Cornea Atlas - 3rd Edition

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CORNEA
Atlas
THIRD EDITION
Jay H Krachmer MD
Former Chairman
Department of Ophthalmology
University of Minnesota Medical School
Minneapolis, MN
USA

David A Palay MD
Associate Clinical Professor
Department of Ophthalmology
Emory University
Atlanta, GA
USA

London New York Oxford Philadelphia St Louis Sydney Toronto

SAUNDERS is an imprint of Elsevier Inc.

© 2014, Elsevier Inc. All rights reserved.

First edition 1995

Second edition 2006

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Contents

Preface vii 6. CONJUNCTIVAL DISEASE: TUMORS AND 10. LID, CONJUNCTIVAL, AND CORNEAL
Acknowledgments ix ANATOMIC ABNORMALITIES 44 MANIFESTATIONS OF CHEMICAL AND
Dedication xi Squamous Neoplasms of the Conjunctiva 44 BIOLOGICAL WARFARE 140
Tribute xiii Melanocytic Neoplasms and Other Pigmented Anthrax 140
Lesions of the Conjunctiva 50 Smallpox 141
Subepithelial Neoplasms and Other Lesions 53
1. CORNEAL SLIT LAMP TECHNIQUES 1 Prolapsed Orbital fat 61
Introduction 1 Conjunctivochalasis 61 11. CORNEAL DYSTROPHIES, ECTATIC
Direct Illumination: Thin Slit Beam 2 DISORDERS, AND DEGENERATIONS 142
Direct Illumination: Broad Oblique Beam 3 Anterior Membrane Dystrophies 142
Indirect Illumination: Indirect Iris Lighting 7. CONJUNCTIVITIS 62 Stromal Dystrophies 150
– Finding Darker Than Background 4 Clinical Features 62 Posterior Membrane Dystrophies 164
Indirect Illumination: Indirect Iris Lighting Bacterial Conjunctivitis 63 Noninflammatory Ectatic Disorders 171
– Finding Lighter Than Background 5 Viral Conjunctivitis 65 Secondary Ectasias 181
Indirect Illumination: Sclerotic Scatter 6 Chlamydial Infections: Adult Inclusion Iridocorneal Endothelial Syndrome 182
Indirect Illumination: Adjacent Beam 7 Conjunctivitis 68 Conjunctival and Corneal Degenerations 185
Indirect Illumination: Red Reflex 9 Trachoma 70
Specular Reflection 10 Ophthalmia Neonatorum 71
Parinaud’s Syndrome 72 12. CORNEAL INFECTIONS 196
Parasitic Conjunctivitis 73 Microbiology 196
2. DISEASES OF THE LID: ANATOMIC Allergic Conjunctivitis 73 Bacterial Infections 198
ABNORMALITIES 12 Vernal and Atopic Keratoconjunctivitis 74 Herpes Simplex Keratitis 200
Ectropion 12 Giant Papillary Conjunctivitis 76 Herpes Zoster Keratitis 208
Entropion 13 Ocular Cicatricial Pemphigoid 76 Fungal Keratitis 213
Trichiasis 14 Linear IgA Disease 78 Acanthamoeba Keratitis 216
Distichiasis 14 Pemphigus Vulgaris 79
Lagophthalmos 15 Stevens-Johnson Syndrome 80
Ptosis 15 Reiter’s Syndrome 82 13. INTERSTITIAL KERATITIS 221
Floppy Eyelid Syndrome 15 Toxic Conjunctivitis 82
Syphilitic Interstitial Keratitis 221
Lower Lid Imbrication 16 Theodore’s Superior Limbic
Nonsyphilitic Interstitial Keratitis 223
Keratoconjunctivitis 83
Ligneous Conjunctivitis 84
3. DISEASES OF THE LID: TUMORS 17 Factitious Conjunctivitis 85
14. NONINFECTIOUS KERATOPATHY 224
Benign Lid Tumors 17
Recurrent Erosion Syndrome 224
Malignant Lid Tumors 23
8. NORMAL ANATOMY AND DEVELOPMENTAL Filamentary Keratitis 226
ABNORMALITIES OF THE CORNEA 86 Thygeson’s Superficial Punctate Keratitis 227
Neurotrophic Keratopathy 228
4. DISEASES OF THE LID: INFLAMMATORY Normal Anatomy 86
Dellen 230
(BLEPHARITIS), IMMUNOLOGIC, INFECTIOUS, Developmental Corneal Opacities and
Neurogenic Keratopathy 230
AND TRAUMATIC 27 Abnormalities of Size and Shape 88
Exposure Keratopathy 231
Blepharitis 27 Anterior Chamber Cleavage Syndromes 93
Radiation Keratopathy 232
Immunologic 31 Toxicity 232
Bacterial Infections 31 Factitious Disease 233
Viral Infections 32 9. CORNEAL MANIFESTATIONS OF SYSTEMIC
Parasitic Infections 33 DISEASE AND THERAPY 97
Allergic Inflammations 34 Metabolic Disorders 97 15. IMMUNOLOGIC DISORDERS OF THE
Alopecia 35 Skeletal Disorders 109 CORNEA 234
Foreign Body 35 Inflammatory Bowel Disease 111
Rheumatoid Arthritis 234
Nutritional Disorders 113
Nonrheumatoid Collagen Vascular Disease 237
Hematologic Disorders 114
Staphylococcal Disease 240
5. DISORDERS OF TEAR PRODUCTION AND Endocrine Disorders 119
Mooren’s Ulcer 241
THE LACRIMAL SYSTEM 36 Dermatologic Disorders 121
Dry Eye 36 Infectious Diseases 126
Dacryoadenitis, Dacryocystitis, and HIV-Related Disorders 130
Canaliculitis 42 Corneal Manifestations of Local and Systemic
Therapies 131

