SLIT LAMP IMAGING GUIDE

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 SLIT LAMP IMAGING GUIDE

A rich history
Slit lamp microscopy

On August 3 rd, 1911, Alvar Gullstrand introduced the first rudimentary model of the slit lamp
illuminator.

An occasion of tremendous significance to ophthalmology had just taken place. Gullstrand de-
scribed a device with the potential to advance the understanding of the eye and its problems as
profoundly as did the direct ophthalmoscope 50 years earlier. By 1916, Henker had developed a
practical combination of Gullstrand’s illuminator and Czapski’s corneal microscope, marking the
first major advance in methods of examining the external eye in more than a century. In 1936
Comberg established the co-pivotal and iso-centric relationship between the microscope and slit
illuminator and, in 1938, Goldmann’s collaboration with Haag-Streit produced the first par-focal
instrument which also featured the single control lever design in use to this day. Goldmann also
influenced the shift to Köhler illumination, greatly improving the efficiency of the slit lamp illumina-
tor, the very heart of this marvellous device.

These significant milestones, with contributions from a host of other individuals, have coalesced
into the highly sophisticated instruments that are placed at our disposal today. In light of such
capabilities in instrumentation, it follows that our results in slit lamp examination and slit lamp
photography will rest on the level of sophistication we apply to the practice of these challenging
and stimulating art forms.

Csaba L. Mártonyi, COPRA, CRA / Emeritus Associate Professor / University of Michigan, Ann Arbor

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Haag-Streit imaging guide
This guide is intended to assist all those who seek to capture images of the
eye using the slit lamp, to improve the quality of their photography by using
simple-to-follow illumination diagrams and high-quality image examples.

We hope this publication provides inspiration and motivation to anyone

involved in the art of documenting the unique properties and pathologies
of the eye, and through Haag-Streit, we offer several instruments to help you.

Haag-Streit greatly appreciates and thanks all those who have contributed to
this publication.

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 Content
Physical and optical conditions ...................................................................................05

Types of illumination ....................................................................................................05

Diffuse illumination ...................................................................................................................05
Direct focal illumination............................................................................................................05
Indirect illumination ..................................................................................................................05
Retroillumination ......................................................................................................................05
Photography with three-mirror contact lens or 90-diopter lens..............................................05
Pictograms.................................................................................................................................05

Slit lamp BQ 900 & Imaging Module 910......................................................................06

Imaging Module IM 910.............................................................................................................07
Ready when you are!................................................................................................................07
Work the way you want............................................................................................................07
A striking image with every shot .............................................................................................07

Image exposure guide for IM 910.................................................................................08

Overview – Diffuse illumination................................................................................................08
Conjunctiva – Diffuse illumination............................................................................................08
Cornea – Narrow slit ................................................................................................................08
Cornea – Moderate slit..............................................................................................................08
Cornea – Tangential illumination...............................................................................................09
Cornea – Retroillumination.......................................................................................................09
Lens – Narrow slit......................................................................................................................09
Lens – Wide slit..........................................................................................................................09
Lens – Retroillumination............................................................................................................10
Iris – Tangential illumination......................................................................................................10
Fundus.......................................................................................................................................10

BX 900 photo slit lamp..................................................................................................11

Technical data...........................................................................................................................12
Standard settings.......................................................................................................................13
Illumination and exposure settings...........................................................................................13
Pictograms.................................................................................................................................13
Diffuse illumination with slit and background illumination......................................................13
Diffuse illumination with background illumination only...........................................................14
Lids – Diffuse illumination.........................................................................................................14
Conjunctiva – Diffuse illumination............................................................................................14
Conjunctiva – Narrow slit..........................................................................................................15
Conjunctiva – indirect illumination...........................................................................................15
Cornea – Diffuse illumination....................................................................................................15
Cornea – Wide slit, tangential illumination...............................................................................16
Cornea – Moderate slit..............................................................................................................16
Cornea – Narrow slit, optical sectioning...................................................................................16
Cornea – Direct retroillumination from the iris.........................................................................17
Cornea – Indirect retroillumination from the iris......................................................................17
Cornea – Sclerotic scatter.........................................................................................................17
Cornea – Topical administration of Sodium Fluorescein..........................................................18
Anterior chamber – Aqueous flare, Tyndall’s phenomenon.....................................................18
Anterior chamber – Goniophotography....................................................................................18
Iris – Wide slit, tangential illumination......................................................................................19
Iris – Transillumination...............................................................................................................19
Iris Angiography.........................................................................................................................19
Lens – Narrow slit, optical sectioning.......................................................................................20
Lens – Moderate slit, direct illumination...................................................................................20
Lens – Moderate slit, tangential illumination............................................................................20
Lens – Retroillumination, red-reflex photography....................................................................21
Vitreous – Narrow slit................................................................................................................21
Fundus – Central retina with a three-Mirror contact lens........................................................21
Fundus – Central retina with a 90-diopter lens........................................................................22

