- Email: [email protected]
Oscillation Slitlamp Photography*
OSCILLATION SLITLAMP PHOTOGRAPHY* PAUL A.
C BIS,t M . D . Missouri
St. Louis, In recent years, slitlamp photography has been advanced (1) by the use of electronic flash units (Dugnani, 1 Stepanik,2 and Littmann 3 ), (2) by voltage booster circuits for the incandescent bulbs of regular slitlamps (Dugnani, 1 Drews 4 ) and (3) by improvement of the depth of field by means of ingenious mechanical devices (Goldmann 5 ) or by the application of certain geometric principles (Scheimpflug,0 Drews 4 ). The latter allow a satisfactory optical solution of focal depth problems. All instruments used in the past were experimental in nature. Littmann's instrument* is the first one that will be commercially available, supposedly at the end of this ye:ir. Prototypes of this instrument (fig. 1) are being tested at several University Eye Clinics in Western Germany. Figure 2 represents a picture taken with this new apparatus by Littmann. The advantages of flashlight slitlamp photography are obvious: short exposure time, elimination of disturbing effects caused by voluntary and involuntary eye movements, use of adequately small apertures and satisfactory depth of field. This paper is written to demonstrate that valuable observations can be made with oldfashioned slitlamps and incandescent light as far as the photographic documentation of lesions in the vitreous and aqueous humor are concerned. They consist in the integration of structural details which by short exposure present themselves as fragmentary * From the Department of Ophthalmology and the Oscar Johnson Institute, Washington University School of Medicine. This work was supported in part by a grant (No. B-1789) from the National Institute of Neurological Diseases and Blindness of the National Institute of Health, Public Health Service. t Deceased. î Carl Zeiss, Oberkochen ( Wuerttemberg) West Germany.
Fig. 1 (Cibis). Photo-slitlamp (prototype) with electronic flash unit of the Carl Zeiss Company, Oberkochen/Wuerttemberg, West Germany. (Courtesy of Dr. G. Littmann, II.)
image details or are not visible at all. Under ordinary conditions the strenuously fixating eye performs small trembling movements averaging an angular range of 2 minutes and 14 seconds at a rate of 5 to 10 per second. According to Adler,7 these movements probably represent the vibration frequency of the extraocular muscles, whereas Lord and Wright 8 attribute them to head movements. In addition to the oscillatory eye and head movements, the eyes break fixation periodically in the form of waves measuring 2.5 to 5 minutes angular deviation. They last less than 2 seconds (Adler 7 ). These fine involuntary eye movements cause the images of tiny light reflexes
OSCILLATION SLITLAMP PHOTOGRAPHY
1063
emitted from minute or coarse opacities in the aqueous and vitreous (o move to and fro on the film, corresponding in angular size and rhythm to the eye movements. Long exposure times (1-8 seconds) and steady fixation of a fixation light by the patient result in a cumulative effect on the exposed areas of the film. The examiner tries to keep the slitbeam aimed at a distinct detail. This way small dots like the precipitates in asteroid hyalosis (fig. 3-A) appear slightly elongated, particularly in the horizontal direction. Longer exposure times lead to enlargement of these image points. At the same time, the number of structural elements recognizable on the photograph increases (fig. 3 - B ) . Only those parts which are optically empty (fig. 4-A and B ) or
Fig. 3 (Cibis). ( A ) Photograph of vitreous opacities caused by asteroid hyalosis (arrow), taken with the regular Zeiss slitlamp. Exposure 2 seconds. ( B ) Same with exposure of 5 seconds. Notice larger number of vitreous opacities depicted ( L ) Lens. (C) Corneal reflex.
Fig. 2 (Cibis). Photograph of Vogt's biomicroscopic discontinuity zones taken with the new photo slitlamp of Carl Zeiss, Oberkochen/Wuerttemberg West Germany. (Courtesy of Dr. G. Littmann, II.)
which are not adequately illuminated (fig. 5) remain uniformly dark. T h e greatest benefit from this kind of integrated oscillation slitlamp photography is obtained with the visualization and documentation of vitreous pathology. This will be demonstrated by a few photographs taken with the regular Zeiss slitlamp.* The exposure times employed vary from 1-8 seconds. Of course, a great deal of the effects achieved depends on the width and the density of the light flux of the slitbeam used. Unfortunately, this has not been recorded in * Serial number of optical system: 1693. Serial number of lighting system: 306371.
