Standard Slit Lamp Examination Research Articles

Feasibility of Tear Meniscus Height Measurements Obtained with a Smartphone-Attachable Portable Device and Agreement of the Results with Standard Slit Lamp Examination

Purpose: We aimed to evaluate the feasibility of using a novel device, the Smart Eye Camera (SEC), for assessing tear meniscus height (TMH) after fluorescein staining and the agreement of the results with measurements obtained using standard slit lamp examination. Methods: TMH was assessed using both SEC and conventional slit lamp examination. The images were analyzed using the software ImageJ 1.53t (National Institutes of Health, Bethesda, MD, USA). A common measurement unit scale was established based on a paper strip, which was used as a calibration marker to convert pixels into metric scale. A color threshold was applied using uniform parameters for brightness, saturation, and hue. The images were then binarized to black and white to enhance the representation of the tear menisci. A 2 mm area around the upper and lower meniscus in the central eye lid zone was selected and magnified 3200 times to facilitate manual measurement. The values obtained using SEC were compared with those obtained with a slit lamp. Results: The upper and lower TMH values measured using the SEC were not statistically different from those obtained with a slit lamp (0.209 ± 0.073 mm vs. 0.235 ± 0.085, p = 0.073, and 0.297 ± 0.168 vs. 0.260 ± 0.173, p = 0.275, respectively). The results of Bland–Altman analysis demonstrated strong agreement between the two instruments, with a mean bias of −0.016 mm (agreement limits: −0.117 to 0.145 mm) for upper TMH and 0.031 mm (agreement limits: −0.306 to 0.368 mm) for lower TMH. Conclusions: The SEC demonstrated sufficient validity and reliability for assessing TMH in healthy eyes in a clinical setting, demonstrating concordance with the conventional slit lamp examination.

Screening for juvenile idiopathic arthritis associated uveitis with laser flare photometry in the pediatric rheumatology office: a prospective observational study

BackgroundJuvenile Idiopathic Arthritis (JIA) Associated Uveitis (JIA-U) remains one of the most serious complications of JIA in children. Historically, pediatric JIA is diagnosed by an Optometrist or Ophthalmologist; however, barriers to scheduling increase wait times that may delay diagnosis and treatment. The purpose of this study was to evaluate laser flare photometry (LFP) use to diagnose JIA-U in the Pediatric Rheumatology clinic for patients with JIA.MethodsThis prospective, observational study assessed pediatric patients diagnosed with JIA without a previous history of uveitis between January 2020 and September 2022. All patients underwent at least one evaluation of both eyes using a Kowa FM-600 laser flare photometer during a routine Rheumatology appointment, as well as a standard slit lamp examination (SLE) by optometry or ophthalmology during routine clinical care. Data collected at patient visits included demographics, JIA characteristics, treatment, LFP readings, and anterior chamber (AC) cell grade score utilizing the SUN grading system. Data were summarized using descriptive analyses and the uveitis false positive rate was calculated.ResultsThe study cohort included 58 pediatric patients diagnosed with JIA. The mean age was 8.4 years (1.2–16.3 years) at diagnosis and 11.9 (4.8–16.5 years) at enrollment. The mean duration of disease at time of enrollment was 42 months (range; 0-157 months). Participants were predominantly female (n = 43, 74.1%) and white/Caucasian race (n = 37, 63.8%). The most common JIA subtypes included persistent oligoarticular JIA (n = 19, 32.8%), and RF negative polyarticular JIA (n = 12, 20.7%). There were 12 ANA positive patients (20.7%). At enrollment, 16 patients (27.6%) were not on medications, with 20 (34.5%) on methotrexate, 20 (34.5%) on adalimumab, 6 (10.3%) on tocilizumab, and 5 (8.6%) on etanercept. During the study period, no eye exams detected active uveitis based on SLE with a SUN grade over 0. However, of the 135 LFP readings, 131 (97.0%) were normal, yielding a false positive rate of 3% (95% CI: 0.8%, 7.4%).ConclusionsLFP is a non-invasive tool that can be utilized in the pediatric rheumatology clinic to evaluate for JIA-U. There is a low false positive rate of LFP when compared with standard slit lamp exam.

