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The BCLA photographic competition
Contact Lens and Anterior Eye, Vol. 20, No. 4, pp. 174-179, 1997 Printed in Great Britain
© 1997 British Contact Lens Association
The BCLAPhotographic Competition The following slides were submitted for the 1997 Annual Clinical Conference of the BCLA.
First Prize - - Corneal Graft: Epithelial Rejection Line J. McCormick, R. W. W. Stevenson, C. M. Kirkness This is the RE corneal graft of a 55 year old male showing an epithelial rejection line with surrounding infiltrates and oedema. The patient had previously undergone a penetrating keratoplasty for corneal scarring due to a viral infection. Following aggressive treatment the rejection episode receded. The clinical signs of graft rejection include keratic precipitates, corneal oedema, corneal infiltrates, and a rejection line (epithelial or endothelial) seen here. Since a significant number of grafts are fitted with contact lenses to correct post graft astigmatism, the contact lens practitioner must be aware of the earliest signs of graft rejection.
Photographic Conditions: First prize
Second prize
The photograph was taken with a Kowa SC1200 slit lamp using indirect illumination at 25× magnification and the film used was Fuji 400.
Second Prize-- Peripheral Dimple-Veil Lyndon Jones Air bubbles may become trapped under a contact lens and produce small indentations in the corneal epithelium, resulting in an appearance similar to the surface of a golf ball. When observed with fluorescein the dimples appear as a series of round discrete dots. These areas cannot be considered to be 'true' staining but merely an accumulation of tears within the superficial dimples. The bubbles usually result from a poor fitting relationship between the cornea and back surface of the tens, particularly with RGP lenses in cases of significant with-the-rule astigmatism (flattest meridian along 180°) in which a compromise spherical fit is attempted. This 34 year old male patient presented to the practice for a routine aftercare examination on his &month old RGP lenses. The patient had recently moved to the area and had been fitted elsewhere 6 months previously. Slit-lamp examination revealed bubbles under the RGP lenses in the area of superior cornea, under the lids. Upon lens removal the area demonstrated typical dimple-veil staining. Examination revealed that the subject had 4.00D of WTR corneal astigmatism, fight lids and had been fitted with a fiat-fitting, large, spherical back-surface lens. The lenses decentred upwards and the poor physical fit resulted in tear pooling and subsequent bubble formation under the lens. The fact that these formations display unreversed illumination (see right side of slide) demonstrates that they are of a lower refractive index than the surrounding epithelium and confirms that they indeed contain air or fluid. Refitting with a fully back surface toric RGP resulted in a better lens fit and eliminated the bubble formation.
Photographic Conditions: The condition was photographed using Ektachrome 200 at 1/250sec on a Nikon FS3 photo slit-lamp, using direct illumination (paraUelpiped) at an original magnification of 26×. The dimple-veil is seen in both direct and indirect illumination.
174
PHOTOGRAPHIC COMPETITION
Third Prize - - R K - Success or Failure? Roseline Robinson
This 37 year old male underwent bilateral radial keratotomy in Italy 10 years ago. Both corneas show irregular 12-cut incisions, which have only 2ram clear cornea centrally. Two of the sutures consequently ruptured following a contusion injury and resulted in significant corneal scarfing. His current acuities are R 6/18+, L 6/9 with -4.00D of myopia remaining. Despite the corneal appearance he comfortably wears high Dk RGP lenses for 14h a day and feels that the surgery was a complete success! However, he is unable to drive at night and suffers from periodic corneal erosion syndrome!
Photographic Conditions: Third prize
The condition was photographed using Ektachrome 200 at 1/240sec on a Nikon FS3 photo slit-lamp, using direct focal illumination at an original magnification of 16×.
175
PHOTOGRAPHIC COMPETITION
II
1A
1B
2
3A
3B
4
5
176
PHOTOGRAPHICCOMPKrlTION
1. Fluorescein Dispersion in Tears Pauline Cho These slides were obtained from a soft contact lens wearer who had just removed his contact lenses when the fluorescein drops were applied. The experiment was repeated a few times (on different days) and each time a 'star'-shaped break up of the tear film was observed (from the inside of the fluorescein pattern outward) (A) which stained after a blink 03). This formarion was not observed in a non-contact lens wearer.
Photographic Conditions: Information not supplied.