Contents v
16. CORNEAL TRAUMA 243 21. PENETRATING KERATOPLASTY 293 24. THERAPEUTIC AND RECONSTRUCTIVE
Foreign Body, Mechanical, Thermal, and Preoperative and Postoperative Appearance 293 PROCEDURES 325
Radiation Trauma 243 Intraoperative and Early Postoperative Scleral Contact Lenses 325
Surgical Trauma 265 Complications 295 Conjunctival Flaps 326
Acid Burns 270 Late Complications 299 Surgery for Pterygia 327
Alkali Burns 271 Rejection Reactions 306 Surgery for Scleral Melt 328
High Astigmatism 310 Glue Application for Corneal Perforation 329
Superficial Keratectomy 330
17. CONTACT LENS COMPLICATIONS 272 Phototherapeutic Keratectomy (PTK) 331
22. DEEP ANTERIOR LAMELLAR Corneal Collagen Crosslinking 332
KERATOPLASTY 312 Keratolimbal Allograft (KLAL) 334
18. DISORDERS OF THE SCLERA 279 Preoperative, Intraoperative, and Postoperative Conjunctival Limbal Autograft (CLAU) 334
Appearance 312 Surgery for Recurrent Erosions 335
Scleral Thinning 279
Intraoperative and Early Postoperative Reconstructive Lamellar Keratoplasty 336
Episcleritis 279
Complications 315 Anterior Segment Reconstruction 337
Scleritis 280
Late Complications 316 Tattooing 339
Rejection Reactions 317 Temporary Keratoprosthesis 339
Permanent Keratoprosthesis 340
19. IRIS TUMORS 283