A new diagnostic method for retinal breaks in patients with posterior vitreous detachment: Ultra-wide-field imaging with the Zeiss Clarus 700.

This study was performed with the aim of finding a more convenient and less time-consuming method to diagnose retinal breaks in posterior vitreous detachment (PVD) patients. A prospective double-blind observational case study was performed with patients who were admitted to the Eye Emergency Department Sahlgrenska University Hospital with PVD symptoms and approved to participate in the study (n=128). Standard slit lamp examination was compared with images from a Zeiss Clarus 700 ultra-wide-field camera (UWFC). Patients were examined and photographed by an independent operator. Data and image review was performed by three independent reviewers with varying experience. Retinal break detection with the two different methods (detailed eye examination by well-trained ophthalmologist and UWFC evaluations) was analysed statistically. After excluding diagnoses other than PVD as well as unclear images due to cataracts, vitreous bleeding, etc., a total of 103 eyes with PVD were evaluated. A total of 38 ruptures in 25 patients were detected by routine examination and were subjected to laser treatment. UWFC images were reviewed by three ophthalmology consultants and compared with routine examinations. Sensitivity values in detecting retinal ruptures in UWFC images of the three reviewers were 0.89, 0.87 and 0.79, and specificity values were 0.88, 0.86 and 0.93 (kappa values: 0.742, 0.689 and 0.728) respectively. Although there have been rapid developments in imaging with UWFC in recent years and it is a very promising method for the future, routine clinical examination is still the only valid method for the detection of retinal tears today.

Relationship Between Central Corneal Thickness and Ganglionic-Inner Plexiform Cell Layer and Retinal Nerve Fibre Layer Thickness in Normal Subjects.

PurposeTo determine the relationship between central corneal thickness (CCT), ganglionic cell-inner plexiform layer thickness and macular nerve fibre layer (RNFL) thickness as measured by optical coherence tomography in a cohort of healthy subjects.MethodsSixty healthy eyes from 60 subjects were included in this study. All subjects had a standard slit-lamp examination and optical coherence tomography. Central corneal thickness was measured using the Optopol spectral domain optical coherence tomography (SD OCT) machine (version 7.2.0). A linear mixed effects model was used to assess the relationship between central corneal thickness (CCT) and ganglionic cell-inner plexiform layer thickness and macular retinal nerve fibre layer thickness (RNFL).ResultsSixty healthy eyes from 60 subjects were included in this study. The average age was 41.8 years (±20.6 years). There were 22 males (37%) and 38 females (63%). The average central corneal thickness was 525.2 ± 35.1 µm (451–601) µm. The average macular retinal nerve fiber layer thickness was 28.9 ± 2.5 µm (23–38µm), and the average ganglionic cell-inner plexiform layer thickness was 88.6 ± 6.3 µm (75–110 µm). We found no statistically significant relationship between central corneal thickness and ganglionic cell-inner plexiform layer thickness (p=0.983) nor with macular RNFL (p =0.285).ConclusionIn this cohort of healthy subjects, there was no statistically significant relationship between central corneal thickness and ganglionic cell-inner plexiform layer thickness or with macular retinal nerve fibre layer thickness.

A case of dense pigment deposition of the posterior lens capsule

BackgroundPigment dispersion syndrome (PDS) is a well-known entity which can lead to pigmentary glaucoma (PG). This case report presents a rare presentation of PG with bilateral dense pigment deposits of the posterior lens capsule.Case presentationA 72-year-old male came for his first appointment due to an asymmetric worsening of visual acuity. The examination showed unilaterally severely increased intraocular pressure, bilateral dense pigment deposition of the posterior lens capsule, and a shallow unilateral optic disk excavation. Gonioscopy revealed moderate pigmentation of the angle and a concave configuration of the peripheral iris in both eyes. The standard slit lamp examination showed no transillumination defects of either iris. Optical coherence tomography showed retinal nerve fiber layer (RNFL) thinning in the peripapillary and macular regions. An antiglaucoma medication was prescribed with a good lowering effect.ConclusionPigment deposition of the posterior lens capsule, which has been rarely reported, is a possible important sign of PDS or PG.

