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S. Sharma et al.
a
Fig. 13.6 The Chang analysis display map of the right
eye of a 64-year-old man shows high internal and total
higher order aberrations contributed mainly by the mature
cataract (a). The dysfunctional lens index (DLI) map
13.3 Scheimpug Imaging
(OCULUS Pentacam®)
A standardized and objective cataract grading is
required from clinical and research perspectives
[15]. The current literature has described several
classication systems, such as the LOCS III, age-
b
shows a DLI value of 0.77 (dotted yellow circle), and the
opacity map depicted a cataract of grade 4 (red dotted
circle) (b). These two parameters suggest a dysfunctional
lens due to a mature cataract
related eye disease study, and laser slit-lamp evaluation [16–18]. Of these, the LOCS III is the most
popular. The grading quality depends on slit-lamp
examination, lens photography, patient age, and
best-corrected visual acuity (BCVA); thus, it is fundamentally a subjective technique that often depends
on the examiner's experience [18, 19]. Scheimpug
imaging has overcome these limitations.
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13.3.1 Principle ofScheimpug
Imaging
The Scheimpug imaging system is credited to
Theodor Scheimpug [18]. It captures an
obliquely inclined object with a maximum depth
of focus and minimal image distortion. This is
accomplished by shifting the plane of the lm
(sensor) in relation to the camera lens. In a conventional camera, the lm plane and lens plane
stay parallel, resulting in a plane of focus that is
also parallel to these planes. The slit-lamp imaging device can only concentrate on a portion of
the crystalline lens at a given time (the anterior
capsule, nucleus, or posterior capsule) [19]. Other
parts remain out of focus and cannot be accurately
analyzed to assess the lens density. The lens plane
is inclined to the lm plane in the Scheimpug
imaging system, causing the focus plane to shift
along the line of intersection (Scheimpug line).
All the points on this line will remain focused and
can be analyzed simultaneously.
The rst Scheimpug imagining system used
to evaluate the crystalline lens invivo was developed by N Brown and subsequently by Hockwin
et al. [20–22]. Since then, an array of imaging
systems have been developed, including the
Oxford Scheimpug System, Topcon SL-45
(Topcon, Tokyo, Japan), Zeiss Scheimpug video
camera (Carl Zeiss Meditec, Dublin CA), and
Nidek EAS-1000 (Nidek, Japan) [23–26]. The
rotating Scheimpug allows a 360-degree examination of lens density, eliminating the need for
multiple scans across multiple meridians. The
Scheimpug densitometry software analyzes the
cataract or loss of lens transparency based on the
principle of reectometry (measuring the reected
light) [27]. The lens density on a scale of 0–100
(0 = no cloudiness to 100 = completely opaque
lens) is calculated using individual photographs.
The peak value at a specic location within the
nucleus is measured and combined with the mean
and maximum nucleus density [28].
13.3.2 Image Acquisition
The patients are positioned comfortably before
the Pentacam® device. They are asked to rest
their chin on the chin rest and focus on a target
within the device. The OCULUS Pentacam® consists of a rotating Scheimpug camera. The rotational measuring procedure generates
Scheimpug images in three dimensions, with
the dot matrix ne-meshed in the center due to
the rotation. The pupil's size, direction, and xation are recorded by a second camera positioned
in the center of the eye. It takes 2s to generate a
complete image of the anterior eye segment. Any
eye movement is detected by a second camera
and corrected in the process. The Pentacam® calculates a 3D model of the anterior eye segment
from as many as 25.000 distinct elevation points.
The topography and pachymetry of the entire
anterior and posterior surfaces of the cornea from
limbus to limbus are calculated and depicted. The
analysis of the anterior eye segment includes a
calculation of the chamber angle, volume, and
height and a manual measuring function that can
be applied to any location in the anterior chamber
of the eye. Images of the anterior and posterior
surfaces of the cornea, the iris, and the anterior
and posterior surfaces of the lens are generated in
a moveable virtual eye. The densitometry of the
lens and cornea is automatically quantied. The
Scheimpug images taken during the examination are digitalized in the main unit, and all image
data are transferred to the computer unit. When
the test is nished, the computer unit calculates a
3D virtual model of the anterior eye segment,
from which all additional information is derived.
Pentacam Nuclear Staging (PNS) is a built-in
lens densitometry program that delivers average
and maximum lens density and a cataract grading
score ranging from 0 to 5 [29]. The surgeon can
create a more specialized preoperative plan for
the cataract surgery with an objective evaluation
of cataract density and volume.