2. Acute Red Eye Deborah Jones Acute red eye reactions occasionally occur in extended wear patients, particularly those who do not regularly replace their lenses. This Chinese midwife was wearing extended-wear lenses for 3 months at a time. She awoke with a unilateral red, photophobic eye and presented to the practice. Examination revealed intense hyperaemia, chemosis, focal peripheral infilFates and an indentation from a bound soft lens. Corneal staining was minimal. Lens wear was stopped for 7 days. Reexamination revealed a clear eye with virtually no infiltrates remaining. The patient was refitted with extended-wear disposable lenses (weekly replacement) and she has had no recurrence of the problem.
Photographic Conditions: The condition was photographed using Ektachrome 200 at 1/250sec on a Nikon FS3 photo slit-lamp, using diffuse illumination at an original magnification of 10×.
3. Vascularised Limbal Keratitis Deborah Jones '3 and 9' o'clock corneal staining can become chronic resulting in corneal neovascularisation and pingueculae formarion. This chronic inflammatory condition has been referred to as 'vascularised limbal keratitis'. This 48 year old female patient presented with a 2 year history of chronic red eyes and reduced wearing time. She had recently noted a red 'lump' temporally. She was moderately myopic (-4.50D) and had worn rigid lenses for 24 years. Examination revealed high riding, poorly wetting RGP lenses with an obvious area of chronic drying, heaping of hyperplastic limbal, and conjunctival epithelium and associated pingueculae formation (A). The mass is clearly evident when observed stained with fluorescein under cobalt blue illumination 03). Subsequent treatment with blinking exercises, rewetting drops, increased lens diameter and a thin periphery RGP did little to alleviate the problem. Finally the patient was refitted with daily wear disposable soft toric lenses. After 5 months the cornea and sclera have cleared and the eyes appear white once more.
Photographic Conditions: The condition was photographed using Ektachrome 200 at 1/250sec on a Nikon FS3 photo slit-lamp, using diffuse illumination at an original magnification of 10×. The fluorescein picture used a Wratten No 12 barrier filter to increase the contrast of the fluorescence.
4. Corneal Abrasion Due to Paper Cut Lyndon Jones Recent calls for optometrists to become more involved in the management of patients with minor eye infections and other
anterior segment complications is likely to result in them having to manage corneal abrasions. This 23 year old female patient presented to the practice in intense pain following a corneal abrasion due to a paper cut 30min previously. She was intensely photophobic and exhibited marked lid spasm and epiphora. Instillation of 0.4% benoxinate was necessary to examine the patient, because of the epiphora. Subsequent examination revealed a moderate (3mm x 3mm) inferior epithelial abrasion with minor stromal involvement, as evidenced by the spread of fluorescein in the superior stromal layers. There were no epithelial tags present, no anterior chamber activity and intraocular pressures were normal, indicating that no secondary uveitis had occurred. Visual acuity was 6 / 6 - . To reduce ciliary spasm and reduce the chance of a secondary uveitis 1% cyclopentolate was instilled and the patient was advised to continue with 8-hourly installations for 3 days. She was advised to take ibuprofen (400mg four times daily) for pain management and a broad-spectrum antibiotic (gentamicin) was obtained, via the GP, which was instilled every 6h for 3 days. To aid epithelial repair a disposable lens was inserted as a bandage lens, which was continued with for 6 days. Followups were scheduled for 24h and then 6 days later. Examination at 6 days revealed a healthy epithelium, with no corneal staining. In order to prevent recurrent erosions the patient used a non-medicated ointment at bedtime (Lacrilube) for 4 fllrther weeks. Despite the risk of epithelial basement membrane complications ensuing (with the subsequent risk of recurrent erosion), the patient remains symptom-free 4 months later.
Photographic Conditions: The condition was photographed using Ektachrome 200 at 1/250sec on a Nikon FS3 photo slit-lamp, using direct illumination (parallelpiped) at an original magnification of 20×.