1064
PAUL
.. C I B I S
my cases. Figure 6 displays vitreous condensations (membranellae) behind the lens and vitreous liquefaction farther posterior. A true detachment and contraction of the
Fig. 6 (Cibis). Oscillation slitlamp photograph depicting vitreous membranellae (condensations of fibrillary mesh work) and vitreous liquefaction (syneresis). Optically empty space to the left of membranellae. Exposure 6 seconds.
Fig. 4 (Cibis). ( A ) Sheath of Cloquet's canal inserting to upper portion of posterior lens capsule ( a r r o w ) . Exposure 2 seconds. (B) Same structures inserting to lower portion of posterior lens capsule (arrow). Exposure 3 seconds. Notice "optical emptiness" of postlenticular space of vitreous. ( L ) Lens. (C) Corncal slitbeam.
Fig. 7 (Cibis). Posterior vitreous detachment with condensed vitreous behind the lens. Optically empty space at left from detached posterior hyaloid membrane.
^
1
f/lfl TOS
Fig. 5 (Cibis). Integrated slitlamp photograph of lens with water clefts in anterior cortex (beginning cataract). Exposure 4 seconds. Slitbeam displaced inferiorly. Upper portion of lens not showing.
OSCILLATION SLITLAMP
PHOTOGRAPHY
1065
posterior hyaloid membrane is depicted in Figure 7. Condensation of the anterior hyaloid membrane is shown in Figure 8. The spherical extension of the slitbeam picture due to proximal illumination of densely packed pulverulent opacities in the nucleus
Fig. 10 (Cibis). Integrated slitlamp picture of aphakic eye with prolapse of vitreous into the anterior chamber. Exposure 8 seconds, very small slitbeam. Notice clear appearance of iris, conjunctiva, and lid due to overcast illumination. Vitreous free of major opacification.
Fig. 8 (Cibis). Oscillation slitlamp photograph depicting condensation of anterior hyaloid membrane (arrow) with otherwise normal lens and vitreous structure. Exposure 3 seconds.
Fig. 11 (Cibis). Oscillation slitlamp photograph of aphakic eye, showing condensed vitreous behind iris sharply delineated to the left from silicone fluid in vitreous body, two years following vitreous replacement by 360 Medical Fluid (Dow Corning Chemical Company). Exposure 3 seconds. Fig. 9 (Cibis). Oscillation slitlamp photograph of lens with nuclear cataract. Spherical enlargement of slitbeam in nuclear area due to dense opacification yielding proximal extension of Tyndall phenomenon. Exposure 1.5 seconds.
of a p r e s e n i l e c a t a r a c t is s h o w n i n F i g u r e 9. O f p a r t i c u l a r v a l u e is t h e i n t e g r a t e d oscill a t i o n s l i t l a m p p h o t o g r a p h y in a p h a k i c e y e s .
1066
PAL'L A. CTBIS
Fig. 12 (Cibis). Oscillation slitlamp photograph of aphakic eye with bubble of liquid silicone in anterior chamber following vitreous replacement with 360 Medical Fluid (Dow Corning Chemical Company). Exposure 4 seconds.
Figure 10 depicts the transpupillary presentation of the anterior vitreous face with a small globular-shaped portion of vitreous prolapsing through an oval window in the hyaloid membrane. T h e clear delineation of condensed vitreous in front of a large bubble of liquid silicone injected into an aphakic eye afflicted by retinal detachment with massive preretinal fibrous tissue organization is shown in Figure 11. T h e delineating membrane ( a r r o w ) separating the silicone i S i ) and the condensed vitreous represents the membranous fibrous tissue which had been peeled off from the surface of the retina during the surgical procedure. Figure 12 shows a similar case with a silicone bubble displaced into the anterior chamber. Because of the long exposure time, overcasting light brought out details of the iris. If regular room illumination is used even a small slitbeam yields a picture with details of lens, iris, conjunctiva and skin of the lids, as illustrated in Figure 13. SUMMARY
T h e involuntary oscillatory movements of the eye are utilized in slitlamp photography with incandescent light and long exposure time to achieve integrated pictures of opacities in the vitreous and aqueous humor which, at short exposure times with flashlight units, would not be demonstrable or would be less defined. 660 South Euclid Avenue (63110).