23. ENDOTHELIAL KERATOPLASTY 318

25. REFRACTIVE SURGERY 342
20. ANTERIOR UVEITIS 288 Tissue Preparation 318
Preoperative, Intraoperative, and Postoperative Incisional Refractive Surgery 342
Sarcoidosis 288 Photorefractive Surgery: Photorefractive
Appearance 319
Fuchs’ Heterochromic Iridocyclitis 289 Keratectomy 343
Intraoperative and Early Postoperative
Behçet’s Disease 290 Photorefractive Surgery: Laser-Assisted In Situ
Complications 321
Vogt-Koyanagi-Harada Syndrome 291 Keratomileusis (LASIK) 345
Late Complications 324
Juvenile Rheumatoid Arthritis 291 Photorefractive Surgery: Laser-Assisted
Rejection Reactions 324
Syphilitic Uveitis 292 Subepithelial Keratectomy (LASEK) 353
HLA-B27-Related Uveitis 292 Intrastromal Rings 354
Thermal Keratoplasty 355
Phakic Intraocular Lenses 356

Index 357

vi Contents
Preface

It was a pleasure for us to have the opportunity to write a • There is a new chapter entitled “Corneal Slit Lamp Tech-
third edition of our Cornea Atlas. We feel that this edition is a niques”. This chapter, written by Jay Krachmer, is a
significant improvement over the previous book. summary of Jay’s observations and teaching points from a
career that lasted more than 30 years.
How does this edition differ from the previous editions? • There is a new chapter entitled “Deep Anterior Lamellar
Keratoplasty”.
• Nearly all the figures from the previous editions have been • There is a new chapter entitled “Endothelial Keratoplasty”.
edited with improvements.
• Many figures have been eliminated or replaced. We hope that this edition is greatly improved but realize that
• There are 203 new figures. we can still do better. As with the previous editions, we ask
• In the first edition, 25% of the figures came from contribu- that readers let us know how we can make a future edition an
tors. In the second edition 36% of our figures came from even greater contribution.
contributors. In this edition, 40% came from outside of our
collections. Using the Internet, we were able to obtain Jay H Krachmer, MD
contributions from Africa, Asia, Europe, and South America. David A Palay, MD
• There are a total of 103 contributors, more than both
previous editions.