Evaluating the efficacy of an educational ergonomics module for improving slit lamp positioning in ophthalmology residents

ObjectiveTo characterize changes in body positioning while performing a standardized slit lamp examination after exposure to an educational module on ergonomics. DesignProspective interventional pilot study. ParticipantsTen ophthalmology residents. MethodsAn educational module discussing ergonomic issues in ophthalmology was created. In a standardized examination lane, participants were recorded performing 3 trials of an indirect slit lamp examination of a volunteer patient, adjusting equipment as they saw fit. Participants were then sent the module and within 2 weeks repeated the trial process. Data were processed using biomechanical software to obtain the Rapid Upper Limb Assessment (RULA) injury risk score, elbow and shoulder joint reaction moments, neck and trunk flexion angles, and spinal curvature magnitudes. ResultsThe RULA injury risk scores decreased after completion of the module (95% CI 2.10−2.77), indicating a lesser risk for injury to the resident. Shoulder flexion and elbow abduction moments also decreased (95% CI −3.2 to −1.5 and −0.44 to −0.04, respectively), suggesting a more neutral body posture. The trunk flexion angle increased after completion of the module (95% CI −5.1 to −1.6), signifying a more upright trunk posture; this was confirmed by the lumbar spine curvature, which flattened postmodule (95% CI 6.6−940). ConclusionsThese results suggest a promising ability for an educational module to mitigate some injury risk in this population during indirect slit lamp examination. It also delineated some awkward postures that persisted despite the module. These results will be reintegrated into the module to optimize its educational utility.

Case Series of Pediatric Sickle Retinopathy By Sensitive Clinical Imaging Technologies Suggests Frequent Early Pathology

Introduction: Sickle cell retinopathy (SCR) reflects disease-related vascular injury. Previous studies of pediatric SCR using standard imaging approaches reported retinopathy in <15% of children (Estepp JH, Br J Haematol 161:402;2013). Sensitive clinical retinal imaging modalities of ultra-widefield fluorescein angiography (UWFA), spectral-domain optical coherence tomography (SD-OCT), and optical coherence tomography angiography (OCT-A) may better characterize early retinal changes in pediatric SCR. Fluorescein angiography detects retinopathy through dynamic visualization of retinal blood flow. UWFA captures up to twice as much retinal area as conventional fluorescein angiography and is more sensitive in identifying peripheral vascular changes in SCR (Friberg TR, Ophthalmic Surg Lasers Imaging 39:304;2008). SD- OCT and OCT-A utilize reflected light to produce detailed cross-sectional images of the retina and allow visualization of blood flow in retinal layers. To our knowledge, this is the first case series using these technologies in pediatric SCR. Methods: A consecutive series of children with sickle cell disease (SCD) of any phenotype, ages 10-19 years, accepting enrollment are described. Examinations including acuity, standard slit-lamp examination (biomicroscopy), UWFA, SD- OCT and OCT-A were performed according to standard acquisition protocols. Testing is non-invasive except fluorescein angiography, which requires a small volume of intravenous dye.Results: Eight children (mean age 16.3 years; 5 HbSS, 2 HbSC,1 HbS-Beta thalassemia0) were evaluated. Three were on hydroxyurea therapy, 1 on chronic transfusion, 1 on both and 3 on no therapy. No patient had vision disturbance at the time of examination. Biomicroscopic examination revealed sunburst lesions in the mid-peripheral retina in 3 patients and subtle vascular changes in the far periphery of all patients. In contrast, UWFA detected extensive capillary non- perfusion of the peripheral retina with abnormal vascular loops (Goldberg Stage I) in all 8 patients; 3 patients had peripheral arteriovenous anastomoses (Goldberg Stage II) that were undetectable by biomicroscopy. No patient had Goldberg Stages III-V. SD-OCT demonstrated thinning of the temporal macula in 2 patients, and OCT-A of both patients revealed flow voids in both the superficial and deep retinal capillary plexus in the area of thinned retina. Both the SD- OCT and OCT-A abnormalities were undetectable with standard biomicroscopy.Conclusions: All 8 children with SCD in this case series demonstrated evidence of SCR using the combination of standard biomicroscopy, UWFA, SD-OCT, and OCT-A imaging. Findings from these sensitive imaging modalities suggest that pediatric SCR is more prevalent than previously suspected. Additional patients and age-equivalent controls will be included in this report to validate the specificity of findings to SCD. Larger cross-sectional and prospective analyses using sensitive retina imaging are needed to confirm our findings and identify their significance for detecting pathology. If confirmed, these approaches may enhance early screening for patients at risk of vision-threatening consequences of SCR.Supported by the Irving Institute CTSA at CUMC and by 2T35HL007616 (DP). [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Corneal Arcus is a Sign of Cardiovascular Disease, Even in Low-Risk Persons