13.3.3 Clinical Applications
13.3.3.1 Preoperative Adjustment
ofPhacoemulsication
Parameters
A preoperative assessment of the cataract density
helps to customize the operative planning for
every individual [28]. Intraoperative phacoemul-
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abc
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S. Sharma et al.
Fig. 13.7 Slit-lamp image of a mature cataract (white
and brunescent) and hyper mature cataract (a–c) with corresponding Scheimpug images on the Oculus Pentacam®
(d–f). A mature nuclear cataract with anterior subcapsular
cataract (a) is seen as a uniform increase in opalescence of
the nucleus, with a band of increased density observed in
the deep anterior cortex, while the cortex anterior to it
appears clear (d). A mature brunescent cataract (b) is seen
sication energy depends on the nuclear density
of the cataract (Fig. 13.7). The Scheimpug
imaging may help the surgeon to plan
phacoemulsication, using the lowest power of
ultrasound energy required to extract the cataract
with a specic density prole, thereby minimizing endothelial cell damage and postoperative
inammation [30].
In the technique described by Nixon, cataracts
are graded using the software on the Oculus
Pentacam® to develop a three-dimensional (3D)
image of the cataract through a dilated pupil [31].
The PNS software does not grade the cortical
portion of a cataract or posterior subcapsular cataract (PSC). Instead, a 3D template is placed posterior to the anterior cortex and anterior to the
posterior cortex, measuring only the optical density of the nucleus. For the rst time, this study
compared the effect of modied phaco-setting
after Scheimpug imaging cataract grading with
standardized phaco-settings in eyes with uneventful cataract surgery. This difference was most
signicant for patients with the lowest and the
highest cataract grades (Grade 1 or Grades 4 and
5), with no signicant difference between the
as an increase in density involving the anterior subcapsular, cortical, and nuclear regions (e). A hypermature cataract (c) shows hypodensity in the anterior subcapsular
area corresponding with the liquied lens matter and
hyperdense areas in the anterior cortex corresponding to
the calcic plaques. The central hyperdense nucleus is
surrounded by a liquied cortex seen as a hypodense area
around the central nucleus (f)
adjusted and standardized parameters in eyes
with Grade 2 or 3 nuclear cataracts.
For grading of lens opacities, the Scheimpug
imaging depends on the morphological lens
changes, which is more precise than the LOCS
III system of cataract grading [27]. Additionally,
it allows detecting even minute changes in the
cataract progression. There is enough literature
supporting a stronger correlation between
Scheimpug imaging grading and phacoemulsication parameters than LOCS III grading.
13.3.3.2 Traumatic Cataract
Cataracts may be an early or late complication of
ocular trauma.
The role of Scheimpug imaging in assessing
the status of the posterior capsule was rst
described in an isolated case report by Grewal
etal. in 2007 [29]. They showed that the posterior
capsule rupture (PCR) with the lens matter escaping into the vitreous cavity (named it “pseudoposterior lenticonus”). Sen et al. reported the
sensitivity and specicity of this technique in
eyes with traumatic cataracts as 70% and 85%,
respectively [32]. However, Scheimpug imag-
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ing is an optical method, and hence it is prone to
poor image quality due to media opacity caused
by corneal scars, very dense cataracts, and
hyphema.
13.4 Anterior Segment Optical
Coherence Tomography
(AS-OCT)
Over the past three decades, optical coherence
tomography (OCT) has evolved from time- domain
OCT (TD-OCT), through spectral- domain OCT
(SD-OCT), to the most current swept-source OCT
(SS-OCT). The SS-OCT (tunable swept laser,
1050nm) is superior to the SD-OCT (diode laser,
840nm) due to increased scanning speed, number,
and area [32]. Pujari etal. described the utility of
the Fourier-domain AS-OCT CASIA-2 (Tomey
Corp.) for preoperative evaluation of the posterior
capsule integrity in patients with posterior polar
cataracts [33]. This imaging modality is a noninvasive and non- contact invivo imaging system
for the ocular tissues that provide cross-sectional
images from the corneal surface to the anterior
hyaloid face, with a detailed assessment of the lens
morphology. With AS-OCT, ocular biometry and
morphological evaluation of the ocular structures
are possible in a short period and with good clinical reproducibility. Currently, two anterior segment OCT (AS-OCT) models are commercially
available, the Visante OCT (Carl Zeiss Meditec,
Dublin, CA, USA) and the slit-lamp OCT
(SLOCT) (Heidelberg Engineering, GmbH,
Dossenheim, Germany) [34].
In the following sections, we describe the role
of AS-OCT in objectively assessing cataract
grades, intralenticular changes in white/mature
cataracts, and posterior capsular changes in posterior polar and traumatic cataracts.
