to change
magnification
Change eyepieces or objective
Eyepieces
Often two sets provided with slit lamp
Typical values 10x, 12.5x, 15x or 20x
Objective
Flip arrangement for rapid change
Usually only two options due to space confinements
Typical values are 1x and 2x
Binocular system
Total angular magnification
Objective lens, O - f1
Tube lenses ,T - f2
Telescopic system W - magnification factor g
Ocular, k –f3
M=5x -50x ,Resolution is limited with greater M
Mechanical unit
It is mainly concerned with:
Positioning of patient.
Adjustment for observer and patient.
Adjustment of illumination and observations system.
Consist of viewing arm, illumination arm and patient
positioning frame
Cont…
Viewing arm
Pairof eyepieces
(oculars)
Housing of
magnification
elements
Magnification knob
Cont..
Illumination arm
Calibrated scale
that indicates the
length of beam
being used; also
used to measure
lesions
Cont.…
The point at which the
microscope is focused
corresponds to the point on
which the light is focused, this
coupling effect is called
parfocality
Allowing the examiner to
direct the light beam
anywhere
Cont.…
Patient
positioning
frame
Base and
table
Clinical procedure
Switch on power & unlock
base screw
Cleaning the forehead band
Changing paper strip from
chin rest
Proper positioning of the pt.
Adjust eyepieces to correct for
examiner’s refractive error
Adjust interpupillary distance Correct positioning
Cont.…
The examination should be commenced using the X10 eyepieces or
the lower powered objective to locate the pathology
Higher magnification should then be used to get more detail.
Select the longest slit-length by means of the appropriate lever.
The angulation between the observation arm and the illumination
arm is adjusted.
Slit lamp illumination types
The slit lamp offers 6 main illuminating options, each with
its own special properties and particular uses:
Direct illumination Indirect illumination
Transillumination, or
Diffuse illumination
retroillumination
Direct focal illumination Indirect lateral illumination
Specular reflection Sclerotic scatter
Diffuse illumination
Illumination of the eye with a broad,
unfocused light beam
Directed obliquely between 30-450
Magnification 6x to 10x
Neutral density filter
Used mainly for obtaining an overview of
ocular surface tissues (e.g., bulbar and
palpebral conjunctiva, cornea)
To pick gross abnormalities of the eyelids,
conjunctiva, sclera, cornea, and iris
Diffuse illumination with the cobalt- Diffuse illumination with red-
blue filter (to enhance the free(green) filter is here used to
fluorescence of fluorescein dye) is enhance visibility of rose Bengal
used here to demonstrate the red dye, which has stained
dendritic corneal ulceration of keratin in intraepithelial
herpes simplex epithelial keratitis (squamous) neoplasia.
Direct focal illumination
Used mainly to show corneal cross
section
Variation in the application of this
illumination technique can be made just
by changing the width and or/height of
the light source - resulting in: Technique
Illumination and observation
Optic section
are focused in the same
Parallelepiped plane
Conical beam. Slit width narrow to broad
Illumination angle 45° to 60°
Magnification 10x-40x
Optical section
Technique
Slit width is less than 1 mm
High intensity of light is used
High illumination and magnification
Assess cornea from one side to Corneal cross –section
other (temporal limbus to nasal Surface of tear film -brighter
limbus) Epithelium layer - darker
Gray wider granular area is
Facilitates a cross-sectional view the stroma
of the cornea and lens Endothelium - brighter
Cont.…
Application
Todetermine the depth or elevation of a
defect or scar of the cornea or
conjunctiva
Locating the depth of an opacity within
the lens of the eye - grading of cataract
To assess iridocorneal angle - Van Herick
method – beam 60 degree on temporal
side
Parallelepiped
Parallelepiped is basically an optic
section, with the exception of the slit
width can vary from 1mm to its full
size
Providing a more three
dimensional view of the cornea or
crystalline lens
Application :
To examine corneal surface,
stroma
To ascertain depth (FB)
Corneal nerves
Pigment on the back of the Corneal scar
Blood vessels
cornea - Krukenbergs spindle
Ghost vessels
-diagnostic of iris atrophy and
pigmentary glaucoma
Conical beam
Conical beam: is a small circular beam
used to examine the presence of cells and
flare
Narrow,short & bright slit of light also
can be used - 1 × 3 mm in size
Light Source - 45-60’ Temporally and
directed in to the pupil
Bright illumination and high magnification
(16X–25X)
Beam is focused between cornea and
anterior lens surface.