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Physical & optical conditions
The binocular examination of the eyes with the slit lamp The accommodative abilities of the photographer’s own eye
takes place in a three-dimensional space with great depth are normally not noticeable during examination. However it
of field. Normal slit lamp imaging is a two-dimensional doc- is important that the photographer establishes the correct
umentation with a very small depth of field. The difference eyepiece setting to compensate for any accommodation or
between the dynamic, stereoscopic clinical examination and refractive errors. Only viewing a sharp image of the cross hair
the static two dimensional image can be surprising and often overlaying a focused image of the eye ensures capturing of a
disappointing. The use of this guide will tackle this issue and sharply focused image.
help users create high quality images.
It should also be considered that the examiner’s attention is
Haag-Streit has developed specific imaging eyepieces with focused on the details that are of interest and by selective
a cross hair which are available for all Haag-Streit imaging viewing the brain suppresses certain artefacts. The camera
systems. however does not!

Types of illumination
The correct illumination will allow optimal recording of ocular pathology.

Diffuse illumination Retroillumination

The slit lamp beam should be completely opened and cov- Retroillumination is a form of indirect illumination. Light re-
ered by the diffusing filter. The background illumination can flected from the fundus or iris illuminates the pathology from
be used in conjunction with the slit illumination for more behind. If the slit beam is decentred and higher magnification
uniform lighting. The diffuse illumination is normally used for is used, unwanted reflections can be minimized.
overview pictures with low magnification (10 x and 16 x).

Direct focal illumination Photography with three-mirror

Direct focal illumination refers to projecting the light on the
subject at the plane of focus. Unlike diffused light, concen-
contact lens or 90-diopter lens
trated light penetrates transparent structures. With a centred With these instruments there are more optical interfaces
slit beam there is always direct focal illumination. (air/glass and glass/cornea). All interfaces cause reflexes and
therefore it is better to take images without the background
illumination. Furthermore any scratches or damage to the
Indirect illumination lens will increase the number of image artefacts. If the space
With indirect illumination the light does not fall directly on between the diagnostic contact lens and the slit illuminator
the pathology. The slit beam is decentred and projected just is very small, the background illumination can be locked in
adjacent to the subject area and it is illuminated by scattered the centre position.
internally reflected light.

Pictograms

Narrow slit beam Moderate slit beam Wide slit beam Slit beam with diffuser

Slit beam centred Slit beam decentred Background illumination Microscope

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 Slit lamp BQ 900 & Imaging Module 910
1. LED illumination head
2. Background illumination
3. Eyepiece with double cross hair reticule
4. Knob for beam splitter/camera on-off
5. Aperture control knob
6. Magnification changer
7. Diffuser
8. Imaging Module 910
9. Shutter-release
10. Illumination control
11. Background illumination control

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Imaging Module IM 910
Slit lamp documentation
at the push of a button

Rely on the leader of slit lamp imaging and let the Imaging Module 910
IMAGING MODULE 910 (IM 910)
(IM 910) take care of the details, so you can be confident you are getting
outstanding and expressive images while concentrating fully on examining
your patients.

Now with 3D functionality, the IM 910 offers an immersive depth impression,

providing a more detailed and authentic representation of the slit lamp exam.

Ready when you are!

The IM 910 is instantly ready when you need it.

Finally, the days of cumbersome slit lamp imaging are over. By the turn of a
knob, the IM 910 shares your view within your microscope directly on your
screen – instantly!

Enjoy a smoother workflow the moment you start image capture. Instead READY WHEN YOU ARE!
of having to stop the exam, move to a computer, and re-start the camera,
simply flip down the slit lamp mirror and you’re ready to go. After you have
captured an image, or multiple images, simply switch off the camera, and
resume 100% light in the eyepieces once again.