Fig. 13 (Cibis). Integrated oscillation slitlamp photograph of eye with cataract. Taken with narrow slitbeam and exposure of 8 seconds, thus resulting in depiction of details of iris, conjunctiva and lid skin by stray light. REFERENCES
1. Dugnani, E. : Die Farben iotobiomikroskopie des Auges mit Spaltbeleuchtung. Klin. Mbl. Augenh., 134:674-680, 1959. 2. Stepanik, J. : Photographie des optischen Schnittes an der Spaltlampe. Klin. Mbl. Augenh., 135 : 259-263, 1959. 3. Littmann, G. : Personal communication. 4. Drews, R. C. : Depth of field in slitlamp photography : An optical solution using the Scheimpflug principle. Ophthalmologica (Basel), 148:143-150, 1964.
OSCILLATION SLITLAMP PHOTOGRAPHY
1067
5. Goldmann, H.: Spaltlampenphotographie und -photometrie. Ophthalmologica (Basel), 98:257-270 (Jan.) 1940. 6. Scheimpflug, T. : Der Photoperspektograph und seine Anwendung. Photographische Korrespondenz, 43:516,1906. 7. Adler, F. H. : Physiology of the Eye. St. Louis, Mosby, 1950, ed. 1, pp. 393-394. 8. Lord, M. P., and Wright, W. D. : Eye movements during monocular fixation. Nature, 162 :25-26 (July 3) 1948.
S T U D I E S O N T H E D E V E L O P M E N T O F T H E E Y E IX 13-15 T R I S O M Y S Y N D R O M E * L E W I S M.
R O C H , II,t M.D., AND A E L E T A N .
J O H N V. PETRUCXT, BARBER, P H . D .
THE
M.D.,
New Orleans, Louisiana Recent advances in the science of cytogenetics have greatly clarified several syndromes of multiple congenital abnormalities. In 1965, Tjio and Levan 1 established with certainty that the human karyotype consists of 22 pairs of autosomes and two sex chromosomes, or a total of 46 instead of 48 as had been previously held. Several autosomal trisomy syndromes with eye defects have been described and the subject has been reviewed by Francois and Van Leuven. 2 T h e 13-15 ( D ) trisomy syndrome seems to have the most severe ocular defects, which include microphthalmia, coloboma, cataracts and retinal dysplasia. 3 " 7 T h e purpose of this paper is to describe the pathology of this ocular anomaly in relation to the developmental process of the eye. C A S E REPORT
history revealed three normal siblings and one infant, who died a few hours after birth of multiple congenital defects. The prenatal course was uneventful. At birth the patient weighed five pounds and 10 ounces. On initial physical examination the infant was noted to have microcephaly, severe microphthalmos, poorly developed orbits with spastic inturned eyelids (fig. 1), incomplete skull calcification with widely patent sutures and fontanelles, low-set ears, bilateral polydactylia, dry scaly skin, clinched hands with overriding digits, a horizontal palmar crease (fig. 2) and macrogenitalia. X-ray studies confirmed the incomplete skull calcification. Hemogram, urinalysis, blood-sugar, bound urea nitrogen and liver-function studies were within normal limits, and the electrocardiogram was normal. The palm print was considered to be compatible with the 13-15 (D) trisome dermal configuration.8 The infant died four months later, the actual cause of death being bronchopneumonia and dehydration. Necropsy revealed the following significant abnormalities : The stature was short with a crown-head measurement of 51 cm, which is below the three percentile for this age and sex. The fon-
The patient was a Negro girl, born at the USPHS Hospital, New Orleans, on November 16, 1963, to a 23-year-old mother after an estimated eight and one-half months' gestation. The father was 24 years of age and in good health. Family * From the Departments of Ophthalmology and Pathology, U.S. Public Health Service Hospital, and the Department of Pathology, Louisiana State University School of Medicine. This study was supported in part by research grant NB-03841 from the National Institute of Neurological Diseases and Blindness of the National Institutes of Health, U.S. Public Health Service, and in part by U.S. Public Health Service Division of Hospitals grant K-64-21. t Present address : USPHS Hospital, Seattle, Washington 98114.