Cont.…
Application
Inflammatory cells
Flare
Pigmented cells
Tyndall phenomenon – scattering of light by
particles in the aqueous humor
Specular Reflection
It is used mainly for examination of
the corneal endothelium
It can also be used for examining
the cornea epithelium, tear film
and lens
Techniques
Observation and illumination
system have same angle with
perpendicular axis to each other
Parallelepiped beam of light is When the slit-lamp’s illumination
used - Slit width < 4mm system and the biomicroscope are at
Low illumination is needed with equal angles of incidence and
higher magnification – 25X–40X reflection the cornea’s endothelium is
viewable
Cont.…
From axial point, slowly move slit beam
across the cornea temporal until a glittering
reflection of the filament is seen
Then focus is moved toward the endothelial
cells
Mosaics of hexagonal cells are seen – Bright reflection is obtained
require high magnification from the surface of the
Endothelial reflection is observed for cornea and a less bright
continuity and uniform intensity reflection from the posterior
surface of the cornea
Cont.
Compromised corneal surface - broken
or rough reflections may indicate
Inadequate tear film
the presence of foreign material
Corneal edema or bullae
The regular endothelial mosaic pattern
can be disrupted by
Largeand small cells of corneal
endothelium
Deep corneal guttae (orange
Irregularities in Descemet’s peel-like, dark indentations of the
membrane endothelium caused by focal
Pigment deposits/ keratic excrescences of Descemet
precipitates - may reflect light membrane) in early Fuchs corneal
dystrophy
Transillumination or
Retroillumination
Techniques
Moderate wide slit beam -
projected onto a part of the eye
that lies deeper than the area to
be studied
Retroillumination - 2 types that
based on the alignment of the
reflected light beam with the area
under observation:
Direct
Indirect - observe adjacent to area of
Indirect
illuminated by the reflected light.
Direct retroillumination
Findings are made visible with high
Cont..
contrast
Illumination angle 45-60°
Indirect illumination
Illumination angle greatly reduced or
increased
Feature on the cornea is viewed
against a dark background
Application
Infiltrations,small scars, corneal vessels,
micro cysts, vacuoles
Retroillumination from
the fundus
This technique is used to observe
media clarities and opacities
With a diffuse red glow (red reflex)
from the fundus
Dilated pupil
Viewing and illuminating systems of the
slit lamp not parfocal
Slit
beam decentered to the edge of
the pupil and nearly straight ahead
Indirect lateral or proximal illumination
Technique
Placeillumination light source at
about 45°
Use a parallelepiped beam
Dark area just lateral or proximal to
the parallelepiped is the area of the
cornea which one examined
through the biomicroscope.
Cont.…
Proximal illumination is generally used to study the corneal
epithelium and tears.
Detection of microcytic edema, faint corneal infiltrates and
other types of irregularities of the epithelium and tears
Facilitates
to locate and determine of size and shape of an
imbedded foreign body
Sclerotic Scatter
Technique
Moderate width and high intensity
beam at the corneoscleral junction
while observer view center of cornea
The light travels the breadth and width
of the cornea by total internal reflection
Normal cornea – limbus glows along its
entire circumference
The normal cornea itself will appear
unilluminated.
Glowing halo
Cont.…
Sclerotic scatter is especially useful
for detecting subtle corneal
changes over a large area of
distribution
Identifycertain disease through
detection of a characteristic,
overall pattern
Cornea verticillata (whorl-like
changes) secondary to epithelial
deposition of the oral drug
amiodarone
Associated instruments
The Slit Lamp as a Measuring Device
By matching the length of the slit-lamp
to to the horizontal and vertical extents
of the subject of interest
Another method for measuring lesions
is the use of an ocular that contains a
micrometer scale
Fundus Examination With the Slit Lamp
Possible with the slit lamp and an accessory lens
A Hruby lens is a high-minus (- 55 D) Plano-concave lens that is
often attached to the slit lamp
High-plus condensing fundus lenses - handheld lenses
+90 D and +78 D lenses commonly but available 60-132 D
Contact lens - Goldmann 3 mirror lens
DIRECT OPHTHALMOSCOPE
Direct Ophthalmoscope
Ophthalmoscope is an
instrument which
commonly used for
examination of the fundus
of the eye
It was introduced by
Hermann von Helmholtz in
1850
A German physician
and physicist
Cont…
It is called direct ophthalmoscope :
Because image of the subject’s retina is formed directly on the
observer’s retina
Unlike this, indirect ophthalmoscope use intermediate inverted
image hence the name indirect
Basic principle of Direct ophthalmoscope
If patient and observer are both emmetropic, rays emanating from
a point in the patient's fundus will emerge as a parallel beam and
will be focused on the observer's retina
Cont…
Field of view of Direct Ophthalmoscope
The field of view is limited by the most oblique pencil of light that
can still pass from the patient's pupil to the observer's pupil
Angle α is the field of views
Increased in dilate pupil
or when the eyes are
brought more closely
together
Refractive error of the
patient also can affect field
of ophthalmoscope
Limited field of view in the direct method because peripheral pencils of
light do not reach the observer's pupil.