Work the way you want

We believe that tools should adapt to your needs and not vice versa. For
this reason, the IM 910 can be used in different ways and integrated into
many different environments.

Whether you are in “standalone mode” storing your images directly to

your EMR, or in “EyeSuite mode” which is fully integrated into the EyeSuite
software, the IM 910 always gives you brilliant and meaningful images at
the push of a button.
WORK THE WAY YOU WANT

A striking image with every shot

The camera sensor and the superb optics of the IM 910 provide you with
outstanding image quality - but that’s not all.

With conventional slit lamp cameras, the success rate of conclusive

images is often disappointing. To overcome this, the IM 910
provides you with smart features that are at work for you in the
background. A performant auto-exposure mode in combination with
the automatic aperture control guarantees great illumination at all time.
In addition, the image selection algorithm ensures that you get the
sharpest and most expressive image possible. Simply concentrate on
your examination and let the IM 910 do the rest. | 07

A STRIKING IMAGE WITH EVERY SHOT

 Image exposure guide for IM 910
Overview – Diffuse illumination
Magnification 10 x or 16 x
Slit illumination open, 45˚, diffused
Slit illumination level 4
Background level 3
Aperture 5
EyeSuite exposure auto-mode

The diffuse illumination with slit beam and background illumination gives a shadow-free illumination with natural colors and two light reflexes.
This is most useful for low magnification overview images.

Conjunctiva – Diffuse illumination

Magnification 10 x or 16 x
Slit illumination open, 45˚, diffused
Slit illumination level 3
Background level 3
Aperture 5
EyeSuite exposure auto-mode

Diffuse illumination provides evenly balanced lighting. Exposure control is more varied due to increased reflectivity.

Cornea – Narrow slit

Magnification 16 x or 25 x
Slit illumination < 0.2 mm wide, > 60 degrees
from microscope
Slit illumination level 10
Background level 1
Aperture 3
EyeSuite exposure auto-mode

A narrow focal slit beam is projected at a 45° to 60° angle. It cuts an optical section through the cornea like a knife. With this technique it is
possible to locate the layer of the pathological changes.

Cornea – Moderate slit

Magnification 16 x or 25 x
Slit illumination 1 – 2 mm wide, > 60 degrees
from microscope
Slit illumination level 10
Background level 1
Aperture 4
EyeSuite exposure auto-mode

The moderate beam produces two different layers of illumination, one on the epithelium and one on the endothelium.

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Cornea – Tangential illumination
Magnification 16 x or 25 x
Slit illumination > 4 mm wide, > 60 degrees
from microscope
Slit illumination level 10
Background level off
Aperture 5
EyeSuite exposure auto-mode

This technique can provide more information as the oblique illumination is reflected and refracted by the cornea and any pathology. Experi-
ment with the illumination angle slit beam width for optimum results.

Cornea – Retroillumination
Magnification 16 x or 25 x
Slit illumination 1 – 3 mm wide, decentred
Slit illumination level 10
Background level off
Aperture 5
EyeSuite exposure auto-mode

A moderate slit beam is decentred and angled to project onto the iris directly behind the pathology. The light reflects and backlights the cor-
nea. If there is some cataract present the lens can also be used to reflect light directly onto the area of interest.

Lens – Narrow slit

Magnification 16 x or 25 x
Slit illumination < 0.2 mm wide > 60 degrees
from microscope
Slit illumination level 10
Background level 1
Aperture 4
EyeSuite exposure auto-mode

A narrow focal slit beam is projected at a 45° angle to the lens as an optical section is made. Because of the problematic depth of field it is
not possible to photograph the entire lens section in focus. It is therefore necessary to focus on the anterior or the posterior lens surface.

Lens – Moderate slit

Magnification 16 x or 25 x
Slit illumination 2 – 4 mm wide, > 60 degrees
from microscope
Slit illumination level 10
Background level 1
Aperture 5
EyeSuite exposure auto-mode

A moderate slit beam is projected at a 45° angle to the lens pathology and is directly illuminated.

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 Lens – Retroillumination
Magnification 16 x, 25 x or 40 x
Slit illumination level 1 – 2 mm wide, < 5 degrees
Slit illumination level 5
Background level off
Aperture 5
EyeSuite exposure auto-mode

The slit illuminator is positioned in an almost coaxial position with the biomicroscope. A wide slit beam is decentred and adjusted to a half
circle by using the slit width and height controls. The decentred slit beam is projected near the pupil margin through a dilated pupil. Careful
composition can minimise the direct reflection.