Preface vii
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Acknowledgments

We are extremely grateful to our many colleagues, associates, 20.7, 20.13, 20.14, 20.17, 20.18, 21.18, 21.32, 24.30, 24.31, 24.32,
and friends who helped with the preparation of this book. We 24.33, 24.34, 25.3)
would like to credit and thank the following contributors for Andrew Huang, St. Louis, Missouri (7.53, 7.56, 9.35, 11.54, 11.55,
sending us materials: 11.189)
Infect Dis Clin North Am, 1992 (9.120)
Wallace L M Alward, Iowa City, Iowa (8.38, 11.142) Int Ophthalmol Clin 29:98-104, 1989 (9.127)
Haggay Avizemer, Tel Aviv, Israel (9.133, 11.68) Joe Iuorno, Richmond, Virginia (1.18, 6.3, 6.4, 6.34, 7.85, 9.138,
Jerry Barker, Winston-Salem, North Carolina (23.1) 11.77, 11.108, 16.2, 16.10)
William Basuk, Deceased (2.7) Timothy Johnson, Iowa City, Iowa (20.12)
Allen D Beck, Atlanta, Georgia (16.8) David Jordan, Ottawa, Canada (5.26)
Michael Belin, Merana, Arizona (11.130) Muriel I Kaiser-Kupfer, Deceased (13.12)
Erick Bothun, Minneapolis, Minnesota (9.15) Jack Kanski, London, England (8.35)
Mario Brunzini, Buenos Aires, Argentina (12.68) Stephen Kaufman, Minneapolis, Minnesota (6.21, 9.10, 9.11, 12.82,
J Douglas Cameron, Minneapolis, Minnesota (6.17, 11.122, 11.174) 16.90)
Emmett Carpel, Minneapolis, Minnesota (11.137) Kenneth Kenyon, Marion, Massachusetts (9.18, 9.34, 11.57)
H Dwight Cavanagh, Dallas, Texas (8.5) William H Knobloch, Deceased (9.8)
Naveen S Chandra, Walnut Creek, California (25.34) David Knox, Baltimore, Maryland (9.52, 9.54)
Steven Ching, Rochester, New York (7.66, 7.67, 7.68, 7.69, 9.102, Steven Koenig, Milwaukee, Wisconsin (16.12)
9.103, 9.104, 11.177, 12.54, 22.2, 22.3, 22.4, 22.5, 22.6, 22.8, 22.9, Regis Kowalski, Pittsburg, Pennsylvania (12.1, 12.2, 12.3 (A,C,D,E,F),
22.15) 12.4)
Gary Chung, Federal Way, Washington (6.14, 6.15, 6.16, 17.9) Burton J Kushner, Madison, Wisconsin (3.8, 3.9)
David Cogan, Deceased (13.11) Ethan Kutzscher, Walnut Creek, California (1.16, 12.86, 12.87,
Elisabeth Cohen, New York City, New York (9.24, 9.25) 25.24, 25.30)
Michael Conners, Setauket, New York (25.37, 25.38) Sergio Kwitko, Porto Alegre, Brazil (11.117, 11.188, 22.7, 22.10, 22.11,
Elizabeth Davis, Minneapolis, Minnesota (25.48) 22.12, 22.16, 23.3, 23.9, 24.56, 25.41, 25.42, 25.43, 25.44,
Michael Diesenhouse, Tucson, Arizona (9.123, 18.11, 18.12) 25.45 25.49)
Claes Dohlman, Boston, Massachusetts (24.53, 24.54, 24.57) Peter R Laibson, Philadelphia, Pennsylvania (7.12, 7.62, 7.77, 7.78,
Fabio Dornelles, Porto Alegre, Brazil (1.27, 1.28, 4.8, 11.91, 11.147, 7.83, 8.7, 11.2, 11.4, 11.19, 11.49, 11.56 (Thiel-Behnke), 11.155,
25.5, 25.6, 25.40) 12.21, 12.25, 12.28, 12.35, 12.49, 12.58, 12.59, 13.6, 13.7, 14.3,
Donald Doughman, Minneapolis, Minnesota (9.114) 14.4, 14.7, 16.37, 16.82)
Richard Eiferman, Louisville, Kentucky (4.34, 8.29, 9.86, 17.2, 18.1, Ronald Laing, Sarasota, Florida (8.4)
18.7, 21.53) Scott Lambert, Atlanta, Georgia (20.16)