Upright image
Extended field of view in the indirect method because the
ophthalmoscopy lens redirects peripheral pencils of light toward the
observer.
Inverted image
Magnification in Direct Ophthalmoscope
Conventional defining of magnification is to compare the
observer's view of a given object with the view that would be
obtained when looking at the same object from a standard
distance.
The usual standard for comparison is 25 cm
The magnification M under which the image is seen through
the ophthalmoscope is given by:
M= P P is the refractive power of the eye -
4 Standard reduced eye, P= 60 and M = 15
Cont….
Myopic patients have extra
plus power - ophthalmoscope
must carry a negative lens
Galileantelescope effect -
fundus details are seen
larger
Reduce field of vision
In hyperopic or aphakic
patients - ophthalmoscope
must carry positive lens
Reverse Galilean telescope
effect – fundus details
appear smaller
Larger field of vision
Cont…
Refractory error can be compensated by:
By having patient and physician wear their respective spectacle
(or contact Lens) correction
For patients with high refractive errors and especially in the case
of marked astigmatism
For small refractive errors,
Single lens in the ophthalmoscope must replace the
mathematical sum of the patient's and the observer's correction
Parts of direct ophthalmoscope
Illumination system
Clinical procedure
Performed with the eye that corresponds to the eye being examined
Focused by twirling the dial for the Rekoss disk
With a dilated pupil patient is instructed to stare into the distance
The focusing lens is set at 0 (or the examiner's refractive error)
The patient's red reflex is checked from a distance of 2 feet
Check opacity in the optical media – dark shadow
The light beam must remain centered within the pupil – to avoid
troublesome corneal light reflexes
While holding the patient's eyelids open, the examiner dials the focusing
lenses to clarify the fund us image
As the patient star at a distance target, the ophthalmoscope is angled
about 15° temporal to fixation
Cont.…
The retinal nerve fiber layer bundles are seen as fine, bright
striations fanning off the optic disc
The green (i.e., red-free) filter enhances the visibility of the
retinal nerve fiber layer
Exmination begin at the inferotemporal region close to the optic
disc then proceeds to the superotemporal region, followed by
the superonasal and the inferonasal parts
The Fundus Record
The retinal drawing is made inside a circle centered on the
fovea
Shows the relative positions of the optic disc, major retinal
blood vessels, and ora serrata
Record of the examination is kept by Standard preprinted
fund us charts , or vitreoretinal charts
Vitreoretinal drawing chart
Optic disc drawing chart
Bulbous retinal detachment with peripheral exudates
(yellow) and large and small horseshoe tears.
INDIRECT OPHTHALMOSCOPE
Introduction
Parts - head set
gggg
Condensing lens
The Examiner positions a variety of convex,
handheld magnifying ("condensing")
diagnostic lenses close to the patient's eye
Usual powers +13 D, +20 D and +28 D.
The observer holds the condensing lens at
arm's length
Illumination
The illumination is provided by an electric lamp mounted on the
observer's head which passes through the condensing lens into
the observed eye.
The light reflected from the observed eye is refracted by the
condensing lens to form a real inverted image between the
condensing lens and the observer
The level of the observer's eye: Is the same as that of the observed
eye.
Binocular viewing system
Is mounted on the observer's head and consists of
Eyepiece – a convex lenses with +2 D - help the observer to view
the fundus
Withoutusing his accommodation - especially if the patient is
aphakic or highly Hyperopic
If the observer is presbyopic
Two reflecting prisms
Reflecting mirrors – 2 in number
Two reflecting prisms -Provide light to the observer's eye by total
internal reflection as the angle of incidence (45°) is greater than the
critical glass/air angle (41°).
