Diagnostic Instruments

Tear Quality and Thickness

The Tearscope-plus (Keeler, United Kingdom) can be used to observe certain characteristics of the tear film noninvasively ( ) ( Fig. 34.2A ). This instrument takes the form of a small white dome with a central sight hole, surrounded by a cold light source. It can be held directly in front of the eye, or used in conjunction with a slit-lamp biomicroscope to gain more magnification ( Fig. 34.2B ). The thickness distribution, quality and freedom of movement of the tears can be assessed by observing the reflected light from the featureless white dome, and the integrity of the aqueous and lipid phases can be inferred from colour fringe interference patterns ( ). Although the Tearscope-plus is no longer manufactured, similar instruments have become available more recently. The EASYTEAR View+ (EASYTEAR, Trento, Italy) is designed and functions in a very similar way to the Tearscope-plus and uses white light emitting diodes to permit the user to observe the dynamic interference patterns of the lipid layer and can be used to determine the break-up time of the tear film by inserting a grid pattern ( Fig. 34.3A and B ) ( ). It can be used as a handheld device or mounted onto a slit lamp, which allows the user access to a greater range of magnification to view the features of interest. The Polaris Tear-Film Analyzer (CSO, Firenze, Italy) is an accessory that can be mounted to a slit lamp that also permits interferometric examination of the lipid layer using an LED cold light source from the device ( ).

Another instrument that can facilitate qualitative observation of the lipid layer is the OCULUS Keratograph 5M (Oculus, Wetzlar, Germany) ( ). The interference colours of the lipid layer and their structure are made visible using white light illumination and this pattern can be recorded. The thickness of the lipid layer is then assessed based on the structure and colour of this image, without using a dedicated interferometer.

Grading the lipid layer using the instruments described so far is limited to subjective interpretation. This can be difficult for those with limited experience of looking at tear film lipid layers, especially when the lipid layer is thin and colour fringes are less apparent ( ). The TearScience LipiView II ocular surface interferometer (Johnson & Johnson Vision, Jacksonville, Florida, United States) was developed to evaluate the tear film in patients with meibomian gland dysfunction (MGD) and dry eye ( ). This instrument ( Fig. 34.4 ) uses interferometry to noninvasively measure lipid layer thickness between blinks, and gives a quantitative assessment in interferometric colour units. Blink dynamics and partial blinks are assessed, in addition to the change in lipid layer thickness and appearance with each blink. It can be valuable to image the tear film before contact lens fitting, as the presence of MGD could result in reduced comfort and potentially altered deposition during lens wear ( ).

Tear Break-Up

Rapid tear break-up can lead to symptoms of dryness and discomfort in both lens wearers and nonlens wearers. Tear film break-up can be assessed by instilling fluorescein into the eye and timing how long it takes for breaks in the even, fluorescent glow to appear. The problem with this fluorescein break-up time approach is that it is ‘invasive’, in that the instillation of fluorescein in itself alters the quality and quantity of the tear film ( ).

The preferred approach is to determine the noninvasive tear film break-up time (NIBUT). This can be achieved by optically projecting a grid pattern on to the cornea and timing how long it takes for the grid to become disrupted. Numerous ‘specialist’ devices employing this principle have been produced ( ), including the instrument stand-mounted ‘NIBUT dome’ or ‘Mengher grid’ ( ) and handheld devices such as the keratometer-mounted Hir-Cal grid ( ), the Loveridge grid ( ) and the Tearscope-plus and EASYTEAR View+ using their respective NIBUT grid attachments ( ). One option to observe the tear film break-up without purchasing a dedicated device is to project the placido rings from a corneal topographer onto the front surface of the cornea and manually count the seconds for the projected grid to distort ( ). Previous attempts have been made to automate this mire distortion ( ). More recently, the Keratograph 5M (OCULUS, Wetzlar, Germany; Fig. 34.5 ) has developed an automated tear film scanning process that allows automatic, examiner independent determination of tear film break-up time, providing a graphic representation referred to as a ‘tear map’, which shows the location of the tear break-up ( ). Colour coding indicates the regions of break-up: green indicates a stable tear film, yellow indicates a thinning tear film and red indicates tear film regions that are unstable ( Fig. 34.6 ).