Robert S Feder, Chicago, Illinois (11.20, 11.21, 11.22, 11.37, 11.38, Michael Law, Kuala Lumpur, Malaysia (11.6, 11.109, 11.118, 15.33,
11.56 (Lattice III)) 16.96, 16.97, 16.98, 21.8, 23.10, 25.10)
Sandy Feldman, San Diego, California (9.55, 9.56) Barry Lee, Atlanta, Georgia (2.14, 7.60, 8.16, 9.99, 11.115, 21.45,
Richard K Forster, Miami, Florida (7.32, 7.33, 10.5, 10.6) 21.46, 23.16)
Denise de Freitas, Sao Paulo, Brazil (1.11, 12.75, 25.35) Michael Lee, Minneapolis, Minnesota (9.151)
Juliana Freitas, Sao Jose de Rio Preto, Brazil (9.105, 9.106, 9.107, Michael Lemp, Lake Wales, Florida (5.1, 5.2, 5.3)
9.108, 16.9) Mary Lynch, Atlanta, Georgia (8.32, 8.36, 8.37)
Herb Friesom, Deceased (4.27, 4.28, 7.37, 7.51, 10.1, 10.2, 10.3, 10.4) Marian Macsai, Chicago, Illinois (24.44, 24.45, 24.46, 24.52)
Lawrence Gans, Hazelwood, Missouri (19.5) Mark Mandel, Hayward, California (16.88)
David Goldman, Palm Beach Gardens, Florida (23.13, 23.14, 23.15, Mark J Mannis, Sacramento, California (4.3, 4.21, 5.20, 7.64, 11.69,
25.33) 11.70, 21.15)
Kenneth Goins, Iowa City, Iowa (22.1) Daniel F Martin, Cleveland, Ohio (6.5, 19.19)
W Richard Green, Deceased (4.26) Darlene Miller, Miami, Florida (12.3 B)
Michael R Grimmett, Palm Beach Gardens, Florida (6.45) Gioconda Mojica, Hayward, California (1.20, 6.66, 6.67, 7.23,
Hans Grossniklaus, Atlanta, Georgia (3.5, 3.10, 3.15, 3.19, 3.18, 3.31, 7.24, 8.22)
3.34, 3.39, 3.41, 6.30, 6.58, 7.65, 8.14, 8.17, 8.28, 8.31, 8.41, 9.26, Andrew L Moyes, Kansas City, Missouri (4.20, 5.27)
11.3, 11.15, 11.32, 11.33, 11.34, 11.50, 11.61, 11.96, 11.99, Jeffrey Nerad, Cincinnati, Ohio (3.18)
11.124, 11.165, 11.178, 12.85) David Park, Stillwater, Minnesota (25.47)
M Bowes Hamill, Houston, Texas (16.43, 16.65) Rachana Patel, Jacksonville, Florida (9.32, 9.33)
Stephen Hamilton, Atlanta, Georgia (9.42, 19.6, 24.55) Charles Pavlin, Toronto, Ontario (6.28, 6.29)
Kristen Hammersmith, Philidelphia, Pennsylvania (21.37) Louis Probst, Westchester, Illinois (25.12, 25.13, 25.16, 25.21, 25.22)
David Hardten, Minneapolis, Minnesota (25.46) John J Purcell, St. Louis, Missouri (11.35, 11.36)
Andrew Harrison, Minneapolis, Minnesota (2.4, 2.6, 3.4, 3.35, 3.36, J Bradley Randleman, Atlanta, Georgia (25.36)
3.37, 9.85) Christopher Rapuano, Philadelphia, Pennsylvania (11.23, 19.13,
Koji Hirano, Nagoya, Japan (11.39, 11.40, 11.41, 11.56 (Lattice IV)) 23.11, 23.12, 24.13, 24.14, 24.21, 24.22, 24.41, 24.42, 25.17,
Lawrie Hirst, Graceville, Australia (16.6, 16.7, 24.8, 24.9) 25.25, 25.27)
Edward J Holland, Cincinnati, Ohio 3.40, 3.42, 5.23, 6.26, 6.46, 6.54, Merlyn Rodrigues, Bethesda, Maryland (11.87, 11.123, 11.169)
7.38, 7.52, 7.81, 7.89, 7.90, 7.91, 9.94, 9.95, 9.96, 9.97, 9.128, Roy Rubinfeld, Chevy Chase, Maryland (11.5, 24.23, 24.24, 24.25,
11.51, 11.52, 11.53, 11.56 (Granular II), 11.64, 11.65, 11.187, 24.26, 24.27, 24.28, 24.29, 25.14, 25.15, 25.18, 25.19, 25.20,
12.11, 12.24, 12.34, 15.20, 15.21, 15.26, 16.84, 16.85, 18.5, 20.3, 25.23, 25.29, 25.31, 25.32)