13.4.1 Principle oftheAS-OCT
The AS-OCT technique creates high-resolution
cross-sectional images of the anterior segment of
the eye using the principle of low-coherence interferometry. The method compares the light reected
by the tissue structure being studied to the light
reected by a reference mirror and evaluates the
delay and intensity of that light. The combination
of these two signals results in an interference phenomenon. The device uses these signals to create a
sagittal cross-section image of the studied structure. The signal intensity is dependent on the optical characteristics of the tissues. The posterior
region of the eye was rst visualized using OCT
technology utilizing a wavelength of 820nm. The
newer models employ a super luminescent diode
(SLD) of a longer wavelength (1310nm) to allow
better penetration through light-retaining tissues
like the sclera and the limbus to improve visualization of the anterior segment.
13.4.2 Image Acquisition
The patient is seated comfortably before the
machine. The patient’s chin is placed on a support, and the patient is advised to focus on a xation target to keep the eye steady during image
capture. A near-infrared light source is directed
into the eye, and the reected light is used to create detailed images. The AS-OCT technique generates a series of A-scans (axial scans)
representing the reections of the near-infrared
light from different tissue layers in the anterior
segment. These A-scans are combined to create a
2D cross-sectional image of the examined structures. The captured A-scan data is processed to
create detailed cross-sectional images. The software performs mathematical analyses to determine the thickness, depth, and shape of the
cornea, iris, anterior chamber, and lens.
13.4.3 Clinical Applications
13.4.3.1 Early Cataract
Automated grading systems for cataracts on the
AS-OCT technique have been constantly
explored to overcome the inter-observer variability and bias of the LOCS III system [35].
Investigators have measured and correlated lens
density on AS-OCT with cataract severity; an
average lens density of 73.8-pixel units was suggestive of cataract with more than 95% sensitivity and 90% specicity [36, 37]. Often, the
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Fig. 13.8 The AS-OCT image showing hyperintensity
along the posterior capsule suggests a posterior polar cataract (a). The posterior capsule appears intact as it can be
traced continuously from the posterior paracentral region
to the most dependent part of the lens under the opacity.
patient’s visual acuity alone may not be sufcient
to assess the severity of the cataract. In these
events, AS-OCT-based nuclear density data can
serve as an additional guide to surgical planning.
Conversely, the hyperintensity is poorly dened with
active herniation of the lens matter into the vitreous cavity, suggestive of a defect in the posterior capsule in the
area of the posterior polar cataract (b)
ture changes, which [40] they graded into three
stages as follows: Stage 1: “vacuolation” or
“early lamellar separation” was characterized
by tiny hypoechoic areas within the anterior
lens substance, indicating early separation of
13.4.3.2 Posterior Sub-capsular
Cataract (PSC)
The AS-OCT technique demonstrates vacuolar
changes along the posterior sub-capsular
region [38].
the lens bers. These cases carried the minimum
risk of rhexis-related intraoperative complications. Stage 2: “advanced stage of lamellar separation” characterized by advanced lens ber
liquefaction causing wider hypoechoic areas
within the anterior lens substance, with minimal
13.4.3.3 Mature/Hypermature/White
Cataracts
Intralenticular and posterior sub-capsular and
capsular changes are difcult to detect clinically
in denser cataracts. As the lens matures, the lens
bers undergo liquefaction with an accumulation of uid within the bag, characterized as
hypoechoic areas detected on the AS-OCT
bulge along the anterior lens surface with no liqueed lens material. These eyes carry fewer
risks of rhexis-related complications. Stage 3:
extensive lysis with excessive accumulation of
liqueed material characterized by large
hypoechoic areas and marked anterior lens
bulge. These eyes carry the maximum risk of
rhexis-related complications.
images. In such eyes, targeted needle aspirations may be performed intraoperatively to
reduce the lenticular bag pressure, thus preventing rhexis- related complications, such as an
uncontrolled extension of the rhexis [39]. Pujari
et al. used AS-OCT images to understand the
natural progression of mature cataracts measuring the intralenticular and anterior lens curva-
13.4.3.4 Posterior Polar Cataract
(PPC)
In eyes with PPC, dysplastic lens bers form a
discoid plaque-like opacity at the posterior pole,
interfering with the assessment of the underlying
capsular integrity during a clinical examination
[33] (Fig.13.8a). The incidence of posterior cap-
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sular rupture (PCR) in PPC ranges from 7.1% to
36% [41]. Preoperative knowledge of the integrity of the posterior capsule (PC) can provide
insight into improving surgical outcomes
(Fig.13.8b).