Osmolarity Assessment

A clinical test that is reportedly highly diagnostic involves measuring tear film osmolality ( ). This is often considered a ‘gold standard’ in the evaluation of patients with dry eye ( ), due to the hypertonic tear film found in dry-eyed individuals ( ). A hypertonic tear film causes ocular surface damage and may lead to discomfort ( ). Even though tear osmolality has been considered a valuable method for diagnosing dry-eye syndrome for several decades, until recently it has not been used widely as a clinical tool due to the lack of available equipment and the fact that most osmometers require a large volume of tears (typically 5–10 µL) ( ), which limits its use in many dry-eye subjects, particularly those with severe disease in which tear volume is very low.

Historically, measuring tear film osmolality was undertaken using a freezing-point depression method ( ), most frequently using the Clifton instrument. However, this instrument requires considerable expertise, is time-consuming, and the equipment is difficult to maintain ( ). More recently new devices have become available that require far less tear fluid and are easier to operate.

TearLab

This so-called ‘lab-on-a-chip’-based osmometer (TearLab: TearLab Corporation, San Diego, California, United States) ( Fig. 34.7 ) uses electrical impedance and requires only 50 nl of tear fluid ( ). A test card is inserted into a ‘pen-shaped’ holder, which is gently placed in contact with the tear film located in the lower tear meniscus for approximately 30 seconds. This is then placed into a portable countertop unit that calculates and displays the osmolarity test result. The reader automatically converts the tear fluid sample data into an osmolarity measurement and displays the reading on the LCD display. This rapid acquisition of osmolality has resulted in an expansion of the utility of osmolality determination in clinical practice ( ). In addition, the adoption of osmolarity as a method to diagnose dry eye disease ( ) has resulted in increased interest in the assessment of osmolarity in patients, including those who are contact lens wearers.

Tear Meniscus Height

An adequate volume of tears is a prerequisite for a healthy ocular surface ( ) and a reduction in the volume of tears gives rise to a greater chance of symptoms of ocular dryness ( ). Estimation of tear volume is often undertaken using Schirmer strips ( ), phenol red threads ( ) or estimating the volume of tears in the inferior tear meniscus ( ). The inferior tear meniscus contains about 90% of the tear volume ( ), and tear meniscus volume is classically determined by estimating the tear meniscus height (TMH) ( ). Studies have shown that TMH estimation is a good clinical indicator in identifying aqueous deficient dry-eyed patients, as it is a direct measure of the quantity of the tear film ( ).

The most common and simple method to determine TMH is visualizing the TMH using a slit-lamp biomicroscope with an eyepiece containing a graticule ( ). However, estimation of the upper border of the TMH is difficult and several studies have achieved this by adding a small volume of fluorescein to the tears ( ). Enhancing the visualization of the upper TMH border by the addition of fluorescein is clearly invasive and may interfere with the tear volume determined, resulting in an overestimation of the TMH.

To overcome such difficulties, a number of noninvasive approaches to measure TMH have evolved, including videography of the meniscus ( ), optical pachymetry ( ) and meniscometry ( ).

Various multifunction devices now exist that can routinely photograph the TMH and include built-in software to determine the TMH. These instruments typically include the measurement of TMH as part of a battery of tear film assessments, such as noninvasive tear-break-up time and meibography, aimed at measuring signs related to various aspects of dry eye disease. Many of these devices allow the user to photograph the lower TMH and use a ruler built into the software to determine the height of the tear meniscus ( Fig. 34.8 ) ( ).

Optical coherence tomography (OCT) has been used to accurately determine TMH ( ). Once the tear prism is visualized, images can be scanned and stored and the height within the OCT slice is calculated ( Fig. 34.9 ). OCT offers an advantage in that it is the only available method to view the tear prism in cross-section to determine cross-sectional area (allowing for tear volume calculation) ( ) and can also be used to determine the TMH of the upper lid ( ).

Illumination System

Virtually all slit-lamp manufacturers have adopted the Koeller illumination system, which is optically almost identical to that of a 35-mm slide projector ( ). A bright illumination system (producing approximately 600,000 lx) is a fundamental requirement for a slit lamp if subtle conditions are to be seen clearly. While tungsten lamps have been the most frequently used illumination sources in the past, halogen and more recently LED illumination sources have now taken over. Illumination sources of currently available slit lamps from manufacturers such as Zeiss or Haag-Streit exclusively rely on halogen and LED lighting ( ). The recently introduced Zeiss SL 800 offers a combination of an LED light source that is accompanied by a halogen filter, termed VarioLight, that is intended to provide the clinician with the benefits of both kinds of illumination sources ( ).