Iris – Tangential illumination

Magnification 16 x or 25 x
Slit illumination Wide open, > 60 degrees
from microscope
Slit illumination level 10
Background level off
Aperture 5
EyeSuite exposure auto-mode

The wide slit beam is projected at an oblique angle of 80° – 90° onto the iris. This illumination creates strong shadows and the surface texture
is enhanced. If the headrest doesn’t allow a wide oblique angle it is sometimes necessary to turn the patient’s head a little away from the
light.

Fundus
Magnification 10 x or 16 x
Slit illumination 2 – 4 mm wide
Slit illumination level 5
Background level off
Aperture 5
EyeSuite exposure auto-mode

A moderate slit beam in the almost coaxial position gives the best results.

Haag-Streit educational video

Haag-Streit has produced a short movie which helps you
to get the most out of your new camera.

Visit our homepage - www.haag-streit.com

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BX 900 photo slit lamp
1. Flash and LED illumination The Haag-Streit BX 900 photo slit lamp is based on the BQ 900 slit lamp.
housing Therefore, it is possible to use the same instrument for ocular examination
2. Cable guide and documentation.
3. Flash intensity changer for
background illumination A photo slit lamp combines a biomicroscope, an illumination system,
4. Camera body and a photo attachment—the BX 900 and the BQ 900 share the same
5. Objective tube microscope. The photo slit lamp’s illumination system has a flash unit and
6. Eyepiece with double cross hair reticule a background illumination.
7. Mirror and diffusion filter
The BX 900’s different components will be explained on the following page.
8. Mirror housing
9. Background illumination
10. Shutter release bar
11. Photo control unit

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5

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9

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 1. The flash housing contains the flash tube. Firing the BX 11. The photo control unit is mounted under the left hand
900 trigger will simultaneously deliver a flash through side of the table. On the front side there are two switches
the illumination system and, via a glass fibre cable, the and four error light indicators. The power switch is only
fill background illumination, while synchronizing with the for the photo control unit. With the flash-intensity switch
camera shutter. in the high position, the flash light increases by one ap-
erture step. Optical and acoustic warning signals will be
2. The cable guide contains the high voltage cable for the activated in the case of an error when the shutter release
flash light. bar is pressed. Once the cause of the problem has been
removed, press the shutter release bar and the optical
3. The Flash intensity changer for the background illumina-
warning signal will be cancelled and the camera will be
tion has seven settings:
ready for use.
= 100% = 50% = 25%

