1. Slit Lamp Exam Findings

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

3. Lids

4. 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. 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. 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 form ed

25. Cornea

26. 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. 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”

51. Anterior Chamber Cells White blood cells and protein in AC

52. Anterior Chamber Flare Scatterings of light in AC from slit lamp beam Due to increased protein in aqueous

53. Anterior Chamber Red Blood Cells (RBC) Red blood cells in AC

54. Anterior Chamber Hypopyon Collection of pus in AC

55. Anterior Chamber Hyphema Blood in AC

56. Anterior Chamber Tube Shunt (may have stitch blocking end) S/P glaucoma sx Document with location (I.e. “shunt s-t”)

57. Anterior Chamber Gas bubble in AC S/P PPVx Document as “gas bubble”

58. Anterior Chamber Silicone Oil bubbles in AC S/P PPVx with Silicone oil Document as “Sil. Oil”

59. Iris

60. Normal

61. Iris Nevus (multiple = nevi) Freckle Document with location (I.e. nevus I-T”)

62. Iris Neovascularization New blood vessel growth on iris May be florid (everywhere) Document with location

63. Iris Atrophy Wasting away of cells or tissue

64. Iris Peripheral Iridotomy (PI) For glaucoma Note if closed or patent (open) Document with location (I.e. “PI Sup”)

65. Iris Posterior Synechiae When iris adheres to lens May also have pigment on lens from previous episodes of broken Post. Syn. Document with location (I.e. “post. Syn. I-N & S-T)

66. Iris Pupillary Membrane Congenital

67. Iris Ectropion Pupillae When the pupil margin folds out Document with location Usually due to iris nv contraction

68. Lens

69. Clear

70. Lens Nuclear Sclerosis (NS) Cataract with increased hardening or density at center of lens

71. Lens Cortical Spokes (CS) Radially arranged opacities on lens cortex

72. Lens Posterior Sub- Capsule (PSC) Cataract on rear surface of lens

73. Lens Posterior Chamber Intra Ocular Lens (PCIOL) Usually edges cannot be seen through an undilated pupil Document as “PCIOL”

74. Lens Pseudoexfoliation (PXF) Deposits of unknown material appearing on lens and iris

75. Lens Subluxated IOL IOL that has fallen down Document as “Sublux. IOL” Misc. – a dislocated lens may not be visible since will be in PC

76. Lens Aphakic Without a lens Through a peaked pupil, you can see there is no lens edge

77. Lens Posterior Capsule Opacity (PCO) Scar tissue that forms after PEIOL Document as “PCO”

78. Lens Yag Capsulotomy Done to make opening in PCO Might not be seen fully til eye is dilated Note if open or closed Document as “Yag open”

79. Lens Feathering Opacity on posterior capsule, S/P PPVx/F-Gx Caused when gas hits lens surface

80. Lens ACIOL Can be seen without dilation Document as “ACIOL”

81. Lens Mature Cataract Can often be seen without use of the slit lamp Document as “white NS”

82. Lens Elshnig’s Pearls Cystic growth of lens epithelial remnants Usually S/P PEIOL

83. Misc.

84. Scleral Thinning Usually noted by a bluish tint to sclera Document as “Scleral thinning”

85. Misc. Translucent Sclera (albinism) Lack of pigment Sometimes more than others