Introduction to Slit Lamp Imaging Basics

By Jeremy Graziano, O.D.

Ocular photography in the optometric office plays a key role in patient records, communication
between eye care professionals, and in patient education. Clarity and accuracy of imaging is
crucial. The paraoptometric is often asked to perform the imaging. Photography in itself is an
art. When you add the dimension of taking the imaging with the use of a slit lamp, the technique
requires the skills of being proficient with the slit lamp and the art of being a photographer.
Follow along as you learn the steps to obtain the most defined and clearest imaging.

How to Get the Best Focus When Imaging

Perhaps the most frustrating experience when capturing an image is to see a structure in
perfect focus through the oculars but the resulting image is blurry. How do I know if it's me or
the device? How do I fix it? Follow along below to get this problem under control!

Install the Focusing Rod

First, you need to have your focusing rod. This should have come as standard equipment with
your Slit Lamp. They are usually interchangeable between brands so if you need to, grab one
from a different unit. It goes into the hole where the lamp and ocular arms pivot. The flat side
faces towards the oculars.

The red arrow is the location of the focusing rod

Focus the Oculars for Your Eyes

Most all of us have some correction necessary. This is how to set the oculars properly for your
eyes.

1. Move the magnification drum to 16x.

2. With the focusing rod in place, narrow the beam until it is a moderate slit (~2 mm wide).
3. Turn the oculars as far to the negative as you can (that is, as far counterclockwise as
possible).
4. You need to do this part of the procedure with only one eye open at a time. (If needed,
put a piece of paper in front of one of the oculars.) While looking through the microscope with
just one eye, slowly turn the ocular towards the plus (clockwise) until you FIRST see the focus
rod come into focus. Do not adjust or fine tune - if you go past the first point of focus, start over.
You do not want to adjust beyond the first point of focus because your eyes can accommodate
and invalidate the calibration.
5. Repeat for the other eye.
6. Take note of the numbers on the oculars - if you have multiple users on the slit lamp
you'll need to set the oculars before you begin to take any pictures, and you can use those
numbers on other slit lamps.

You now know that your eyes are parfocal with the slit lamp.

Ensure the Camera is Focused

Now, confirm that the imaging system and the slit lamp are indeed parfocal (when the slit lamp
is properly in focus the image will be as well). If the imaging system has a Live View, bring it up
on the screen and check the focus. The image of the focusing rod should be in clear focus. If
the system does not have a Live View setting, then take a picture. The image should be clear
and in focus.

If your Live View or picture is not clear, you should stop now - the camera needs to be focused.
The system is not parfocal and needs to be calibrated for you to have success moving forward.
You may need to contact the manufacturer.

Still Not Right?

The camera, the slit lamp, and the oculars should now all be parfocal; however, you may still
find your images come out blurry! What could be happening?

Your own eye's focusing system may be getting in the way - you may be accommodating. This
allows you to move the slit lamp closer to the subject than the parfocal point.

You have two options at this point.

The first requires a special focusing ocular with a reticle. The correct focus position is when both
the subject and the reticle are in focus. This method is reliable but requires additional equipment
and requires concentrating on two subjects at the same time.

A simpler method I found to be very effective is to thwart the eye's accommodation reflex:

1. Find the area of interest and then pull the slit lamp back a tiny amount until it is slightly
out of focus.
2. Push the slit lamp forward until the subject FIRST comes into focus and immediately
take the shot.

The trick is to not continue driving forward as that is when you are accommodating.You can
experience this easily by simply getting into that point of first focus and continue pushing
forward. You will notice the subject remains clear for a short distance. This is why your images
may be blurry when the subject looked so clear in the oculars.

Move the slit lamp towards target and stop at first point of focus

A well-focused image is a beautiful thing. A little set-up and a couple of simple habits can
ensure it will be yours.
When and How to Use the Diffuser

The slit lamp has a beam spot size that is much smaller than the viewable area at low
magnifications. Slit lamps can have spot sizes ranging from 8 mm up to around 14 mm but this
can leave a great deal of information for the photographer in an unlit area.

No diffuser at 10x mag

Doctors will often want to not only see the lit area but also the surrounding tissue for a greater
point of reference.

Enter the Diffuser

An external light source can be an excellent method to fill in the dark zones, but sometimes one
may not be handy. Fortunately, the majority of slit lamps come with a diffuser that can spreads
out the light.

Red arrow show the diffuser in up (engaged) position.

The diffuser is very effective on reflective tissue such as the eyelid, conjunctiva, and even the
iris. It is not a good option for the cornea except in the case of capturing fluorescein.
 Same image as above with diffuser in place

The Difference

The effects you can expect are:

1. Some reduced reflection

2. A loss of shadow and perceived depth
3. An extension of the spot beam to fill in most of the viewable area.

A likely limitation of the diffuser is that, unlike with an external light source, the center of the lit
area is the brightest with it dimming some as it spreads outwards.

Watch Out!