Haag-Streit incorporated halogen background illumination as a secondary light source to some slit-lamp models (e.g. standard in BX 900 or optional for BI 900, BP 900 or BQ 900), to allow for more uniform illumination when imaging clinical findings ( ). Illumination brightness is controlled by a rheostat or multi-position switch, such that brightness can be adjusted to obtain the correct balance between patient comfort and optimal visibility of the area of interest.

To allow for appropriate illumination for a variety of clinical conditions, the illumination system of a slit lamp should include the following features:

• Sharply demarcated edges of the slit within the illumination system.

• An adjustable slit width and height such that any shaped patch from a slit to a circle may be projected, as this will increase the variety of illumination methods possible.

• A graduated slit width, which is particularly useful when measuring the size of a lesion.

• An ability to rotate the lamp housing such that the slit may be used in meridians away from the vertical is useful, particularly if a protractor scale is included. Such a system enables, for example, the angle of rotation of a soft toric lens away from the vertical to be accurately measured.

• The slit beam must have the capability to be displaced or offset sideways (‘decoupled’). This ability to break the linkage between the illumination and observation systems facilitates indirect illumination techniques.

A number of filters can be incorporated into the illumination system; these serve to enhance the visibility of certain conditions:

• Green (‘red-free’) filter – enhances contrast when looking for corneal and iris vascularization, since red vessels appear black if viewed through such a filter. In addition, it may be used to increase the visibility of rose bengal staining on both the cornea and conjunctiva.

• Neutral-density filter – reduces beam brightness and increases comfort for the patient.

• Polarizing filter – reduces unwanted specular reflections and can be useful to enhance the visibility of subtle defects.

• Diffusing filter – diffuses the illumination source over a wide area and is used to provide broad, unfocused illumination for low-magnification viewing of the general ocular surface.

• Cobalt blue filter – provides a suitable means of exciting sodium fluorescein for examination of ocular surface integrity. Illumination of fluorescein with cobalt blue light of 460–490 nm produces a greenish light of maximum emission 520 nm. Any abraded area will absorb fluorescein and display a fluorescent green area against a general blue background. The filter is occasionally used on its own to aid in the diagnosis of keratoconus. A frequent finding in this corneal ectasia is Fleischer’s ring, which is formed by an annular iron deposition within the stroma at the base of the cone. The iron pigment is often difficult to see in white light but will usually appear in greater contrast when viewed through the cobalt blue filter.

• Kodak Wratten number 12 (yellow) filter – this filter is not contained within the illumination system but is used as a supplementary barrier filter that is placed in front of the viewing system. It significantly enhances the contrast of any fluorescent staining observed with the cobalt blue filter as it allows transmission of the green fluorescent light but blocks the blue light reflected from the corneal surface ( ). Many newer slit lamps incorporate it within the viewing system, but many practitioners use it as an ‘add-on’ device that is placed over the observation lens when required. Custom-made barrier filters for certain slit lamps are available from some manufacturers ( Fig. 34.15 ). Inexpensive handheld versions may be constructed by using a cardboard mask and Lee filters number 101 yellow.

  

The Microscope

A key prerequisite for a slit-lamp biomicroscope is a viewing system that provides a clear image of the eye and has sufficient magnification for the practitioner to view all structures of interest. Magnification is an important consideration, and ideally magnifications of up to 40× should be possible; this may be achieved through interchangeable eyepieces and/or variable magnification of the slit-lamp objective ( ). More recently, the addition of digital imaging modules and subsequent image analysis has resulted in magnifications of up to 200× being possible ( ), allowing very fine details of the cornea and other external structures to be visible. Magnification greater than this level is usually unnecessary and is often counterproductive, as small involuntary eye movements will render the image too unstable to view. Ideally the practitioner should be able to change magnification swiftly and easily, which gives slit lamps with three or more objectives an advantage. Zoom systems have the added advantage of allowing the practitioner to focus on a particular structure without losing sight of it during changes in magnification. Of course, the magnified image must also be clear, and the importance of choosing a slit lamp with a high-quality optical system cannot be overemphasized. Ideally the microscope should have excellent resolution and a good depth of field. However, these factors are inversely linked and so a compromise must be accepted.