5. Complex Scleral Lens Fitting Francis J. Petticrew This patient's management has been complex. First contact lens treatment more than 30 years ago comprised impression scleral PMMA lenses to obtain the best possible correction for keratoconus. The whole gambit of corneal lenses (of various materials) was used and following corneal transplantation both central corneas were clear and avascular with cylinders - 18.00D and - 14.00D. Further treatment with soft, hard, and pick-a-back lenses followed with partial success. A return to scleral PMMA lenses gave good sight but wearing time was limited. In 1996 this patient was registered blind without contact lenses. With scleral lenses acuities remained good at R6/18+L6/12+. Contact lenses (impression scleral) were made with PMMA, consisting of a white transparent haptic and tinted blue RGP corneal portion. This gave much improved wearing time and relief from photophobia. The patient was able to open his eyes wider and he found placement/removal easier. Note limbal blanching at 9 o'clock. The tint falls short of overlapping the cornea at 3 o'clock and some bubbles can be observed under the haptic flange at this location indicating that tightening in this area could help. Overall, the cosmetic appearance is satisfactory.
Photographic Conditions: The condition was photographed using Fujichrome Sensia 400 on a Minolta XG 1/60sec f16 with teleplus MC7 macro lens and mecablitz flash.
177
QO
©
L~
E~ 0
PHOTOGRAPHIC COMPETITION
6. Contact Lens Fitting in Alopecia M. F. Petticrew The absence of body hair in alopecia is a relatively rarely encountered problem for contact lens practitioners. This patient has no eyebrows or lashes. Note the anterior cortical stellar lenticular opacities (A). To some degree he has developed the habit of lowering his brown (hence the sharp shadow) in compensation (B). This patient has successfully worn RGP lenses (B). His acuities are not wonderful at R6/18 L6/18, but he has managed to wear contact lenses without the protecting help of eyebrows against perspiration and eyelashes against foreign bodies.
Large amounts of astigmatism can be due to tight sutures, a tilted donor cornea, a mismatch in the size of the donor button, and possibly a changing orientation of the button between the donor and host, One suture was protruding through the epithelium resulting in the gross staining in the photograph.
Photographic Conditions: The picture was taken using a Zeiss 110 slit lamp, with a beam splitter and diffused flash. Fuji Provia film, ASA 400, was used.
9. Endothelial Dystrophy Photographic Conditions: The condition was photographed using Fujichrome Sensia 400 on a Minolta XG 1/60sec f16 with teleplus MC7 macro lens and mecablitz flash.
7. Pigment Dispersion R. W. W. Stevenson, J. McCormick, C. M. Kirkness The patient was a 35 year old male referred for assessment of suitability for contact lenses to correct myopia. The slit lamp photograph shows extensive pigment deposition on the corneal endothelium, typical of the spindle shape appearance associated with the pigment dispersion syndrome (Krukenberg spindle). Contact lenses were not contraindicated in this case but intraocular pressures should be checked on a regular basis since there is an association between the pigment dispersion syndrome and glaucoma.
Photographic Conditions: The photograph was taken with a Kowa SC1200 photo slit lamp using scleral scatter at a magnification of 25x. The film was Fuji 400.
8. Penetrating Keratoplasty A. J. Elder Smith This case is that of a male patient aged 20 years. Keratoconus was diagnosed January 1994. Contact lenses are worn during all waking hours but VA is 6/9 and comfort is never satisfactory. A right keratoplasty was performed on 28 February, 1996. In June 1996, the first visit to the practice after the operation, revealed a refraction of R -10.00/+11.50 × 15. Vision was 6/7.5.
Robert Terry A 30 year old female presented with a positive family (maternal) history of corneal dystrophy, keratoconus, and corneal graft. At the examination she was asymptomatic but endothelial cell layer assessment showed a very low cell density (800 cells/ram 2) and severe polymegethism. The slide highlights the irregular endothelial cell appearance, unevenness and presence of a black zone within each cell. A flow-like pattern in the tear film lipid layer is seen in the front surface specular reflection.
Photographic Conditions: The slide was recorded using Kodak Ektachrome 100 film at F 2.8 with a shutter speed of 1/60sec. An Olympus OM-40 camera was mounted on the eyepiece of a Nikon Photo-slit lamp. 10. Corneal Graft for Keratoconus Robert Terry A 48 year old male had a corneal graft performed at age 28 for advanced keratoconus. Subsequent to the graft he had worn PMMA at RGP lenses successfully. The slide highlights the graft in partial profile using the illumination technique of sclerotic scatter which clearly shows the irregular transition from the donor to host cornea. The suture marks are also clearly visible.
Photographic Conditions: The slide was recorded using Kodak Ektachrome 200 film with a shutter speed of 1/60sec. A Nikon FS-3 photo-slit lamp was used with a manual flash setting of 8.