= 10% = 5% = 0% = blue filter

Technical data
Biomicroscope
4. Haag-Streit has selected a number of SLR cameras and
Magnification changer 6.3 x, 10 x, 16 x, 25 x, 40 x
has made the necessary adaptations. The correct func-
Ocular magnification 12.5 x
tion of the photo-slit lamp is guaranteed only by the use
Range of adjusting oculars +7 to -7 dioptries
of cameras that are recommended by Haag-Streit. Note Reticule Right ocular
that the camera has to be in the «MANUAL» operating Inter-pupillary distance 52 – 78 mm
mode and the shutter speed should be set to 1/125 sec.
The recommended ISO rating for general use is 500 and
color temperature of the flash is 6000 k but users have Slit lamp illumination
the option to apply other settings as required. Slit height 1 – 8 mm
Slit width 0 – 8 mm
5. The camera body is mounted on the objective tube on Spotlight 0.2, 1, 2, 3, 5, 8 mm diameter
the top of the biomicroscope allowing full visibility of the Horizontal arc +/-90°
patient’s eyes from either side of the microscope. Vertical arc 5°, 10°, 15°, 20°
Filters Blue, green (red free), gray 10 %
6. The 12.5x eyepiece with double cross hair reticule is in- Slit beam diffuser Yes
serted into the right ocular of the microscope. This must Light source LED 24 VDC / 1 A
be correctly focused for the user’s eye to ensure sharp
images are captured. Note that the setting on the eye- Photo attachment
piece is not the user’s refractive error. Image delivery Quick return mirror 100% light for
examination or photography
7. With the diffusion filter the slit beam can be covered al-
Objective tube focal length 170 mm
lowing overview pictures with diffuse illumination. Light source flash light Normal 200 Ws, high 400 Ws
8. The principal component of the Haag-Streit photo-slit
lamp BX 900 is the mirror housing with its built-in dia- Depth of field
phragms. It mounts between the magnification changer Dependent on magnification and aperture.
and the binocular tube. When capturing an image all Magnification Extent of focus (+/- in mm) with aperture
light is directed, via a mirror, to the camera. This allows
the maximum utilisation of the available light: 100% for
1 2 3 4 5
the examination and 100% for the image. The built-in
diaphragm setting with five apertures is applied auto- 6.3 x 1.3 1.8 2.6 3.6 5.2
matically on image capture. For the aperture intervals: 10 x 0.5 0.7 1 1.4 2
Step 1 = largest aperture, Step 5 = smallest aperture. 16 x 0.2 0.3 0.4 0.5 0.8
The small knobs on each side of the mirror housing can 25 x 0.1 0.1 0.15 0.2 0.3
be used during examination to quickly activate the dia- 40 x 0.05 0.05 0.05 0.1 0.15
Values will be increased by 35% in transparent media of the eyes.
phragm to the preset position. This allows a preview prior
to capture so that the image subject and depth of field
may be checked. Image & magnification data
Setting at
9. The background illumination is swivel-mounted on a hori- magnification changer
zontal level and is illuminated through a glass fibre cable.
The flash fill illumination is delivered from the illumination 15 x 22
Magnification in
head and the modeling light is produced by the LED. The
plane of the sensor
modelling light is used to show where any reflection of 6.3 x 1.3 2.6
the fill flash will fall. 10 x 0.5 1
16 x 0.2 0.4
10. The shutter release bar is conveniently positioned in front
25 x 0.1 0.15
of the joystick on the cross-slide. It can be used either
40 x 0.05 0.05
right or left-handed.
Circles: visible field of the eyepiece.

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Standard settings
The BX 900 has many different adjustments in order to give 4. Define the image field, close the left eye (note the differ-
optimal illumination and exposure. It is best to always start ence between eyepiece and photo tube picture)
with a standard setting and to make adjustments after each 5. Focus control (eyepiece setting correct?)
image captured. An example for a standard setting is the dif- 6. Capture Image
fuse illumination:
1. Main switch on, photo control unit POWER ON and Illumination & exposure settings
camera body on The following table shows the different settings of illumina-
2. After waiting a few seconds, set the Flash intensity on tion and exposure adjustments. This table is also used for
HIGH practical examples and will give a starting point.
3. 100% Background illumination 45°angle between micro-
ISO 500 (Standard)
scope and background illumination
Flash intensity high / normal
Slit beam vertical
BGI* intensity 100 %, 50 %, 25 %, 10 %, 5 %, 0 %, blue filter
Slit beam fully open (slit width and height)
BGI* angle 0° – 90°
Slit beam centred (screw tightened)
Slit beam 0 (closed) – 8 mm (fully open)
100% slit illumination (without filter) Filter blue, red free (green), gray 10 %, diffused
Slit beam covered with the diffusion filter Illumination angle 0° – 90°
Angle between microscope and illumination device Magnification 10 x 16 x 25 x 40 x
30° – 45° Magnification 10x Aperture 4 with a sensor Aperture 1–5
rating ISO 500 BGI* = Background Illumination

Pictograms

Narrow slit beam Moderate slit beam Wide slit beam Slit beam with diffuser

Slit beam centred Slit beam decentred Background illumination Microscope

Diffuse illumination with slit & background illumination

The diffuse illumination with slit beam and background illumination gives a shadow free illumination with natural colors and two light re-
flexes. This is most useful for low magnification overview images.
ISO 500 BGI angle 30° – 45° Illumination angle 30° – 45°
Flash intensity high Slit beam fully open Magnification 10 x 16 x 25 x 40 x
BGI intensity 100 % Filter diffused Aperture 4 4 3 2

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 Diffuse illumination with background illumination only

The diffuse illumination with only the background illumination increases the contrast. The structures of the iris are more visible and there is
only one light reflex.

ISO 500 BGI angle 30° – 45° Illumination angle –

Flash intensity high Slit beam closed Magnification 10 x 16 x 25 x 40 x
BGI intensity 100 % Filter – Aperture 4 3 3 2

Lids – Diffuse illumination

Diffuse illumination provides evenly balanced lighting.