A common mistake for photographers using a flash-based photo slit lamp is to have the diffuser
into place before opening the slit up to a full spot. To ensure adequate lighting, one should first
open the slit and then move the diffuser into position. Do not narrow the slit until you capture the
image you want.

light at full power but slit engaged and diffuser used

A Useful Tool

The diffuser is an excellent tool when taking images of the eyelid, conjunctive and iris regions
and should be avoided with cornea or lens photography. It can be more forgiving than imaging
with a slit, more valuable information can be often captured, and some of the annoying
reflections can be mitigated.

6.3 mag with diffuser and without diffuser comparison

Basic Cornea Dystrophy Photography Technique

Corneal defects are one of the more tricky images to capture well because you are dealing with
a transparent surface. Today's topic focuses on capturing a defect using direct lighting.

The basic steps to capture a corneal defect with direct lighting are:

Step 1:
Position the light stack approximately 45 degrees from the oculars.
Step 2:
Adjust slit width to fully cover the defect you wish to capture.
Step 3:
Fine tune light slit to ensure the light hitting the iris is not acting as a background to the defect.
You want the background to be dark and this means utilizing the pupil if possible.

You can see how the defect extending halfway into the illuminated iris thereby making it very
hard to see.
Images courtesy of Dr. Mark Mandel, M.D. of Optima Eye Clinic.
To bring the defect into full view, a slight rotation of approximately 10 degrees nicely creates the
ideal view.

A wonderful example of capturing a corneal dystrophy using direct lighting after moving the light
stack a few degrees further.
Quick tips:

1. Take advantage of the pupil if possible. If the defect is a little off the pupillary axis,
having the patient look in the direction that brings the defect more towards the doctor will often
place the pupil behind it. It can also improve the depth of field.
2. A dilated pupil helps a lot when you need the dark background.
3. Don't forget you can move the oculars as well; they do not need to just be facing straight
ahead.

Obtaining the most defined and clearest image is an art that can be achieved with practice. By
paying attention to the details and utilizing the steps defined in the article, you will be able to
enhance the patient record and patient education for the practice.

About our Author

Jeremy Graziano, O.D. graduated Optometric School in 1999 from Pacific University. Subsequently 
opened a private practice called OGLE until 2010 when he launched Eye Photo Systems Inc, acting as the 
President. Eye Photo

No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any
form or by any means (electronic, mechanical, photocopying, recording, or otherwise) without the prior
written permission of the publisher.
Copyright© 2015 by The American Optometric Association 
 

Introduction to Slit Lamp Imaging Basics

To receive one hour of continuing education credit, those taking the quiz must be an AOA Associate
member paraoptometric and answer 7of the 10 questions correctly. This exam consists of multiple-choice
questions designed to measure the level of understanding of the material covered in the continuing
education article “Introduction to Slit Lamp Imaging Basics.”

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$95 renewal payment will be due to the CPC by November 1. All quizzes submitted by October 1 will be
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Select the option that best answers the question.
 

1: Which of the following structures is NOT a good choice for using a diffuser: 

A. Conjunctiva 
B. Cornea 
C. Eyelid 
D. Iris 

2: What magnification should be used when focusing the oculars? 

A. 6x 
B. 10x 
C. 16x 
D. 25x 
E. 40x 

3: What does parfocal mean? 

A. When the slit lamp is properly in focus the image will be as well 
B. When the slit lamp is NOT properly in focus the image will not be as well 
C. Your eyes are accommodating and getting in the way 
D. Looking through the microscope with both eyes 

4: Which of the following angles would be best to move the light stack when capturing a typical corneal 
defect? 

A. 10 degrees 
B. 20 degrees 
C. 30 degrees 
D. 40 degrees 

5: What structure would be best to have acting as a background when capturing a corneal defect? 

A. Iris 
B. Limbus 
C. Pupil 
D. Conjunctiva 

6: How much of a slit should be used when using the diffuser? 

A. ¼ open 
B. ½ open 
C. ¾ open 
D. Full open 
 

Introduction to Slit Lamp Imaging Basics pg. 2

 
7: How should you focus the oculars? 

A. One eye at a time 
B. Both at the same time 
C. In a well lit room 
D. In a darkened room 

8: In which direction do you first turn the oculars before you begin the procedure? 

A. Clockwise 
B. Counterclockwise 
C. Inward, closer to the patient 
D. Outward, away from the patient 

9: What does a diffuser do? 

A. Increases the shadows and perceived depth 
B. Decreases the shadows and perceived depth 
C. Increase the shadows and decreases depth 
D. Decreases the shadows and increases depth 

10: Slit lamps can have spot sizes ranging from: 

A. 1mm up to 4 mm 
B. 5mm up to 7mm 
C. 8mm up to 14 mm 
D. 15 mm up to 18mm 

 
No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any
form or by any means (electronic, mechanical, photocopying, recording, or otherwise) without the prior
written permission of the publisher.
Copyright© 2015 by The American Optometric Association 

Introduction to Slit Lamp Imaging Basics pg. 3