Fig. 1 (Roch, Petrucci and Barber). Clinical photograph of the patient showing spastic inturned eyelids and small, deeply recessed globe.
C BIS,t M . D . Missouri
St. Louis, In recent years, slitlamp photography has been advanced (1) by the use of electronic flash units (Dugnani, 1 Stepanik,2 and Littmann 3 ), (2) by voltage booster circuits for the incandescent bulbs of regular slitlamps (Dugnani, 1 Drews 4 ) and (3) by improvement of the depth of field by means of ingenious mechanical devices (Goldmann 5 ) or by the application of certain geometric principles (Scheimpflug,0 Drews 4 ). The latter allow a satisfactory optical solution of focal depth problems. All instruments used in the past were experimental in nature. Littmann's instrument* is the first one that will be commercially available, supposedly at the end of this ye:ir. Prototypes of this instrument (fig. 1) are being tested at several University Eye Clinics in Western Germany. Figure 2 represents a picture taken with this new apparatus by Littmann. The advantages of flashlight slitlamp photography are obvious: short exposure time, elimination of disturbing effects caused by voluntary and involuntary eye movements, use of adequately small apertures and satisfactory depth of field. This paper is written to demonstrate that valuable observations can be made with oldfashioned slitlamps and incandescent light as far as the photographic documentation of lesions in the vitreous and aqueous humor are concerned. They consist in the integration of structural details which by short exposure present themselves as fragmentary * From the Department of Ophthalmology and the Oscar Johnson Institute, Washington University School of Medicine. This work was supported in part by a grant (No. B-1789) from the National Institute of Neurological Diseases and Blindness of the National Institute of Health, Public Health Service. t Deceased. î Carl Zeiss, Oberkochen ( Wuerttemberg) West Germany.
Fig. 1 (Cibis). Photo-slitlamp (prototype) with electronic flash unit of the Carl Zeiss Company, Oberkochen/Wuerttemberg, West Germany. (Courtesy of Dr. G. Littmann, II.)
image details or are not visible at all. Under ordinary conditions the strenuously fixating eye performs small trembling movements averaging an angular range of 2 minutes and 14 seconds at a rate of 5 to 10 per second. According to Adler,7 these movements probably represent the vibration frequency of the extraocular muscles, whereas Lord and Wright 8 attribute them to head movements. In addition to the oscillatory eye and head movements, the eyes break fixation periodically in the form of waves measuring 2.5 to 5 minutes angular deviation. They last less than 2 seconds (Adler 7 ). These fine involuntary eye movements cause the images of tiny light reflexes
OSCILLATION SLITLAMP PHOTOGRAPHY
1063
emitted from minute or coarse opacities in the aqueous and vitreous (o move to and fro on the film, corresponding in angular size and rhythm to the eye movements. Long exposure times (1-8 seconds) and steady fixation of a fixation light by the patient result in a cumulative effect on the exposed areas of the film. The examiner tries to keep the slitbeam aimed at a distinct detail. This way small dots like the precipitates in asteroid hyalosis (fig. 3-A) appear slightly elongated, particularly in the horizontal direction. Longer exposure times lead to enlargement of these image points. At the same time, the number of structural elements recognizable on the photograph increases (fig. 3 - B ) . Only those parts which are optically empty (fig. 4-A and B ) or
Fig. 3 (Cibis). ( A ) Photograph of vitreous opacities caused by asteroid hyalosis (arrow), taken with the regular Zeiss slitlamp. Exposure 2 seconds. ( B ) Same with exposure of 5 seconds. Notice larger number of vitreous opacities depicted ( L ) Lens. (C) Corneal reflex.
Fig. 2 (Cibis). Photograph of Vogt's biomicroscopic discontinuity zones taken with the new photo slitlamp of Carl Zeiss, Oberkochen/Wuerttemberg West Germany. (Courtesy of Dr. G. Littmann, II.)
which are not adequately illuminated (fig. 5) remain uniformly dark. T h e greatest benefit from this kind of integrated oscillation slitlamp photography is obtained with the visualization and documentation of vitreous pathology. This will be demonstrated by a few photographs taken with the regular Zeiss slitlamp.* The exposure times employed vary from 1-8 seconds. Of course, a great deal of the effects achieved depends on the width and the density of the light flux of the slitbeam used. Unfortunately, this has not been recorded in * Serial number of optical system: 1693. Serial number of lighting system: 306371.
