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Slit Lamp Fundoscopy
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Slit Lamp Fundoscopy

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The technique of performing ophthalmoscopy using a slit lamp and a high diopter lens (+60D, +78D, +90D etc.). The complete manual for a beginner.

The technique of performing ophthalmoscopy using a slit lamp and a high diopter lens (+60D, +78D, +90D etc.). The complete manual for a beginner.

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Slit Lamp Fundoscopy Slit Lamp Fundoscopy Presentation Transcript

  • Slit Lamp Fundoscopy Dr. Anton Vurdaft Zambia
  • Slit Lamp Fundoscopy Biomicroscopy with simultaneous fundus examination. Using high-diopter lens (+60D, +78D, +90D, +120D and others). Ophthalmoscopy with slit lamp is the most difficult skill in ophthalmic examination. Ophthalmoscopy using slit lamp and the lens gives the most clear picture of the fundus: magnified, 3D, very bright).
  • Slit Lamp Fundoscopy Slit lamp with teaching piece View slide
  • Slit Lamp Fundoscopy It is possible to do fundoscopy with wide AND with narrow pupil most of the times. The latter is surely more difficult for inexperienced examiner. Moreover, it is difficult and some times not possible to examine fundus periphery with narrow pupils. View slide
  • Slit Lamp Fundoscopy Principles Use slit lamp as you do for anterior segment. The task is to focus the beam light on the fundus. The beam is narrow. Examine fundus stepwise. Everything what is not into the beam light focus – is not seen or seen poorly.
  • Slit Lamp Fundoscopy Principles With slit lamp fundoscopy we only see SLIT image, we do not see the picture as a whole at one time. We have to move the slit in certain directions. NOTICE the glare, which is moved out of the picture with a mild tilting of the lens.
  • Slit Lamp Fundoscopy Technique Prepare for the examination: • Make the room as dark as possible • Fixate your arms comfortably, using the armrest • Dilate the pupils of the patient (important if you are not experienced) – use tropicamide or combination of tropicamide with phenylephrine
  • Slit Lamp Fundoscopy Technique DILATE THE PUPILS!
  • Slit Lamp Fundoscopy Technique The armrest you can make yourself of any suitable material or using carpenters. This is especially important for those who have short hands. Sometimes you can use the case of high-diopter lens
  • Slit Lamp Fundoscopy: Set Slit Lamp First use magnification of x15 or less (i.e. x10). The bigger the magnification, the harder it is for inexperienced examiner to set the focus on the fundus and to orient within the fundus. Set the light beam as narrow as possible. The narrower the pupil, the narrower the beam should be. The height of the beam is not so important. The width can be regulated during the examination.
  • Slit Lamp Fundoscopy: Set Slit Lamp Set the brightness of the beam to the level most comfortable for you (usually it is the brightest) and for the patient (usually patients are more comfortable with darker beam). Height, width and brightness of the beam can be regulated during the procedure, that is especially important with uncooperative patients and patients with photophobia. The light-source and the pieces of the slit lamp should be aligned into one axis (90 degree to the patient).
  • Slit Lamp Fundoscopy: Start Exam Fixate a chin and a forehead of the patient (using chinrest and headrest). Ask patient to look straight or in other needed gauze position. Focus the beam on the center of the pupil. Fix your hand with the lens on a cheek of a patient or using a headrest. It is more suitable to use left hand for a right eye of a patient, and vice versa.
  • Slit Lamp Fundoscopy: Technique DO NOT USE ONE HAND FOR BOTH EYES. SWITH YOUR HANDS. IT IS EASY TO GET USED TO ONE HAND, AND IT WILL SPOIL YOUR EXAMINATIONS LATER.
  • Slit Lamp Fundoscopy: Technique Grab the lens with big and index finger, the rest of the fingers will help you to tilt the lens and pull the upper eyelid up. Set the center of the lens on the center of the pupil (use the beam to check it). The working distance of the lens is 5-10 mm. It does not matter what side of the lens should be faced to the patient, if the lens is double aspheric (volk, ocular instruments). Otherwise – the letters on the lens rim should be directed towards the patient (see the foto).
  • Slit Lamp Fundoscopy: Technique The picture is floating in the air actually. Notice the direction of letters of the lens rim.
  • That is how you focus a beam on the center of a pupil. Notice how the hand is fixed. Slit Lamp Fundoscopy: Technique
  • Slit Lamp Fundoscopy: Technique Patient should look in the needed direction. Light source of the microscope moved closely to the patient. Slowly you pull the microscope back to you. Focus of the beam is moving from the cornea to the lens, than we see the image of the fundus, it is formed somewhere in the air. Stepwise examination follows.
  • Slit Lamp Fundoscopy: Technique Practice makes perfect! Do at least one dilated and one non- dilated fundoscopy of the disc EVERY DAY. After 2-3 weeks you may add the macula to your daily MUST DO list.
  • Slit Lamp Fundoscopy: The Image The image which you see – is inverted. It means that you see it upwards down and left-to-right. If you see something in the upper part of your picture – it is actually in the lower part of that part of the fundus, which you are examining. The same goes to “left or right” parameters. The illustration of that fact is the relation of optic disc and macula. The latter is always temporally (closer to the temple), the disc is nasally (closer to the nose). But with the slit lamp fundoscopy we see the picture inverted – disc is always temporally there.