Mastering all of the possible illumination techniques with the slit lamp is essential if the instrument is to be used to its full potential. Practice with the instrument is critical to becoming comfortable with its subtle but extensive variety of uses. Readers are advised to consult other texts for information concerning the use of the many and varied illumination techniques available with the slit lamp ( ).

Benefits of Digital Imaging for Contact Lens Practice

There are numerous features and benefits of using digital imaging ( ), including:

• Instant imaging – the record is simply and instantly made.

• Minimal costs – once a digital imaging system is set up, the unit cost for each image is virtually zero. With modern computers having terabyte-sized internal or external storage capacity, many thousands of images may be easily stored and retrieved.

• Image manipulation and quantification – after an image is captured, the brightness, contrast or colour may be enhanced. Furthermore, image parameters can be quantified by the computer (e.g. blood vessel length, scar dimensions and cup / disc ratio) or graded using a validated grading system. However, care must be taken not to alter an image that may be legal evidence.

• Video movies – dynamic conditions such as contact lens fits or certain dynamic forms of pathology evaluation can be captured as a short movie on the computer ( ). Lens performance is much easier to understand and interpret when a moving (versus static) image is presented.

• Portability and accessibility– images can be easily transferred and viewed on smartphones. Some patients love to post their images on social media sites like Facebook or Instagram.

• Once the digital image has been captured in an electronic format, this opens up the following possibilities:

• Improved patient care – one problem with written notes and drawn diagrams is variability between observers. Even within the same observer, over a long interval between exams, some interpretation of the notes may be required. Photo documentation is valuable to evaluate progression or the impact of a treatment intervention in the patient’s condition.

• Patient education – there is a benefit in the patient immediately seeing their own condition. The patient ‘wow’ factor is also beneficial to practice growth, and this may be the biggest pay-off from imaging ( ).

• Paperless office – the majority of contact lens practices use electronic medical records for patient visits. Digital imaging is a logical adjunct to electronic records and has great value in cases of potential legal action ( ). With the internet and secured cloud-based storage solutions, patient records can be accessed at more than one office location.

• Image transfer – increasingly, clinicians are communicating by email or in virtual meetings. A digital image is already on the computer and this allows for simple sharing with colleagues and patients, and has made consultations with colleagues from all over the world simple, affordable and fast.

• Presentations and publications – high-quality digital images and videos can be easily included in presentations, publications or patient handouts.

In summary, photo documentation enhances communication with patients as well as improving the quality of clinical records. With the increased use of electronic medical records, hand-drawing is reduced, making digital imaging more necessary ( ). The merits of photo documentation are numerous and digital imaging has taken clinical documentation to another level.

Resolution Requirements for Anterior Digital Imaging

The basic principle of digital imaging is that a light-sensitive silicon computer chip is used in a camera. The silicon chip is known as a charge-coupled device (CCD), and the number of light-sensitive elements on the CCD determines the image resolution for video and digital cameras. The most frequently used types for slit lamp-based digital imaging are digital single lens reflex (SLR) cameras, video slit-lamp imaging systems using a wide variety of devices and, increasingly, smartphone cameras. Modern smartphone cameras can take good-quality high-resolution images through the eyepiece of a slit lamp at varying illumination levels ( ).

The image resolution refers to the image dimensions (width × height) in units of the number of dots (pixels). As the image proportions for most cameras are in a 4:3 aspect ratio, the resolutions are simply referred to as a million pixel count (e.g. 10 MP). One way to consider this question of ‘how much resolution is enough’ is by the unit of detail that needs to be recorded. Fig. 34.16 shows a number of clinical signs that an ideal digital imaging system should be able to capture. Examples are: (1) corneal punctate staining, (2) keratic precipitates, (3) endothelial cells and (4) epicapsular stars. These features are 20–50 μm in size and if the digital imaging system can surpass this resolution by a factor of 10 (i.e. 2–5 μm), then the characteristics of each feature should be discernible in the final image. A 15-MP camera on a slit lamp with 16 × magnification should give this resolution (i.e. 3 μm). Ye and colleagues ( ) measured the spatial resolution of a commercial slit lamp with an SLR camera to be near 2 μm, although they commented that the spatial resolution apparent to the observer was higher still.