Acknowledgments ix
Alan Sadowksy, Fridley, Minnesota (9.93, 9.98, 9.100) Keith Walter, Winston-Salem, North Carolina (7.8, 7.9, 24.49, 24.50)
Steven Schallhorn, San Diego, California (25.9, 25.11, 25.28) Michael Ward, Atlanta, Georgia (24.1, 24.2)
Ivan Schwab, Sacramento, California (9.137) George O Waring III, Atlanta, Georgia (6.23, 6.31, 8.9, 11.162, 24.58)
Wendell J Scott, Springfield, Missouri (9.14) Michael Warner Hermiston, Oregon (6.1, 6.6, 6.20, 6.41, 6.43, 6.44,
Neal Shear, Minneapolis, Minnesota (1.19, 9.78, 9.79) 6.61)
Roni Shtein, Ann Arbor, Michigan (11.12, 12.84) Robert Weisenthal, Dewitt, New York (11.94, 22.17, 22.18, 22.19)
Gilbert Smolin, Deceased (9.9, 9.12, 9.13, 9.81) John Wells III, West Columbia, South Carolina (9.49, 9.50)
Tomy Starck, San Antonio, Texas (11.144) Theodore Werblin, Princeton, West Virginia (25.4)
Walter Stark, Baltimore, Maryland (21.58) Jonathan Wirtschafter, Deceased (9.65, 9.66)
Alfred O Steldt, Minneapolis, Minnesota (16.62) Ted H Wojno, Atlanta, Georgia (2.1, 2.2, 2.3, 2.5, 2.8, 2.11, 2.12,
Alan Sugar, Ann Arbor, Michigan (11.97, 1198) 3.13, 3.14, 3.16, 3.20, 3.21, 3.22, 3.23, 3.24, 3.25, 3.26, 3.29, 3.30,
Joel Sugar, Chicago, Illinois (9.116, 9.117, 9.118, 9.119, 11.97, 11.98, 3.32, 3.33, 3.38, 4.17, 6.48, 6.64, 6.65, 7.3, 9.101, 16.28)
15.23) Tom Wood, Memphis, Tennessee (6.11, 6.12, 6.13, 15.30, 15.31,
Laurence Sullivan, East Melbourne, Australia (2.15, 7.42, 11.76, 17.8, 15.32)
22.13, 22.14, 25.39) Martha Wright, Minneapolis, Minnesota (11.143, 11.160, 11.161)
C Gail Summers, Minneapolis, Minnesota (9.7, 9.16) Sonia Yoo, Miami, Florida (23.17)
Survey of Ophthalmology 38:229, 1993 (9.115)
Hugh Taylor, Carlton, Australia (9.121, 9.122) We would like to thank the staff at Elsevier/Saunders for their
Thieme, New York, New York 1998 (24.19, 24.20) wonderful support. It was a pleasure working with them.
Keith Thompson, Atlanta, Georgia (11.47, 25.1, 25.2) Although many individuals were involved, it was Russell
Gregory L Thorgaard, Ottumwa, Iowa (14.22, 14.23) Gabbedy, Sharon Nash, and Caroline Jones who went to bat
Elias Traboulsi, Cleveland, Ohio (9.44)
for us when we had ideas which might cost the publisher
David T Tse, Miami, Florida (2.16, 2.17)
Gary Varley, Cincinnati, Ohio (5.14, 12.19)
extra money but in the end would definitely be value-added.
Arthur W Walsh, Lebanon, New Hampshire (9.143)