1064
PAUL
.. C I B I S
my cases. Figure 6 displays vitreous condensations (membranellae) behind the lens and vitreous liquefaction farther posterior. A true detachment and contraction of the
Fig. 6 (Cibis). Oscillation slitlamp photograph depicting vitreous membranellae (condensations of fibrillary mesh work) and vitreous liquefaction (syneresis). Optically empty space to the left of membranellae. Exposure 6 seconds.
Fig. 4 (Cibis). ( A ) Sheath of Cloquet's canal inserting to upper portion of posterior lens capsule ( a r r o w ) . Exposure 2 seconds. (B) Same structures inserting to lower portion of posterior lens capsule (arrow). Exposure 3 seconds. Notice "optical emptiness" of postlenticular space of vitreous. ( L ) Lens. (C) Corncal slitbeam.
Fig. 7 (Cibis). Posterior vitreous detachment with condensed vitreous behind the lens. Optically empty space at left from detached posterior hyaloid membrane.
^
1
f/lfl TOS
Fig. 5 (Cibis). Integrated slitlamp photograph of lens with water clefts in anterior cortex (beginning cataract). Exposure 4 seconds. Slitbeam displaced inferiorly. Upper portion of lens not showing.
OSCILLATION SLITLAMP
PHOTOGRAPHY
1065
posterior hyaloid membrane is depicted in Figure 7. Condensation of the anterior hyaloid membrane is shown in Figure 8. The spherical extension of the slitbeam picture due to proximal illumination of densely packed pulverulent opacities in the nucleus
Fig. 10 (Cibis). Integrated slitlamp picture of aphakic eye with prolapse of vitreous into the anterior chamber. Exposure 8 seconds, very small slitbeam. Notice clear appearance of iris, conjunctiva, and lid due to overcast illumination. Vitreous free of major opacification.
Fig. 8 (Cibis). Oscillation slitlamp photograph depicting condensation of anterior hyaloid membrane (arrow) with otherwise normal lens and vitreous structure. Exposure 3 seconds.
Fig. 11 (Cibis). Oscillation slitlamp photograph of aphakic eye, showing condensed vitreous behind iris sharply delineated to the left from silicone fluid in vitreous body, two years following vitreous replacement by 360 Medical Fluid (Dow Corning Chemical Company). Exposure 3 seconds. Fig. 9 (Cibis). Oscillation slitlamp photograph of lens with nuclear cataract. Spherical enlargement of slitbeam in nuclear area due to dense opacification yielding proximal extension of Tyndall phenomenon. Exposure 1.5 seconds.
of a p r e s e n i l e c a t a r a c t is s h o w n i n F i g u r e 9. O f p a r t i c u l a r v a l u e is t h e i n t e g r a t e d oscill a t i o n s l i t l a m p p h o t o g r a p h y in a p h a k i c e y e s .
1066
PAL'L A. CTBIS
Fig. 12 (Cibis). Oscillation slitlamp photograph of aphakic eye with bubble of liquid silicone in anterior chamber following vitreous replacement with 360 Medical Fluid (Dow Corning Chemical Company). Exposure 4 seconds.
Figure 10 depicts the transpupillary presentation of the anterior vitreous face with a small globular-shaped portion of vitreous prolapsing through an oval window in the hyaloid membrane. T h e clear delineation of condensed vitreous in front of a large bubble of liquid silicone injected into an aphakic eye afflicted by retinal detachment with massive preretinal fibrous tissue organization is shown in Figure 11. T h e delineating membrane ( a r r o w ) separating the silicone i S i ) and the condensed vitreous represents the membranous fibrous tissue which had been peeled off from the surface of the retina during the surgical procedure. Figure 12 shows a similar case with a silicone bubble displaced into the anterior chamber. Because of the long exposure time, overcasting light brought out details of the iris. If regular room illumination is used even a small slitbeam yields a picture with details of lens, iris, conjunctiva and skin of the lids, as illustrated in Figure 13. SUMMARY
T h e involuntary oscillatory movements of the eye are utilized in slitlamp photography with incandescent light and long exposure time to achieve integrated pictures of opacities in the vitreous and aqueous humor which, at short exposure times with flashlight units, would not be demonstrable or would be less defined. 660 South Euclid Avenue (63110).