ISO 500 BGI angle 30° – 45° Illumination angle 30° – 45°
Flash intensity Normal Slit beam fully open Magnification 10 x 16 x 25 x 40 x
BGI intensity 50 % Filter diffused Aperture 4 4 3 2

Conjunctiva – Diffuse illumination

Diffuse illumination provides evenly balanced lighting. Exposure control is more varied due to increased reflectivity.

ISO 500 BGI angle 30° – 45° Illumination angle 30° – 45°
Flash intensity Normal Slit beam fully open Magnification 10 x 16 x 25 x 40 x
BGI intensity 50 % Filter diffused Aperture 5 5 4 3

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Conjunctiva – Narrow slit

A centred, narrow slit beam projected at a 45° angle demonstrates surface topography and trans-illumination of the lesion. The background
illumination gives the position of the slit beam.

ISO 500 BGI angle 30° – 45° Illumination angle 45°

Flash intensity high Slit beam 0.1 mm Magnification 10 x 16 x 25 x 40 x
BGI intensity 10 % Filter – Aperture 3 2 2 1

Conjunctiva – Indirect illumination

A moderately wide and decentred slit beam is projected just adjacent to the border of the lesion. The light penetrates conjunctiva and
illuminates the clear fluid below. In the presence of blood or scar tissue, the light is absorbed.

ISO 500 BGI angle 30° – 45° Illumination angle decentred

Flash intensity high Slit beam 2 – 4 mm Magnification 10 x 16 x 25 x 40 x
BGI intensity 10 % Filter – Aperture 2 2 1 1

Cornea – Diffuse illumination

This illumination technique can only be used in the presence of dense corneal pathologies because diffuse light does not penetrate very
well through the cornea. Dilating the pupil can enhance pathology by creating a darker background.

ISO 500 BGI angle 30° – 45° Illumination angle 30° – 45°
Flash intensity high Slit beam fully open Magnification 10 x 16 x 25 x 40 x
BGI intensity 100 % Filter diffused Aperture 4 4 3 2

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 Cornea – Wide slit, tangential illumination

This technique can provide more information as the oblique illumination is reflected and refracted by the cornea and any pathology.
Experiment with the illumination angle slit beam width for optimum results.

ISO 500 BGI angle 45° Illumination angle 60° – 80°

Flash intensity high Slit beam fully open Magnification 10 x 16 x 25 x 40 x
BGI intensity 0 – 25 % Filter 10 % Aperture – 4 3 2

Cornea – Moderate slit

The moderate beam produces two different layers of illumination, one on the epithelium and one on the endothelium. Note the corneal
changes are closer to the posterior reflection and therefore they lie deep in the cornea.

ISO 500 BGI angle 30° Illumination angle 45°

Flash intensity high Slit beam 2 – 3 mm Magnification 10 x 16 x 25 x 40 x
BGI intensity 0 – 25 % Filter – Aperture – 3 3 2

Cornea – Narrow slit, optical sectioning

A narrow focal slit beam is projected at a 45° to 60° angle. It cuts an optical section through the cornea like a knife. With this technique it is
possible to locate the layer of the pathological changes. These examples demonstrate endothelial and surface pathology.

ISO 500 BGI angle 45° Illumination angle 60° – 90°

Flash intensity high Slit beam 0,1 mm Magnification 10 x 16 x 25 x 40 x
BGI intensity 5% Filter – Aperture – 2 1 –

16 |
Cornea – Direct retroillumination from the iris

A moderate slit beam is decentred and angled to project onto the iris directly behind the pathology. The light reflects and backlights the
cornea. If there is some cataract present the lens can also be used to reflect light directly onto the area of interest.

ISO 500 BGI angle – Illumination angle decentred

Flash intensity high Slit beam 1 – 2 mm Magnification 10 x 16 x 25 x 40 x
BGI intensity 0% Filter – Aperture – 2 1 1

Cornea – Indirect retroillumination from the iris

The moderate slit beam is now decentred even more and angled to project onto the iris adjacent to the area behind the area of interest. The
background is dark and the edges of non-pigmented lesions are well defined by the diffuse light reflecting from the iris.