x Acknowledgments
 With great love and appreciation, I dedicate this book to
my wife, Kathryn, our children, Edward, Kara, and Jill,
our parents, Paul and Rebecca Krachmer
and Louis and Gertrude Maraist

Jay H Krachmer

To my wife and best friend, Debbie, and my children Sarah and Matthew,
and my parents Sandra and Bernard.
Without their love and support this would not have been possible.
I dedicate this book in memory of my father, Bernard H. Palay MD.

David A Palay
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Tribute: Tuesdays with Jay
I have had the honor and privilege to work with Jay on all three editions of the Cornea Atlas. The first edition was conceived
during my cornea fellowship with Jay. Although the primary goal of the fellowship was to learn about diseases of the cornea,
Jay’s fellowship was also a philosophical inquiry into how to live one’s life. It included discussions of science, research, politics,
human relations, and ethics. So much of how I practice and live my life today was influenced by the time I spent with Jay.
During my regular Tuesday conference call with Jay for this third edition, the book was discussed, but so too were many other
life topics, cooking, movies, TV shows, politics, and the state of medicine just to name a few. My “Tuesdays with Jay” allowed
me to relive the wonderful year I spent with him during my fellowship.
Jay achieves a level of perfection with his work that few will ever achieve. Similar to training with a great athlete, Jay pushes
you to levels you didn’t realize were attainable.
Just one figure in this atlas took Jay over eight hours to construct. The lighting, color, and cropping must be perfect. The
pathology must be highlighted in a way that is effortless for the viewer to discern. Most viewers will glance at the figure for a
few seconds not realizing the dedication and time utilized to construct each figure. Cumulatively, this work represents hun-
dreds of hours of work. It is often assumed that a third edition will take less time than a first or second edition. However, in
this case each edition has taken more time to construct. The pursuit of perfection runs deeper with each subsequent edition.
“The slit lamp examination is a work of art. The examiner uses light like an artist uses a paintbrush; always looking for ways
to see or demonstrate his/her view of the subject.” – Jay Krachmer.
Chapter 1, Corneal Slit Lamp Techniques, is a summary of Jay’s observations and teaching points over a career that spanned
more than 30 years. Jay has an innate power of observation; he is able to see things that most others miss. I remember showing
a video at a conference of a difficult surgical case. The entire audience saw the surgical maneuvers in the video, only Jay
noticed that the eye speculum I was using was highly unusual and it was a prototype of a new eyelid speculum. Every viewer
was naturally drawn to the action in the center of the screen; only Jay saw the action in the center and the static speculum in
the periphery of the screen.
It is with great appreciation and fondness that I write these words of thanks to Jay. He has guided me in my career to be an
outstanding physician and human being and he has similarly served as a mentor to many fellows and residents. His teaching
will live on: not only through this book but also with each generation of his students who will teach subsequent generations of
students.
Thank you, Jay.
David Palay
This page intentionally left blank
Chapter 1

Corneal Slit Lamp Techniques

Introduction
Except for some refinements, such as better optics and illumination, the current slit lamp is
basically the same instrument Vogt used nearly 100 years ago. Ocular illustrations from that
time were spectacularly detailed, indicating a degree of excellence rivaling today’s slit lamps.
We hope that we will not go another 100 years without having a better instrument.
It is assumed that the reader is familiar with the mechanical use of the slit lamp and is
therefore able to reproduce the techniques that will be discussed. The examiner uses one hand
to control the light source (beam brightness, height, width, direction, color, and whether it is
parfocal with the biomicroscope) and the other hand to focus the biomicroscope and change
its magnification.

Points to Remember
• Adjust the eye-pieces for your eyes. If you do not, you will miss a great deal of pathology.
• Look at what is there – not what should be there.
• Look for what is different – not what is the same.
• Expand the number of parameters that you use to describe a finding.
• Do not be too quick to label (name) what you see.
• Use bright light.
• Use the full range of slit lamp magnification.
• Ask the patient to blink. Your attention will be drawn to what does not move (what is part
of or attached to the cornea).
• Findings have different appearances when different types of illumination are used.
• Be sure that the thin slit beam is focused directly on an object for which you are determin-
ing depth.
• Paint with light the way an artist uses a paintbrush.
• Always focus on the tissue you want to examine.
• Enjoy examining the cornea. It is a privilege.

Three Basic Forms of Illumination

Are you focusing the microscope directly within the light beam as it illuminates the cornea? If
so, you are using a form of direct illumination. Or, are you not focusing the microscope within
the beam on the cornea? If so, you are using a form of indirect illumination. A third form of
illumination is the most difficult and will be described in its own category, specular reflection.