To examine the association of corneal arcus to cardiovascular disease (CVD) in an adult, ethnic Indian population. Population-based cross-sectional study. Population-based study of ethnic South Asian Indians 40 to 80 years of age in Singapore from June 2007 through March 2009. We obtained a 75.5% response rate (3397/4497). All participants underwent standardized interview and systemic and ocular examinations, followed by nonfasting blood sampling. Corneal arcus was detected using a standardized slit-lamp examination. The main outcome measure was CVD, defined from a self-reported history of previous myocardial infarction, angina, or stroke. Corneal arcus, found in 1701 (50.1%) of 3397 participants, was associated with older age (odds ratio [OR], 3.07; 95% CI, 2.78 to 3.40; P < .001), male gender (OR, 2.17; 95% CI, 1.81 to 2.62; P < .001), higher levels of total cholesterol (OR, 1.14; 95% CI, 1.05 to 1.24; P = .002), hypertension (OR, 1.14; 95% CI, 1.05 to 1.24; P = .013), and cigarette smoking (OR, 1.59; 95% CI, 1.25 to 2.03; P < .001). Corneal arcus was associated with CVD (OR, 1.31; 95% CI, 1.02 to 1.7; P = .0038) independent of the above-named cardiovascular risk factors. Participants with low-risk Framingham scores were more likely to be associated with CVD if they had corneal arcus (men: OR, 2.02; 95% CI, 1.20 to 3.40; P = .008; women: OR, 2.78; 95% CI, 1.36 to 3.01; P < .001). Corneal arcus was associated with CVD independent of the Framingham score (men: Akaike information criterion, 1524.39 for Framingham Score and corneal arcus vs 1527.38 for Framingham Score alone; women: 1000.14 vs 1003.54, respectively). Corneal arcus is associated with CVD, independent of risk factors in ethnic Indian adults, even in those at low risk for vascular disease.

Retinal Video Recording: A New Way to Image and Diagnose Diabetic Retinopathy

To validate the use of retinal video recording for diabetic retinopathy screening by comparing with standard retinal photography and slit-lamp examination. Evaluation of a new diagnostic technique. One hundred patients. All fundus images were captured using standard retinal still photography (FF 450 plus; Carl Zeiss) and retinal video (EyeScan; Ophthalmic Imaging System, Sacramento, CA), followed by a gold standard slit-lamp biomicroscopy examination. All videos and still images were de-identified, randomized, and interpreted by 2 senior consultant ophthalmologists (M.L.T-K. and L.L.). Kappa statistics, sensitivity, and specificity for all the diabetic retinopathy signs and grades were calculated with reference to slit-lamp examination results as the gold standard. Sensitivity and specificity of video recording for detecting diabetic retinopathy signs and grades. The mean age (± standard deviation [SD]) of participants was 52.8 ± 15.1 years, mean duration of diabetes (± SD) was 13.7 ± 9.7 years, and the mean glycosylated hemoglobin level was 8.0 ± 1.7%. Compared with the gold standard slit-lamp examination results, the sensitivity and specificity of video recording for detecting the presence of any diabetic retinopathy was 93.8% and 99.2%, respectively (ophthalmologist 1), and 93.3% and 95.2%, respectively (ophthalmologist 2). In contrast, the sensitivity and specificity of retinal photography was 91.8% and 98.4%, respectively (ophthalmologist 1), and 92.1% and 96.8%, respectively (ophthalmologist 2), for detection of any diabetic retinopathy. Both imaging methods had 100% sensitivity and specificity in detecting sight-threatening diabetic retinopathy. For overall diabetic retinopathy grading by both ophthalmologists, the measurements of agreement (Cohen's κ coefficient) between the overall grading obtained from the retinal video versus slit-lamp examination and retinal photography versus slit-lamp examination were more than 0.90. Technical failure rate for retinal video recording and retinal photography were 7.0% and 5.5%, respectively. This study demonstrated that retinal video recording was equally as effective as retinal photography in the subjects evaluated in this study. It is a novel alternative diabetic retinopathy screening technique that not only offers primary eye care providers the opportunity to view numerous retinal fields within a short period but also is easy to learn by nonexperienced personnel with minimal training. Proprietary or commercial disclosure may be found after the references.