Several studies attempted preoperative identication of posterior capsular defects in eyes with
PPC using cross-sectional images of the lens
[42]. However, limitations like image resolution
and magnication resulted in discrepancies
between AS-OCT predictions and intraoperative
ndings. Pujari et al. used a modied posterior
segment OCT (with a +20D lens) to predict posterior capsule integrity in eyes with PPC [33].
Two important parameters are the “contour” and
“capsule.” They proposed that the PC be traced
from the adjacent paracentral region to the
posterior- most dependent part of the lens from
either side. The PC can be labelled “intact” if the
continuity is maintained throughout. The posterior “contour” can have 3 possibilities: (1) conical sign: “active herniation” of the lens matter
into the anterior vitreous cavity; (2) “moth-eaten
appearance”: the lens excavates into the posterior
lens substance; (3) “zigzag ectatic appearance”:
inherent weakness of the posterior capsule.
Concerns such as the quality of the scan and
magnication should be addressed before any
conclusions are made. Better-quality images
were obtained using the swept source
AS-OCT.This device provides images from the
anterior to the posterior lens capsule in a single
frame, with better resolution and magnication
of up to 200 times, with minimal degradation of
the image quality.
13.4.3.5 Traumatic Cataracts
In traumatic cataracts, accurate assessment of the
cataract is often hampered due to coexisting complications like corneal laceration, severe inammatory reactions in the anterior chamber, swollen
cortical matter, and hyphema. A thorough
preoperative knowledge of posterior capsule
integrity is important to prevent unintentional
extension of the PCR and loss of lens material
into the vitreous cavity [43]. Preoperative
AS-OCT helps identify any traumatic damage to
the lens capsule, cortex, zonules, and vitreous
prolapse. Kuriyan etal. reported AS-OCT-based
vacuolar changes representing intracellular
spaces in the anterior subcapsular region in an
eye with a traumatic subluxated cataract [43].
The lens capsule and zonular integrity dictate the
placement of the IOL; the ASOCT can detect and
prepare the surgeon accordingly.
13.5 Ultrasound B-Scan
In people with mature and total cataracts, the
fundus view is obscured. In such cases, B-scan
ultrasonography is an indispensable tool that
helps in surgical planning. Ultrasound is safe,
inexpensive, and readily available than other
imaging techniques, such as computed tomography (CT) and magnetic resonance imaging
(MRI) [44].
13.5.1 Principle
Acoustic waves in ultrasound are produced by
particle consistency oscillation within the
medium. The B-scan gives vital information
about the vitreous, retina, choroid, and sclera.
The B (brightness) mode demonstrates the shape
and topographic relationship of lesions in the
posterior segment. A high-frequency (8–10MHz)
probe is used in ocular echography because it
provides a more detailed picture than the lowfrequency probes.
13.5.2 Image Acquisition [45]
Ultrasound can be performed through the
patient’s eyelids or by placing the probe directly
on the surface of the eye with adequate topical
anesthesia. The patient is advised to look in the
direction of the quadrant to be examined, with the
probe marker pointing superiorly or nasally.
Initially, the gain is set high. From the limbus to
the fornix, rocking and rotational movements are
performed so that the probe tip moves a smaller
distance than the base of the probe, which moves
signicantly. The probe is rotated around the
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globe in different quadrants so that the sound
waves pass through the center of the eye. Since
anterior segment structures require a standoff
couplant, the immersion B-scan uses a water bath
over the eyes. This method allows the probe to be
offset from the eye sufciently to place the anterior segment in the focal plane to observe the
anterior segment, including the entire lens.
13.5.3 Clinical Applications
S. Sharma et al.
13.5.3.1 Detection ofPosterior
Segment Pathology
Several studies have reported the usefulness of
B-scan ultrasonography in identifying posterior
segment pathologies in eyes with mature and
traumatic cataracts [46, 47]. The reported incidence of posterior segment pathology in eyes
with opaque media is up to 66% [47]. Posterior
vitreous detachment is the most common nding,
with a sensitivity of 64.2% and specicity of
100%. Parchand etal. reported the sensitivity and
specicity of this technique in identifying rhegmatogenous retinal detachment (92.31% and
98.31%, respectively), posterior vitreous separation (96.2% and 100%, respectively), and vitreous hemorrhage (100% for both) [48].
13.5.3.2 Detection ofZonular
Weakness andPosterior
Capsule Breach
In traumatic cataract, or where the view of the
lens is obscured either due to corneal pathologies
such as edema, scars, or anterior chamber
hyphema, immersion or contact B-scan can
detect gross zonular dehiscence, lens subluxation
or dislocations, and larger posterior capture
ruptures.