Field of view of Indirect Ophthalmoscope
Field of view of various lenses =
Lens diameter/Focal length = Lens diameter ×
dioptric power
Lenses with equal power - a larger lens provides a
wider field of view
Lenses with equal diameter , a stronger lens provides
a wider field of view
Imaging in Indirect Ophthalmoscope
Aerial image is an intermediate, inverted and reversed real
image of the patient's fundus is formed in the focal plane of the
ophthalmoscopy lens.
The observer must accommodate on this image
Cont..
Indirect ophthalmoscopy is that it requires a considerable distance
between the patient and the observer
Act like an astronomical telescope
Patient's
cornea and crystalline lens act as astronomical
telescope's objective lens
Condensing lens acts as the astronomical telescope's eyepiece
lens
It offers a wider field of view than does direct ophthalmoscopy, but this
advantage is at the expense of decreased magnification.
Magnification of Indirect Ophthalmoscope
2 component:
Aerial image
magnification
=Aerial
image/Fundus
detail
=60/lens power
Magnification
from aerial image
to the observer's
retinal image
Refractory error compensation
Cont…
An interesting case exists for a patient with 20-D myopia.
The myopic eye forms its own aerial image without the help of the
ophthalmoscopy lens.
Examination overview
Headset Adjustment
Should be positioned comfortably on the examiner's head
Use the frontalis muscle to raise and lower the headset
slightly.
Eyepiece adjustment
The eyepieces should be situated as close as possible to the
examiner's eyes perpendicular to the pupillary plane, without
touching the bridge of the nose
Knob to adjust the angle of the eyepiece-light housing
Refractory error – near and distant – of the observer if there are
greater the ocular lens power it should be corrected
Adjust the interpupillary distance of the oculars
Light beam adjustment
Mirror angle or tilt control knob – used to aligned the light beam
vertically until the light occupies the upper half of the field of
view for an arm's length working distance
Brightness control knob
Prolonged examination should use a reduced power setting of
the headset light and a condensing lens with an ultraviolet filter
or yellow coating
Choosing and Positioning the Condensing Lens
+20 D aspheric lens – used for routine examination
+30 D lens – when wider field is needed – diffuse retinal anomalies
+14 D lens - reserved for examining the optic nerve lesion
Working distance
Examination is performed at arm 's length, normally with about 40-
50 cm
Difficulty seeing through a small pupil
Withdrawing to a greater examination distance
Use a higher-power lens.
Distance between the examiner and the lens does not have to be
fixed
Sequence of the Examination
Begin indirect ophthalmoscopy without the condensing lens – to
a get red reflex
Condensing lens is then brought into position
Image is completely inverted and reversed.
Identifying the optic disc
Retinal vessels from the optic disc to the equator.
Superior or nasal before the inferior and temporal fundus
To reduce photophobia
Finally, scleral depression
Scleral depression
To examine the area between the equator of the fundus (14 mm from
the limbus) and the ora serrata (8 mm from the limbus)
RETINOSCOPE
Introduction
Retinoscope – an instrument that we use to illuminate inside of eye
and to observe light reflected from the fundus
Retinoscopy is the name given to the objective method of
determining the refractive errors by using retinoscope
Provide a starting point of subjective refraction
Only option for people who are unable to communicate
Non-refractive use of retinoscopy
To see optical media opacity - on lens, cornea, iris even early
opacity by retro-illumination from retina
Keratoconus –b/c it distort the reflex
Retinal detachment –b/c central distort the reflecting surface and
a gray reflex may be seen
Perform indirect ophthalmoscopy using high plus lens (monocular
indirect ophthalmoscopy
Cont.…
Retinoscope parts
Eyepiece
Mirror assembly – plane and concave mirror
Light source
Spot or streak bulb
Collar
Moves up and down to change the
vergence of the light
Rotates to change the angle of the beam
On/off/brightness control
Types of Static retinoscopy
Static retinoscope - use in patient with relaxed accommodative
status achieved by looking at distance or using cycloplegic drugs
The spot retinoscope: The source of light used produces a
circular image.