Effects of acutely lowering intraocular pressure on the results of multifocal visual evoked potential testing

There have been many reports in the literature on the apparent reversal of optic nerve cupping in patients with glaucoma after lowering intraocular pressure (IOP) on clinical examination, as well as improvement in visual field testing, and increased nerve fibre layer thickness on optical coherence tomography. No studies to date have looked at improvement of multifocal visually evoked potentials (mfVEP) after lowering IOP. This was a prospective study of twenty consecutive patients with elevated IOP seen in the glaucoma department of Wills Eye Institute. Patients who met the inclusion criteria for this study had a complete eye examination including IOP measurement and underwent testing with mfVEP, Heidelberg Retinal Tomograph (HRT) and static achromatic automated perimetry with SITA-Standard 24-2 program Humphrey visual field (HVF) studies at baseline and 2 h post-IOP reduction. A minimum of 30% IOP reduction was required. IOP changes were then compared with various parameters of mfVEP, HRT and HVF using Spearman rank correlation coefficients. The Spearman rank correlation values between change in IOP versus various parameters were calculated: Accumap severity index (ASI), 0.37 (p = 0.14); Accumap superior hemifield, 0.049 (p = 0.85); Accumap inferior hemifield, 0.030 (p = 0.91); HVF mean deviation, 0.081 (p = 0.76); HRT rim area, 0.17 (p = 0.51); HRT cup area, -0.006 (p = 0.98). Weak positive but insignificant correlations were seen for all parameters except cup area. This pilot study failed to confirm statistically significant correlations between IOP reduction and changes in Accumap, HVF and HRT measures, although positive correlations were seen for most measures.

Temba glaucoma study: a population-based cross-sectional survey in urban South Africa

Objective To determine the prevalence and features of glaucoma in an urban South African black population. Design Random sampling cross-sectional population survey. Participants Black residents of Temba, North West Province, South Africa, age ≥40 years. Main outcome measures Automated visual field testing and detailed, standardized slit-lamp examination were attempted on all subjects. Glaucoma was diagnosed by use of the scheme proposed by the Working Group for Defining Glaucoma of the International Society of Geographical and Epidemiologic Ophthalmology on the basis of evidence of end-organ damage. Results Of 1120 subjects, 839 (74.9%) were examined. The age- and gender-adjusted prevalence of glaucoma of all types was 5.3% (95% confidence interval [CI], 3.9%–7.1%). Primary open-angle glaucoma (POAG) was the most common glaucoma diagnosis, with an adjusted prevalence of 2.9% (95% CI, 1.9%–4.3%). Secondary glaucoma occurred with an adjusted prevalence of 2.0% (95% CI, 1.2%–3.3%). Exfoliative glaucoma was responsible for 16% of all glaucoma cases. The prevalence of primary angle-closure glaucoma was 0.5% (95% CI, 0.13%–1.2%). Of all subjects with glaucoma, 58% were blind in at least one eye. The prevalence of all types of glaucoma increased with age. Of subjects with POAG, 87% had not been previously diagnosed. Conclusions The prevalence of glaucoma in this South African population was higher than that found in white populations, and most cases were undiagnosed and untreated. Glaucoma is a major cause of blindness in this population.