ISO 500 BGI angle – Illumination angle decentred

Flash intensity high Slit beam 1 – 2 mm Magnification 10 x 16 x 25 x 40 x
BGI intensity 0 – 10 % Filter – Aperture – 2 1 1

Cornea – Sclerotic scatter

The wide decentred slit beam is projected onto the limbus. The light striking the limbus is internally reflected through the corneal tissue
like a fibre optic. Corneal changes or abnormalities can be visualized by reflecting the scattered light. Careful post capture cropping can
enhance images.
ISO 500 BGI angle – Illumination angle decentred
Flash intensity high Slit beam 2 mm Magnification 10 x 16 x 25 x 40 x
BGI intensity 0% Filter – Aperture – 2 1 1

| 17
 Cornea – Topical administration of Sodium Fluorescein

Sodium fluorescein is applied gently to the bulbar conjunctiva. The patient should blink once or twice for the dye to be dispersed over the
eye. If the epithelium of the conjunctiva or the cornea is damaged, the fluorescein stains the underlying tissue. The remaining dye fluoresces
a yellow green color when excited by the blue light. Healthy epithelium does not stain.

ISO 500 BGI angle 30° Illumination angle 60° – 80°

Flash intensity high Slit beam fully open Magnification 10 x 16 x 25 x 40 x
BGI intensity blue filter Filter blue filter Aperture 3 3 2 1

Anterior chamber – Aqueous flare, Tyndall’s phenomenon

Cells, pigment or proteins in the aqueous humour reflect the light like a faint fog. To visualize this the slit illuminator is adjusted to the small-
est circular beam and is projected through the anterior chamber from a 40° to 90° angle. The strongest reflection is possible at 90°.

ISO 500 BGI angle 30° Illumination angle 50°

Flash intensity high Slit beam 0,1 – 1 mm Magnification 10 x 16 x 25 x 40 x
BGI intensity 0 % – 25 % Filter – Aperture – 1 1 1

Anterior chamber – Goniophotography

The desired mirror of the gonioscopy lens is positioned opposite to the area of pathology. A wide slit beam is projected in the desired mirror
from a near coaxial position to the biomicroscope. Light reflections can be eliminated by tilting the lens.

ISO 500 BGI angle – Illumination angle 10°

Flash intensity high Slit beam 2 mm Magnification 10 x 16 x 25 x 40 x
BGI intensity 0% Filter – Aperture – 5 5 4

18 |
Iris – Wide slit, tangential illumination

The wide slit beam is projected at an oblique angle of 80° – 90° onto the iris. This illumination creates strong shadows and the surface tex-
ture is enhanced. If the headrest doesn’t allow a wide oblique angle it is sometimes necessary to turn the patient’s head a little away from
the light.

ISO 500 BGI angle 45° Illumination angle 80°

Flash intensity high Slit beam fully open Magnification 10 x 16 x 25 x 40 x
BGI intensity 0 % – 10 % Filter – Aperture 5 5 4 4

Iris – Transillumination

The slit illuminator is positioned coaxially to the biomicroscope and adjusted to provide a small circular beam of light. This beam is projected
through the pupil which should be at mid dilation. The light reflects from the fundus and backlights the iris. Normally the iris pigment ab-
sorbs the light, but pigmentation defects let the red fundus light pass through.
ISO 500 BGI angle 45° Illumination angle coaxial
Flash intensity high Slit beam 1 – 2 mm Magnification 10 x 16 x 25 x 40 x
BGI intensity 0 % – 10 % Filter – Aperture – 2 1 1

Iris Angiography

The illumination technique of the iris angiography is like the tangential illumination with the background illumination opposite the slit beam.
Both slit illuminator and background illumination have a blue excitation filter. The yellow barrier filter is positioned between the magnifica-
tion changer and the mirror housing. The barrier filter only works on the image from the right eyepiece which is directed to the camera.
Control of the focus of the image during the angiography is possible through the left eyepiece.
ISO 800 BGI angle 45° Illumination angle 45°
Flash intensity high Slit beam fully open Magnification 10 x 16 x 25 x 40 x
BGI intensity blue filter Filter blue filter Aperture – 1 – –

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 Lens – Narrow slit, optical sectioning

A narrow focal slit beam is projected at a 45° angle to the lens as an optical section is made. Because of the problematic depth of field it is
not possible to photograph the entire lens section in focus. It is therefore necessary to focus on the anterior or the posterior lens surface.