13.5.3.3 Intralenticular Foreign
Bodies
In rare cases, the presence of an intra-ocular
foreign body due to penetrating trauma (such
as those occurring during a road traffic accident, blast injury, or hammer/chisel injury),
when a foreign body is suspected but not
immediately visible due to swollen cortical
Fig. 13.9 Ultrasound B-scan immersion technique photograph showing high reective dot echo (yellow arrowhead) within the lens matter with an intact posterior
capsule (green arrow) conrming the diagnosis of an
intralenticular foreign body
matter, poor patient cooperation, or anterior
chamber inflammation, the precise anatomical
location of the intralenticular foreign body can
be obtained using the immersion B-scan [49]
(Fig.13.9).
13.6 Conclusion
Preoperative imaging modalities are relatively
simple and rapid, with a fairly easy learning
curve. Anatomical details of the crystalline lens,
such as the lens density, integrity of the posterior
capsule, type of cataract, and existing comorbidities, can be assessed quickly and objectively with
good repeatability. Aberrometry guides the surgeon in selecting an appropriate IOL and helps
diagnose the cause of post-operative distressing
symptoms. These techniques also have great
potential in documenting cataract progression in
longitudinal studies and clinical trials.
Scheimpug imaging is a rapid and simple-toperform diagnostic procedure. It is extremely
useful in children whose cooperation is usually
poor. The lens densitometry measurements are
easy, quick, repeatable, and objective methods to
assess lens changes over time. The versatility of
the Scheimpug imaging technique is useful in
diagnosing various degrees of cataract, posteriorcapsule rupture, and traumatic cataracts; this
makes it an invaluable but neglected tool for
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modern cataract surgeons. The AS-OCT technique is helpful in complex lenticular pathologies. Finally, the immersion mode of B-scan
ultrasound is useful in uncooperative patients and
open globe injuries.
Over the years, people's expectations have
increased with the evolution of cataract surgery
techniques and technologies. Consequently, the
preoperative assessment has expanded to include
discussions of the patient’s visual expectations
and various surgical options, each of which may
have its own medical and nancial considerations. Various diagnostic tests performed at the
preoperative visit enable the surgeon to anticipate
and address these to achieve optimal functional
outcomes.
Funding None.
Disclosure None.
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Slit Lamp Biomicroscopy
https://t.me/med1917
14
AnahitaKate andSayanBasu
14.1 Introduction
Ophthalmology distinguishes itself from other
medical disciplines by the unique advantage of
directly examining the organ it focuses on. The
most important instrument that facilitates this is
the slit lamp biomicroscope. This indispensable
tool provides a gamut of information on the various parts of the eye, from the external ocular surface and adnexa to the lens and posterior segment
structures. These can be viewed at different magnications and with additional lters. The binocularity of this compound microscope augments
ocular evaluation and elicits subtle signs [1]. The
versatility and precision of the slit lamp have
A. Kate
Kode Venkatadri Chowdary Campus, L V Prasad Eye
Institute, Vijayawada, India
e-mail: dranahitakate@lvpei.org
S. Basu (*)
Shantilal Shanghvi Cornea Institute, Kallam Anji
Reddy Campus, L V Prasad Eye Institute,
Hyderabad, India
Prof. Brien Holden Eye Research Centre,
Champalimaud Translational Centre for Eye
Research, L V Prasad Eye Institute, Hyderabad, India
e-mail: sayanbasu@lvpei.org
made it an indispensable device for diagnosing
and monitoring various ocular conditions,
empowering eye care professionals to provide
targeted treatments. While there is a general
familiarity with the basic functioning of this
device, an in-depth understanding can allow ophthalmologists to maximize the potential of a slit
lamp in their daily practice. In this chapter, we
will explore the different components and applications of the slit lamp, highlighting its invaluable role in ophthalmic practice.
14.2 History
The unique feature of a slit lamp is the alterable
slit beam for illumination and the fact that the
focal planes of the illuminating and the observer
arm coincide to give a binocular, well- illuminated
eld. The development of the slit lamp has
spanned more than two centuries; it can be understood in terms of each of these sections.
Historically, the observer arm was put through
several innovations while keeping the illumination uniform. In 1823, Purkinje was the rst to
examine the iris with a microscope and a xed
source of illumination [2]. Nealy, 40years later,
Louis de Wecker used an objective, eyepiece, and
a condensing lens to develop the rst uniocular
slit lamp [3]. Siegfried Czapski subsequently
introduced binocularity; it provided the examiner
with a stereoscopic view of the ocular structures
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
T. Das, P. Satgunam (eds.), Ophthalmic Diagnostics, https://doi.org/10.1007/978-981-97-0138-4_14
167
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