  • Slit Lamp Fundoscopy: The Image Fundus of the left eye (egg), as if we see the eye in horizontal cross- section. As it should be with the left eye – the optic disc is closer to the nose than macula.
  • Slit Lamp Fundoscopy: The Image Fundus of the same left eye (egg) with the using of high-diopter “+” lens. Equally to the +90D or +78D, the image gets inverted. Macula and disc have changed their places and got upside-down.
  • Slit Lamp Fundoscopy: The Image When you are drawing the fundus picture in the file – there are two ways you can do it. The first one implies mental gymnastics – you may try to picture the findings immediately in the way they are really located in the fundus (direct picture). The other way is to rotate your file on 180 degree and draw the picture JUST exactly how you’ve seen it in inverted way. If you’ll rotate this file back to 180 degree – the findings will be in correct position and direct. Use mental gymnastics! It is useful for a brain and will help you to understand the topography of the fundus better.
  • Slit Lamp Fundoscopy: The Image The area of fundus which you can see depends on refractive power of the lens. The more powerful is the lens, the bigger part of fundus you see at a one time. For example, with +60D you will struggle trying to see the periphery with narrow pupil, but +120D lens will easily allow you to see it.
  • Slit Lamp Fundoscopy: The Image The field of fundus which is seen – depends not only on the lens, but also on the patient’s cooperation. The more precisely patient follows your instructions, the bigger piece of fundus you will see. It is wise to do the fundoscopy in the next order: optic disc (patient fixates the contralateral ear of the examiner), macula (patient fixates straighth), periphery (patient fixated every needed direction).
  • Slit Lamp Fundoscopy: Retinal Periphery It is most comfortable for the beginner to examine periphery of the retina starting from 12 o’clock meridian going clockwise and seeing the 1-30, 3, 4-30, 6, 7-30, 9 and 10-30 o’clock meridians.
  • Slit Lamp Fundoscopy: Retinal Periphery For the beginner it is difficult to orient within the fundus in a certain gauze direction of a patient. It is quiet easy. Patient looks at the direction of the piece of fundus which you see. Patient looks down – we see the lower periphery. Patient looks up – we see the upper periphery. Etc.
  • Slit Lamp Fundoscopy: Retinal Periphery Patient fixated straight. We receive macula in the field of view.
  • Slit Lamp Fundoscopy: Retinal Periphery Patient fixated the contralateral ear of examiner. We receive optic disc in the center of a fundus picture.
  • Slit Lamp Fundoscopy: Retinal Periphery Patient looked at the ceiling, we see upper periphery (12 o’clock).
  • Slit Lamp Fundoscopy: Retinal Periphery Patient looked at the floor, we see lower periphery (6 o’clock).
  • Slit Lamp Fundoscopy: Retinal Periphery Patient looked left, we see temporal periphery (3 o’clock).
  • Slit Lamp Fundoscopy: Retinal Periphery Patient looked right, we see nasal periphery (9 o’clock).
  • Slit Lamp Fundoscopy: Retinal Periphery Inversion of the picture of upper periphery
  • Slit Lamp Fundoscopy: Retinal Periphery Inversion of the picture of upper periphery
  • Slit Lamp Fundoscopy: Fundus Structure
  • Slit Lamp Fundoscopy: Fundus Structure
  • Fundus Structure
  • Picturing The Fundus Optic disc is always nasally, while macula is temporally
  • Optic Disc Structure
  • Measuring the Cup of the Disc Measurement is not so precise, do not struggle
  • Measuring the Cup of the Disc For our practice we need approximate cup/disc ratio
  • Measuring the Cup of the Disc This cup/disc ratio is approximately 0,7. Notice the absence of the neuroretinal rim from the temporal side
  • Measuring the Cup of the Disc This cup/disc ratio is 0,9, almost total (1,0). Notice the absence of the neuroretinal rim everywhere except nasal side of the disc.
  • Measuring the Cup of the Disc: Stereo The color is not enough to assess the real cup-disc ratio. Use stereopsis!
  • Notice the absence of neuroretinal rim at the lower part of the disc Measuring the Cup of the Disc: Stereo
  • Measuring the Cup of the Disc: Stereo Vessels bayoneting demarcates the borders of cupping
  • Measuring the Cup of the Disc: Stereo Normal disc picture (10)
  • Lenses Care:
  • Lenses Care: 1)Do not touch the lens itself, touch only the rim! 2)Occasionally you may clean the lens surface gently with a smooth tissue without fibers. 3)Put the lens into the case immediately after use!
  • References: (1) S.Barnard, A.Field, "Slit Lamp Indirect Ophthalmoscopy", American Academy of Optometry, http://www.academy.org.uk/tutorials/volklens.htm (2) "Practical Ophthalmology - A Manual for Beginning Residents", 5th ed., American Academy of Ophthalmology, 2005 (3) James Benjamin, "Ophthalmology Investigation and Examination Techniques", 2006 (4) Контактные диагностические линзы и фиксация локтя: http://terra-ophthalmica.blogspot.com/2012/06/blog-post_21.html (5) Rosalind A. Stevens, Patrick J. Saine, Marshall E. Tyler, "Stereo atlas of fluorescein and indocyanine green angiography", 1999 (6) William L. Jones, "Peripheral Ocular Fundus (Third Edition)", 2007 (7) Vortex Veins and Blonde Fundus, http://www.optos.com/RecognizingPathology/pages/Visualization/VortexVeins- 8.html (8) S.A. Rizvi, "A simple method to view stereo-images of the optic nerve head on ordinary computer monitors", Eye (2009) (9) My own fotos
  • Thank you!