179
© 1997 British Contact Lens Association
The BCLAPhotographic Competition The following slides were submitted for the 1997 Annual Clinical Conference of the BCLA.
First Prize - - Corneal Graft: Epithelial Rejection Line J. McCormick, R. W. W. Stevenson, C. M. Kirkness This is the RE corneal graft of a 55 year old male showing an epithelial rejection line with surrounding infiltrates and oedema. The patient had previously undergone a penetrating keratoplasty for corneal scarring due to a viral infection. Following aggressive treatment the rejection episode receded. The clinical signs of graft rejection include keratic precipitates, corneal oedema, corneal infiltrates, and a rejection line (epithelial or endothelial) seen here. Since a significant number of grafts are fitted with contact lenses to correct post graft astigmatism, the contact lens practitioner must be aware of the earliest signs of graft rejection.
Photographic Conditions: First prize
Second prize
The photograph was taken with a Kowa SC1200 slit lamp using indirect illumination at 25× magnification and the film used was Fuji 400.
Second Prize-- Peripheral Dimple-Veil Lyndon Jones Air bubbles may become trapped under a contact lens and produce small indentations in the corneal epithelium, resulting in an appearance similar to the surface of a golf ball. When observed with fluorescein the dimples appear as a series of round discrete dots. These areas cannot be considered to be 'true' staining but merely an accumulation of tears within the superficial dimples. The bubbles usually result from a poor fitting relationship between the cornea and back surface of the tens, particularly with RGP lenses in cases of significant with-the-rule astigmatism (flattest meridian along 180°) in which a compromise spherical fit is attempted. This 34 year old male patient presented to the practice for a routine aftercare examination on his &month old RGP lenses. The patient had recently moved to the area and had been fitted elsewhere 6 months previously. Slit-lamp examination revealed bubbles under the RGP lenses in the area of superior cornea, under the lids. Upon lens removal the area demonstrated typical dimple-veil staining. Examination revealed that the subject had 4.00D of WTR corneal astigmatism, fight lids and had been fitted with a fiat-fitting, large, spherical back-surface lens. The lenses decentred upwards and the poor physical fit resulted in tear pooling and subsequent bubble formation under the lens. The fact that these formations display unreversed illumination (see right side of slide) demonstrates that they are of a lower refractive index than the surrounding epithelium and confirms that they indeed contain air or fluid. Refitting with a fully back surface toric RGP resulted in a better lens fit and eliminated the bubble formation.
Photographic Conditions: The condition was photographed using Ektachrome 200 at 1/250sec on a Nikon FS3 photo slit-lamp, using direct illumination (paraUelpiped) at an original magnification of 26×. The dimple-veil is seen in both direct and indirect illumination.
174
PHOTOGRAPHIC COMPETITION
Third Prize - - R K - Success or Failure? Roseline Robinson
This 37 year old male underwent bilateral radial keratotomy in Italy 10 years ago. Both corneas show irregular 12-cut incisions, which have only 2ram clear cornea centrally. Two of the sutures consequently ruptured following a contusion injury and resulted in significant corneal scarfing. His current acuities are R 6/18+, L 6/9 with -4.00D of myopia remaining. Despite the corneal appearance he comfortably wears high Dk RGP lenses for 14h a day and feels that the surgery was a complete success! However, he is unable to drive at night and suffers from periodic corneal erosion syndrome!
Photographic Conditions: Third prize
The condition was photographed using Ektachrome 200 at 1/240sec on a Nikon FS3 photo slit-lamp, using direct focal illumination at an original magnification of 16×.
175
PHOTOGRAPHIC COMPETITION
II
1A
1B
2
3A
3B
4
5
176
PHOTOGRAPHICCOMPKrlTION
1. Fluorescein Dispersion in Tears Pauline Cho These slides were obtained from a soft contact lens wearer who had just removed his contact lenses when the fluorescein drops were applied. The experiment was repeated a few times (on different days) and each time a 'star'-shaped break up of the tear film was observed (from the inside of the fluorescein pattern outward) (A) which stained after a blink 03). This formarion was not observed in a non-contact lens wearer.
Photographic Conditions: Information not supplied.