The streak retinoscope: The source of light used produces a
linear image. - More commonly used
Adv. - Each meridian can be neutralized separately
Easier to apply and require less time
Cont.…
Retinoscope has 2 system
Observation system -
the examiner looks
through a plane mirror
with central perforation
Illumination system
The illuminated area of
fundus is not seen by the
observer but only acts as a
source for - retinoscope
shadow or reflex at subject
pupil
Illumination
system
Light source
Condensing lens
Mirror at 45°
To give both systems
of illumination - plane
and concave mirror
effects by altering
distance between light
source and
condensing lens
Cont.….
The illuminated fundus area moves with the movement of the plane mirror
and against the movement of the concave mirror, irrespective the
refractive state of the observed eye
Observation system
Reflex movement under
plane mirror effect can be
Opposite movement
with concave mirror
effect
“ with” movement
A image of the illuminate retina is formed at the patient’s far point
Far
point is at infinity for emmetropic, in front of the eye for
myopic and behind the eye for the hyperopic
“ with” movement seen when the Far point is behind the examiner
Emmetrope
Hyperope
Myope less than working distance (FP> WD) – less than –1.5 D if
working distance is 0.75 m
“against” movement
“against” movement seen when the Far point is in front
the examiner
Myopia greater than the working distance greater
than – 1.5 D if working distance is 0.75 m
Neutral point
Achieved when the far point of the patient’s eye is
equal to the examiners working distance
Refractive error Plane mirror effect Concave mirror
effect
Myopia With- < WD Against
No- = WD NO
Against > WD With
Hyperopic With against
Emmetropia No No
Observe the reflex optical characteristics
The direction of the reflex
The relative speed of the movement
The brightness of the reflex
The width of the reflex
Shape of the reflex
Cont.….
The speed of movement of the reflex is useful in determining refractive
status
the slower the movement- higher refractive error
the faster the movement –the less the refractive error
The speed of movement does not depend on the speed of movement
of the retinoscope, but is related/compared to it
Cont.….
The brightness of the red reflex
If the reflex is dull, then a high refractive error
If the reflex is brighter, then a low refractive error
The width of the reflex
The higher the refractive error, the narrow reflex width
The Lower the refractive error, the wider reflex.
Cont.….The shapes of the red reflex
Retinoscopy techniques
The examining room light s are dimmed.
Examiner sits facing the patient
Patient should look past the examiner's ear at a fixation target
located at effective optical infinity (20 feet or more)
The examiner’s eyes on the same level as the patient
At standard distance, usually about arm's length
Examine right eye of the patient with right eye of yours and do
the same to the left eye
Cont.…
It is critical to know that the eye being examined is the fixating
eye
Retinoscopic reflex should be in the visual axis ,rather in the
axis of the deviation - in order to measure the correct
refractive error in the visual axis
Manifest strabismus
Occlude the eye not being examined so that the eye being
examined can be fixating eye
Working distance
The distance between the examiner and the patient 's eye
Must be measured and converted into diopters
Most examiners use a working distance of arm's length, usually about
66 cm - corresponding working lens of +1.50 D.
The working distance must remain constant throughout the
examination
Cont.…
If retinoscopy is done through a working lens
The additional lens power that results in neutralization is the
refractive err or.
If a working lens is not used-
theexaminer must subtract the dioptric equivalent of the
working distance from the sphere of the refractive error
reached in retinoscopy.
Neutralization With a Retinoscope
Neutralization refers to the achievement of the point at which a
lens placed before the patient's eye effectively "neutralizes" the
retinoscopic reflex which means :
The patient's pupil fills with reflected light – full width of
retinoscopy reflex
No movement of the retinoscopy reflex
The closer one approaches to neutral:
The wider, brighter and faster the reflex.
Recording of the retinoscopic results
This is usually done in the form of a cross (power
cross) which indicates the neutralization point of the
two main meridians and also their orientation
Vertical streak – move nasal to temporal
Cylindrical axis is – 900
Power meridian or axis is – 1800
Change the power cross into axis cross Power cross
Lens transposition
Checking of the neutral point
If the power of the lens in the trial frame is Increased by 0.5D -
The movement of the red reflex will be reversed.
If the observer moves his head backwards - The red reflex
moves against the movement of the mirror.
If the observer moves his head forwards - The red reflex moves
with the movement of the mirror
References
Slit-lamp Biomicroscopy in Primary Eye Care
Clinical optics - third edition
Practical ophthamology, manual for beginning residents,
seventh edition
Duane’s clinical ophthalmology 12 edition
BCSC, Clinical optics, 2016-2017
internet source – slideshare and pictures
Thank you
Questions?
