 Carla’nne Dukes, DO, MBA, FACEP

 Emergency Medicine Residency Director

 St. Joseph’s Mercy of Macomb
 Clinton Twp, MI
 dukesca@trinity-health.org
 Credit
 http://eyelearn.med.utoronto.ca/default.htm
 University of TorontoThe Ophthalmology
Teaching Website
The Slit Lamp Exam
 Although the slit lamp
has become almost
universally available
to the emergency
room physician, a
reluctance on the part
of many physicians to
use this device persists
Magnification
 a patient who came to
the emergency with a
sensation of a foreign
body in the eye. The
emergency physician,
without the aid of
magnification, spent 20
to 30 minutes trying to
remove the small
brown dot that is just
visible in this slide.
Magnification
 the same patient
using the
magnification, the
brown dot can
actually be seen to
be two brown nevi,
benign pigmented
accumulations of
cells
Fluorescein & Cobalt Blue Filter
 By the fluorescence elicited by the cobalt
blue illumination, subtle lesions of the
cornea, including smaller corneal
abrasion, herpes simplex, dendritic ulcers
and foreign bodies can be easily seen
 Landmark Identification
 Landmark 1 will be the anterior surface
of the cornea, the first to be struck by the
slit lamp beam.
 Landmark 2 will be the posterior surface

of the cornea where the slit lamp beam

exits from the cornea.
 Landmark Identification
 Landmark 3 will be the plane of the iris
and lens surface.
 Landmark 4 will be the posterior surface of

the lens which has a reverse curve and can

be most easily seen with the beam angled
more closely to the line of observation
Landmark Identification
 landmarks 1, 2 and 3
are out of focus but
landmark 4 is in focus
and a white opacity
on landmark 4 is seen
- the typical posterior
subcapsular cataract
produced by extended
use of topical steroids
and easily identified
with the slit lamp
Landmark Identification

 The nature of these

lines becomes
apparent with the
angled slit beam
Landmark Identification
 Between landmarks 2
and 3 a vertical
transparent membrane
may be seen which
peels off the back of
the cornea superiorly
and curls up upon itself
inferiorly. The upper
line seen in the flat-
illumined view was
where the endothelium
had been peeled off the
back of the cornea
Landmark Identification
 Landmarks 4 and 3 can
be seen, 1 and 2 are out
of focus. Between
landmarks 4 and 3 there
is a big, diffuse yellow
haze. Its position
relative to landmarks 3
and 4 reveals that it is
right in the center of the
lens and hence it is the
nucleus.
Landmark Identification
 a mature cataract
is being viewed
with flat
illumination.
This reveals no
information with
regard to the
position of the
cornea relative to
the lens and iris,
Landmark Identification
 the line of slit beam
on the front of the iris
is seen to be
coincident with the
slit beam exit on the
back of the cornea,
indicating no anterior
chamber at this site
and the iris is
plastered against the
back of the cornea.
Landmark Identification
 Observe the relation
between landmarks 1
and 2. One and 2
proceed from above to
below with uniform
separation until just
below the mid-point.
Landmark 1 can be seen
to dip in and out,
revealing a shallow pit
which was left after
foreign body removal.
Landmark Identification
 landmarks 1 and 2 can
be seen coming out
from below and
joining, indication that
the stroma of the
cornea is gone in the
central portion as a
result of multiple
surgical procedures on
this cornea
Landmark Identification
 The light is coming
from the observer's
right-hand side and
strikes first of all the
cornea, and then the
iris and lens. A large
gap may easily be
seen between the slit
beam on the cornea
and the slit beam on
the lens.
Thinning the Cut
Thinning the Cut
Depth
 the cornea of an
eight-year-old boy is
demonstrated in
which the wound to
his cornea is V-
shaped and resulted
from a brass hose
coupling slipping
and flying up and
cutting the front of
his cornea
Depth
 the slit lamp beam
has been moved
further to the left
and the line of the
cut in the cornea
again is
demonstrated to be a
shelving rather than
a penetrating
incision.
Depth
 Easy Miss without Slit Lamp
 An enamel flake cut the eye in a shelving
manner which was self-sealing so that there
was no pupillary distortion. There was no
prolapsed iris, and without the application of
the angled slit beam to achieve serial optic
sections the discovery of the wound which did
in fact penetrate to the interior of the eye could
not have been discerned at the initial
encounter.
Easy Miss without Slit Lamp
 Easy Miss without Slit Lamp
 A nail slipped and stuck in the patient’s eye. He came
to the emergency department, but the emergency
intern, who was on his first week in service, had no
facility with the slit lamp. He did use fluorescein dye
and found that there was staining, but was
unsuccessful in reaching the ophthalmologist on call.
He brought the patient back to the clinic two days
later at which time the typical iris distortion, linear
discontinuity on the cornea and protruding iris
indicated a penetrating wound of the eye.
Easy Miss without Slit Lamp
 Easy Miss without Slit Lamp
 Magnication would have revealed protruding
iris tissue and the diagnosis could have been
made at the initial encounter. After the eye
was sewn up the patient was found to have a
vitreous abscess. This was removed surgically
following which the retina detached.