Improving Image Brightness

There are four commonly used illumination techniques for photo documentation:

• Diffuser – this is best for opaque tissues, such as the conjunctiva, sclera and eyelids. It is used in conjunction with a full-width slit, and the brightness of the beam is varied for optimum exposure.

• Slit section – this is most useful for transparent tissues. An angled slit beam gives a dark-field background to highlight features. A slit section can also be used with retroillumination so as to highlight opaque tissue changes.

• Fluorescein staining – surface defects are best shown with the combination of a cobalt blue illumination filter and a yellow barrier filter with a wide slit beam ( ).

• Tear film assessment – specular illumination with the slit lamp or other instrument will show lipid layer patterns, tear film thickness and break-up ( ).

Underexposure of anterior eye digital images is a common problem. The camera needs to have good low-light performance to obtain high-contrast slit images or to show fluorescein staining with filters in place. Smartphone cameras are typically fully automatic and obtaining an image with the slit lamp on a high light level at a low magnification will often provide images at an appropriate illumination level. In certain scenarios, the use of external light sources that provide additional, uniform lighting may be of benefit to obtain better images.

A low magnification gives a larger exit pupil for the biomicroscope optics, so more light will enter the camera. Where possible, turn off the smartphone flash and autofocus. Excellent results can be obtained with a digital SLR camera. For a modern digital SLR camera, it is preferable to apply the manual settings (e.g. a high ISO speed of 1600 or more and a slower shutter speed of 1/15th to 1/25th of a second). A full-featured digital slit lamp has a flash system built in to the illumination path; however, such slit lamps carry a higher cost and are more complex.

Examples of digital images for each of the illumination types are shown in Fig. 34.17 .

Commercial Digital Imaging Systems

Contact lens practitioners wishing to commence digital imaging in their practice have the choice of purchasing a commercially produced system or getting started using a smartphone camera via a dedicated adaptor. A commercially produced digital imaging system can be defined as a ready-to-use integrated system, sold by an ophthalmic equipment supplier. It will typically consist of a slit-lamp biomicroscope attached to a video camera or digital still camera, and a computer with a database and image manipulation software.

A commercial digital imaging system is probably the best alternative for most practitioners, as these systems have the benefit of a relatively simple interface and an easy-to-use database for managing records. The company supplying the equipment will have taken care of the technical issues related to setting up image acquisition by the computer from the video camera. Examples of commercially available digital imaging systems include the Haag-Streit BX 900 slit lamp with a digital SLR camera and Xenon flash (Haag-Streit AG, Koeniz, Switzerland), or the Zeiss SL 800 slit lamp in combination with the SL Imaging Solution (Carl Zeiss Meditec AG, Jena, Germany).

The advantage of a digital still camera is in the high quality and resolution of the image. Professional digital SLR cameras afford high resolution (15 million pixels or more), good low-light performance and options for attaching them to various instruments. For example, the Takagi slit-lamp biomicroscope (Takagi-Seiko Co., Nagano-Ken, Japan) can be attached to a Canon EOS 500 D camera (Canon Inc., Tokyo, Japan) or a camera of equivalent specification. Other features of such a system include:

• The digital camera adaptor (TD-2A) includes a yellow written filter to give high-contrast fluorescein images of staining or lens fittings.

• The camera adaptor places the camera away from the binocular eyepieces, to avoid interference with stereo viewing by the observer.

• The slit lamp has an integrated trigger button included on top of the joystick. In this way, photos are taken with the maximum of convenience in normal slit-lamp operation.

• An accompanying computer is connected via a USB cable, so that the images taken are instantly viewed and saved. The computer may be directly interfaced with the practice medical record system, for easy integration of file access and connection to the patient record.

• A separate background fibreoptic illuminator is included for broad illumination of the ocular and preocular tissues.

A commercial digital imaging slit lamp with an SLR camera has the highest image spatial resolution compared with other slit-lamp imaging methods ( ). Yuan et al. ( ) found the spatial resolution of a Nikon FS-2 slit lamp connected to a Canon 60 D digital SLR camera (18 MP) was comparable with ultra-high-resolution OCT, but for a fraction of the cost.

