Slit Lamp Exam Findings

1. Slit Lamp Exam Findings

2. Components: • Lids • Adnexa • Conjunctiva • Cornea • Anterior Chamber • Iris • Lens

3. Lids Lids

4. Lids Normal

5. Lids Ectropion • Eyelid turning outward • Document with location (I.e. “ectropion LLL”)

6. Lids Entropion • Eyelid turning inward • Document with location (I.e. “entropion LLL”)

7. Lids Dermatochalasis (D’chalasis) • Redundancy of skin in eyelids • Atrophy of elastic tissue

8. Lids Upper Lid Folds • Increased amount of folds • Document as: “high UL folds”

9. Lids Hooding • When upper lid comes over lid margin • Document as: “Hooding”

10. Lids Ptosis • Drooping of the upper eyelids • Document with location (I.e. “Ptosis RUL”)

11. Lids Papilloma • Growth on eyelid • Document with location (I.e. “papilloma RUL”)

12. Lids Trichiasis • Inward growth of eyelashes • Document with location (I.e. “trichiasis RLL”)

13. Lids Chalazion • Inflamed lump in meibomian gland

14. Lids Blepharitis • Inflammation of eyelid margins • Redness, swelling, itching, crusting

15. Lids Ecchymosis • Bruising • Document with location (I.e. “ecchymosis RUL”)

16. Adnexa

17. Adnexa Normal

18. Adnexa Decreased Tear Lake • Tear lake not smooth • Also can have increased break up time • Document as: “decreased tear lake” • Misc – TBUT = 10 sec

19. Conjunctiva

20. Conjunctiva Quiet

21. Conjunctiva Injection • Tissue redness and swelling

22. Conjunctiva Sub-Conjunctival Hemorrhage (SCH) • Blood below conjunctiva and above sclera • Document as: “SCH” with location (i.e. “SCH OD temp, inf, nas”)

23. Conjunctiva Hyperemia • Congestion of blood vessels • Causes redness

24. Conjunctiva Bleb • S/P trabeculectomy for glaucoma • Document if flat or formed

25. Cornea

26. Cornea Normal

27. Cornea Arcus • White deposit of cholesterol

28. Cornea Edema • Swelling of tissue from fluid accumulation

29. Cornea Superficial Punctate Keratitis (SPK) • Small superficial corneal lesions • Often due to dryness • Usually seen with staining

30. Cornea Anterior Stromal Scarring • Scarring on the Stroma (middle layer of the cornea)

31. Cornea Amiodarone Whorls • Deposits from long-term use of Amiodarone

32. Cornea Abrasion • Scraped area of corneal surface • Accompanied by loss of epithelium • Usually seen with staining

33. Cornea Astigmatic & Radial Keratomtery (AK / RK) cuts • S/P AK or RK • Document with location (I.e. “AK cuts OU”)

34. Cornea Keratic Precipitates (KP) • Inflammatory cells and white blood cells that enter aqueous and adhere to corneal endothelium

35. Cornea Guttata • Small whitish hyaline deposits on inner surface of cornea

36. Cornea Lasik Flaps • S/P Lasik • Location = direction of flap opening • Document with location (I.e. “Lasik flap inf. – healed”)

37. Cornea Neovascularization • New blood vessel growth • Document location (I.e. “OD inf.”)

38. Cornea Pinguecula • Benign yellowish-brown elevation of sub-conjuntival tissue on either side of cornea

39. Cornea Pterygium • Wedge-shaped growth in bulbar conjunctiva • May advance over the cornea

40. Cornea PK • S/P corneal transplant • Note sutures: • None • 360* • Running 360*

41. Cornea Suture • occ. used S/P PEIOL • Document with location (I.e. “suture temp.”)

42. Cornea Descemets Folds • Folds in the Descemet’s membrane

43. Cornea Ulcer • Area of epithelial loss • Associated with inflammatory cells in cornea & AC

44. Cornea Band Keratopathy • Horizontal band of calcium deposits • In superficial layer of cornea

45. Cornea Haab’s Striae • Breaks or tears in Descemet’s membrane • Usually from forceps use during delivery

46. Anterior Chamber

47. Anterior Chamber Deep & Quiet • Deep = Large distance between both beams • Quiet = No abnormal matter in AC • Document as “D&Q”

48. Anterior Chamber Shallow • Minimal distance between both beams • Document as “shallow”

49. Anterior Chamber Moderate Depth • Moderate distance between both beams • Document as “moderate depth”

50. Anterior Chamber Closed • Irido-Corneal touch • Document as “Closed”