ISO 500 BGI angle 45° Illumination angle 45°

Flash intensity high Slit beam 0.1 mm Magnification 10 x 16 x 25 x 40 x
Background 25 % Filter – Aperture – 1 1 –

Lens – Moderate slit, direct illumination

A moderate slit beam is projected at a 45° angle to the lens pathology and is directly illuminated. Dilation of the pupil is required for effec-
tive imaging.

ISO 500 BGI angle 45° Illumination angle 45°

Flash intensity high Slit beam 2 – 4 mm Magnification 10 x 16 x 25 x 40 x
Background 10 % Filter – Aperture – 2 2 1

Lens – Moderate slit, tangential illumination

A moderate to wide slit beam is projected at an angle greater then 45 degrees to provide oblique tangential illumination that can enhance
detail by providing shadows. Pupil dilation will aid this illumination technique.

ISO 500 BGI angle 45° – 60° Illumination angle 45° – 60°
Flash intensity high Slit beam 2 – 6 mm Magnification 10 x 16 x 25 x 40 x
Background 10 % Filter – Aperture – 2 2 1

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Lens – Retroillumination, red-reflex photography

The slit illuminator is positioned in an almost coaxial position with the biomicroscope. A wide slit beam is decentred and adjusted to a half
circle by using the slit width and height controls. The decentred slit beam is projected near the pupil margin through a dilated pupil. Careful
composition can minimise the direct reflection.
ISO 500 BGI angle – Illumination angle decentred
Flash intensity high Slit beam 2 mm Magnification 10 x 16 x 25 x 40 x
Background 0% Filter – Aperture – 2 1 1

Vitreous – Narrow slit

Without diagnostic lenses it is only possible to examine and to document the anterior part of the vitreous. Anterior Vitreous pathology can
be seen with a narrow slit beam. Only when the dioptric power of the eye is reduced is it possible to focus more posteriorly.

ISO 500 BGI angle 45° Illumination angle 45°

Flash intensity high Slit beam 0,1 – 1,0 mm Magnification 10 x 16 x 25 x 40 x
Background 0 % – 10 % Filter – Aperture – 1 1 –

Fundus – Central retina with a three-Mirror contact lens

The slit illuminator is positioned in an almost coaxial position with the biomicroscope. Awide slit beam is decentered and adjusted to a half
circle by using the slit width and height controls. The decentred slit beam is projected near the pupil margin through a dilated pupil. Careful
composition can minimise the direct reflection.

ISO 500 BGI angle – Illumination angle 5° – 10°

Flash intensity high Slit beam 2 mm Magnification 10 x 16 x 25 x 40 x
Background 0% Filter 10 % Aperture – 2 1 1

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 Fundus – Central retina with a 90-diopter lens

Without diagnostic lenses it is only possible to examine and to document the anterior part of the vitreous. Anterior Vitreous pathology can
be seen with a narrow slit beam. Only when the dioptric power of the eye is reduced is it possible to focus more posteriorly.

ISO 500 BGI angle – Illumination angle 5° – 10°

Flash intensity high Slit beam 2 mm Magnification 10 x 16 x 25 x 40 x
Background 0% Filter 10% Aperture – 2 1 –

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Recommended Reading
Clinical Slit lamp Biomicroscopy and Photo Slit lamp
Biomicrography / Martonyi, Bahn & Meyer
Time One Ink, Ltd. / Sedona, AZ
Copies of this and other books of interest to the
Ophthalmic Photographer can be found at:
www.twinchimney.com

Photos by:
Cees van Beek / Leyenburg Hospital, Den Haag,
Netherlands
Tarek Shaarawy / University Hospital of Geneva,
Switzerland
Haag-Streit, Bern, Switzerland
John McCormick / Tennent Institute of Ophthalmology
University of Glasgow, Scotland

Haag-Streit educational video

Haag-Streit has produced a short movie which helps
you to get the most out of your new camera.

Watch the video

Visit www.haag-streit.com

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 HS-Art.No. 1500.7200668.02120

HAAG-STREIT AG
Gartenstadtstrasse 10
3098 Koeniz
Switzerland
Phone +41 31 978 01 11
Fax +41 31 978 02 82
[email protected]
www.haag-streit.com

©Haag-Streit AG, 3098 Koeniz, Switzerland

12. Edition / 2024 – 05
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