A video slit lamp may be a relatively low-cost method to capture an image, for display on a screen or to input into a computer. It has the advantage over the smartphone method of being a permanent installation, but typically has a lower resolution and quality than a digital SLR camera. The two key steps are to connect a video camera to the slit lamp and to input the video signal into the computer. The permanent connection of a video camera to a slit lamp requires a beam splitter in the slit-lamp observation system.

Some slit lamps, like the Haag-Streit BD900 (Haag-Streit AG, Koeniz, Switzerland), are supplied with a built-in beam splitter. This is a neat design, since it is in line with the observation system and makes it easy to connect a video (CCD) camera. Other slit lamps, such as the Zeiss SL120 or CSO SL990, have a modular design and the beam splitter and camera can be readily added together. Similarly, some manufacturers offer optional digital camera attachments with a built-in beam-splitter, such as the Topcon DC-4 digital camera attachment (Topcon Medical Systems Inc., Oakland, United States), thus allowing for retrofitting many existing slit-lamp models with high-quality video recording options. In general, if a digital video camera is to be added, it is always recommended to check with the slit lamp or video camera supplier as to whether imaging attachments are compatible with an existing slit lamp or if a suitable beam splitter is available for purchase.

For slit lamps that already include or are retrofitted with a beam splitter, a compatible video camera must be selected. In those cases, a single- or three-CCD microcamera with separate power supply is a suitable option. These are known as ‘lipstick’ cameras, owing to their compact size, making them suitable for an ophthalmic instrument. The low-light performance, resolution and colour rendering are acceptable for most slit-lamp applications. If a video camera with a digital (Firewire or USB) output is selected, then it will connect directly to the computer. The image can then be displayed on the computer, saved or printed. This option has the benefits of good low-light performance, live image preview and the facility for digital movie capture.

Smartphone Digital Imaging

The ever-increasing resolution and image quality that can be achieved with the newest smartphone models make a compelling case for choosing smartphones as the imaging solution to retrofit an existing slit lamp. Perhaps the best reasons to consider using a smartphone for digital imaging is the ease of getting started, the low entry cost and the portability – a fraction of the price of a commercial system. Assuming the availability of a smartphone with imaging capabilities, the only costs are an eyepiece adaptor and potentially a beam splitter (if not already available as part of the existing slit-lamp biomicroscope). While custom-made 3D-printed adaptors have been successfully used for smartphone imaging for a few years ( ), more and more smartphone adaptors are also becoming commercially available, such as the MicroREC ClickNFit system (Custom Surgical, Munich, Germany) or the ACCU-Beam UNIVERSAL Smart Phone adaptor (TTI Medical, San Ramon, United States). The MicroREC ClickNFit optical system also includes the dedicated MicroREC App, a mobile application for managing images and videos of microscopy procedures captured using smartphones. Smartphone adaptors are compatible with most slit lamps, including models by Haag-Streit, Zeiss, Topcon or Keeler, and are available for many smartphone models.

As with any digital imaging system, there is a learning curve towards taking good-quality images. Where possible, turn off the smartphone flash and autofocus. Initially the best images will be most readily taken using a uniform illumination of the eye, with a broad beam or diffuser in front of the light beam. Obtaining images of opaque tissues such as eyelids, the conjunctiva, sclera or iris should be straightforward. Lower-light imaging such as obtaining fluorescein images, narrow optic sections or higher magnifications may take more time to determine the optimum settings. Images can be transferred from the phone to the practice computer system, usually using wireless ‘drop boxes’ online or via email. There is also the potential for global telemedicine using a smartphone for real-time slit-lamp eye examination ( ).

Digital imaging applications for smartphones are increasingly being described in the literature. It is possible to quantify pupillary anisocoria using a smartphone as a macro-camera ( ), or to use a smartphone for imaging through a desktop microscope ( ) or for the clinical assessment of ocular pathogens such as Demodex ( ).

Recording Digital Movies

Two important uses for movies include recording the dynamic procedures involved in lens fittings, and showing corneal complications as the light source is moved or scanned. Viewing of fluorescein patterns, lens centration and movement, or the assessment of the lens surface for defects or looking at lens wettability benefits immensely from the use of digital movies. Recording of videos also allows the visualization of meibum quality during meibomian gland expression. Most smartphones, video and digital SLR cameras have included software to allow movie recording and these video files can then be linked to the patient record.