Examination Flow
To examine the cornea, first scan with a broad oblique beam. As you are doing so, vary the
beam’s width and direction (from the left or right) and notice findings that come into view
between the beam on the cornea and the beam falling on the iris. What you see between the
corneal and iris beams will be out of focus. Therefore, you must constantly alternate focus
from in the corneal beam to between the corneal beam and light falling on the iris. Remind
the patient to blink. In that way, as you scan across the cornea, particles in the tear film will
move and your attention will be drawn to that which does not move. When you are focusing
in the corneal beam, you are using direct illumination. When you are not focusing in the
corneal beam, you are using indirect illumination. Use a thin slit to determine the depth of
pathology and corneal thickness. Other techniques, such as sclerotic scatter, adjacent beam, red
reflex, and specular reflection are important but are used less frequently.
The two best forms of illumination for making observations are:
• Broad oblique beam; or
• Indirect illumination.

Corneal Slit Lamp Techniques 1

Order of Technique Presentation
Slit lamp techniques and illustrations follow in this order:
• Direct illumination
• Thin slit beam
• Broad oblique beam
• Indirect illumination
• Indirect iris lighting – finding darker than background
• Indirect iris lighting – finding lighter than background
• Sclerotic scatter
• Adjacent beam
• Red reflex
• Specular reflection.

Direct Illumination: Thin Slit Beam

Thin Slit Beam – direct illumination

(to determine depth of findings or shape of the cornea)

Create a thin
bright beam

Focus directly within

the lit optical section
of the cornea to determine
the anterior/posterior depth

Light of the findings

source and
shape of the cornea

Fig. 1.1 Thin slit beam. The thin slit beam has very specific purposes. Use it
to determine the depth of findings or the shape of the cornea. Unfortunately, it is
probably the most commonly used form of illumination and therefore the reason
why so many features of the cornea are missed.

Fig. 1.2 Thin slit beam. A bright thin slit creates a cross section of the cornea demonstrating detailed anatomy. It is kind
to the patient not to irritate them by having a bright light shining in their eye. It is unkind to the patient if important
findings are missed.

2 Cornea Atlas
 Fig. 1.4 Thin slit beam. The thin
slit is used to show the contour and
thickness of the cornea. In this case,
there is thinning with protrusion of the
cornea above the thinning. This feature
helps to distinguish this patient’s
pellucid marginal degeneration from
keratoconus, where the protrusion is in
the area of thinning.

Fig. 1.3 Thin slit beam. The bright, thin slit discloses the anterior–posterior
location of this patient’s polychromatic proteinaceous deposits. They are at all
depths, and even in the tear film.

Direct Illumination: Broad Oblique Beam

Broad Oblique Beam – direct illumination

Broad beam at washes light creating highlights bringing out
1
an oblique angle over cornea and shadows great detail

Light Focus directly within

source light on cornea
Fig. 1.6 Broad oblique beam. You
can see that the beam is oblique by its
curvature and that it is obviously
broad. Whatever the findings are, there
is no way to know their anterior–
posterior location using this technique. Fig. 1.7 Thin slit beam of
This patient has keratoconus. The previous figure. The same cornea
photo shows heavy white scars, thin using a thin slit shows that the scars
white opacities which go away with are anterior and the folds are posterior.
pressure on the cornea because they The cornea is thin and protruding.
Fig. 1.5 Broad oblique beam. Using a broad oblique beam, along with are Descemet’s folds, and part of a ring This and the previous photo make a
indirect illumination techniques, is both good and bad. The good news – you will of pigment (Fleisher ring) above the powerful combination. They furnish
observe ten times more corneal findings. The bad news – you will spend a lot pupil (1). information that neither can disclose
more time wondering if what you see is normal or pathologic. The broad oblique alone.
beam makes a detail more obvious than a less angled beam. Imagine that you
want to photograph a pimple on someone’s skin in a way to maximize its
features. Would the lighting be better from the side (oblique) or straight on?

Corneal Slit Lamp Techniques 3