Fig. 13 (Cibis). Integrated oscillation slitlamp photograph of eye with cataract. Taken with narrow slitbeam and exposure of 8 seconds, thus resulting in depiction of details of iris, conjunctiva and lid skin by stray light. REFERENCES
1. Dugnani, E. : Die Farben iotobiomikroskopie des Auges mit Spaltbeleuchtung. Klin. Mbl. Augenh., 134:674-680, 1959. 2. Stepanik, J. : Photographie des optischen Schnittes an der Spaltlampe. Klin. Mbl. Augenh., 135 : 259-263, 1959. 3. Littmann, G. : Personal communication. 4. Drews, R. C. : Depth of field in slitlamp photography : An optical solution using the Scheimpflug principle. Ophthalmologica (Basel), 148:143-150, 1964.
OSCILLATION SLITLAMP PHOTOGRAPHY
1067
5. Goldmann, H.: Spaltlampenphotographie und -photometrie. Ophthalmologica (Basel), 98:257-270 (Jan.) 1940. 6. Scheimpflug, T. : Der Photoperspektograph und seine Anwendung. Photographische Korrespondenz, 43:516,1906. 7. Adler, F. H. : Physiology of the Eye. St. Louis, Mosby, 1950, ed. 1, pp. 393-394. 8. Lord, M. P., and Wright, W. D. : Eye movements during monocular fixation. Nature, 162 :25-26 (July 3) 1948.
S T U D I E S O N T H E D E V E L O P M E N T O F T H E E Y E IX 13-15 T R I S O M Y S Y N D R O M E * L E W I S M.
R O C H , II,t M.D., AND A E L E T A N .
J O H N V. PETRUCXT, BARBER, P H . D .
THE
M.D.,
New Orleans, Louisiana Recent advances in the science of cytogenetics have greatly clarified several syndromes of multiple congenital abnormalities. In 1965, Tjio and Levan 1 established with certainty that the human karyotype consists of 22 pairs of autosomes and two sex chromosomes, or a total of 46 instead of 48 as had been previously held. Several autosomal trisomy syndromes with eye defects have been described and the subject has been reviewed by Francois and Van Leuven. 2 T h e 13-15 ( D ) trisomy syndrome seems to have the most severe ocular defects, which include microphthalmia, coloboma, cataracts and retinal dysplasia. 3 " 7 T h e purpose of this paper is to describe the pathology of this ocular anomaly in relation to the developmental process of the eye. C A S E REPORT
history revealed three normal siblings and one infant, who died a few hours after birth of multiple congenital defects. The prenatal course was uneventful. At birth the patient weighed five pounds and 10 ounces. On initial physical examination the infant was noted to have microcephaly, severe microphthalmos, poorly developed orbits with spastic inturned eyelids (fig. 1), incomplete skull calcification with widely patent sutures and fontanelles, low-set ears, bilateral polydactylia, dry scaly skin, clinched hands with overriding digits, a horizontal palmar crease (fig. 2) and macrogenitalia. X-ray studies confirmed the incomplete skull calcification. Hemogram, urinalysis, blood-sugar, bound urea nitrogen and liver-function studies were within normal limits, and the electrocardiogram was normal. The palm print was considered to be compatible with the 13-15 (D) trisome dermal configuration.8 The infant died four months later, the actual cause of death being bronchopneumonia and dehydration. Necropsy revealed the following significant abnormalities : The stature was short with a crown-head measurement of 51 cm, which is below the three percentile for this age and sex. The fon-
The patient was a Negro girl, born at the USPHS Hospital, New Orleans, on November 16, 1963, to a 23-year-old mother after an estimated eight and one-half months' gestation. The father was 24 years of age and in good health. Family * From the Departments of Ophthalmology and Pathology, U.S. Public Health Service Hospital, and the Department of Pathology, Louisiana State University School of Medicine. This study was supported in part by research grant NB-03841 from the National Institute of Neurological Diseases and Blindness of the National Institutes of Health, U.S. Public Health Service, and in part by U.S. Public Health Service Division of Hospitals grant K-64-21. t Present address : USPHS Hospital, Seattle, Washington 98114.
Fig. 1 (Roch, Petrucci and Barber). Clinical photograph of the patient showing spastic inturned eyelids and small, deeply recessed globe.