2. Acute Red Eye Deborah Jones Acute red eye reactions occasionally occur in extended wear patients, particularly those who do not regularly replace their lenses. This Chinese midwife was wearing extended-wear lenses for 3 months at a time. She awoke with a unilateral red, photophobic eye and presented to the practice. Examination revealed intense hyperaemia, chemosis, focal peripheral infilFates and an indentation from a bound soft lens. Corneal staining was minimal. Lens wear was stopped for 7 days. Reexamination revealed a clear eye with virtually no infiltrates remaining. The patient was refitted with extended-wear disposable lenses (weekly replacement) and she has had no recurrence of the problem.
Photographic Conditions: The condition was photographed using Ektachrome 200 at 1/250sec on a Nikon FS3 photo slit-lamp, using diffuse illumination at an original magnification of 10×.
3. Vascularised Limbal Keratitis Deborah Jones '3 and 9' o'clock corneal staining can become chronic resulting in corneal neovascularisation and pingueculae formarion. This chronic inflammatory condition has been referred to as 'vascularised limbal keratitis'. This 48 year old female patient presented with a 2 year history of chronic red eyes and reduced wearing time. She had recently noted a red 'lump' temporally. She was moderately myopic (-4.50D) and had worn rigid lenses for 24 years. Examination revealed high riding, poorly wetting RGP lenses with an obvious area of chronic drying, heaping of hyperplastic limbal, and conjunctival epithelium and associated pingueculae formation (A). The mass is clearly evident when observed stained with fluorescein under cobalt blue illumination 03). Subsequent treatment with blinking exercises, rewetting drops, increased lens diameter and a thin periphery RGP did little to alleviate the problem. Finally the patient was refitted with daily wear disposable soft toric lenses. After 5 months the cornea and sclera have cleared and the eyes appear white once more.
Photographic Conditions: The condition was photographed using Ektachrome 200 at 1/250sec on a Nikon FS3 photo slit-lamp, using diffuse illumination at an original magnification of 10×. The fluorescein picture used a Wratten No 12 barrier filter to increase the contrast of the fluorescence.
4. Corneal Abrasion Due to Paper Cut Lyndon Jones Recent calls for optometrists to become more involved in the management of patients with minor eye infections and other
anterior segment complications is likely to result in them having to manage corneal abrasions. This 23 year old female patient presented to the practice in intense pain following a corneal abrasion due to a paper cut 30min previously. She was intensely photophobic and exhibited marked lid spasm and epiphora. Instillation of 0.4% benoxinate was necessary to examine the patient, because of the epiphora. Subsequent examination revealed a moderate (3mm x 3mm) inferior epithelial abrasion with minor stromal involvement, as evidenced by the spread of fluorescein in the superior stromal layers. There were no epithelial tags present, no anterior chamber activity and intraocular pressures were normal, indicating that no secondary uveitis had occurred. Visual acuity was 6 / 6 - . To reduce ciliary spasm and reduce the chance of a secondary uveitis 1% cyclopentolate was instilled and the patient was advised to continue with 8-hourly installations for 3 days. She was advised to take ibuprofen (400mg four times daily) for pain management and a broad-spectrum antibiotic (gentamicin) was obtained, via the GP, which was instilled every 6h for 3 days. To aid epithelial repair a disposable lens was inserted as a bandage lens, which was continued with for 6 days. Followups were scheduled for 24h and then 6 days later. Examination at 6 days revealed a healthy epithelium, with no corneal staining. In order to prevent recurrent erosions the patient used a non-medicated ointment at bedtime (Lacrilube) for 4 fllrther weeks. Despite the risk of epithelial basement membrane complications ensuing (with the subsequent risk of recurrent erosion), the patient remains symptom-free 4 months later.
Photographic Conditions: The condition was photographed using Ektachrome 200 at 1/250sec on a Nikon FS3 photo slit-lamp, using direct illumination (parallelpiped) at an original magnification of 20×.
5. Complex Scleral Lens Fitting Francis J. Petticrew This patient's management has been complex. First contact lens treatment more than 30 years ago comprised impression scleral PMMA lenses to obtain the best possible correction for keratoconus. The whole gambit of corneal lenses (of various materials) was used and following corneal transplantation both central corneas were clear and avascular with cylinders - 18.00D and - 14.00D. Further treatment with soft, hard, and pick-a-back lenses followed with partial success. A return to scleral PMMA lenses gave good sight but wearing time was limited. In 1996 this patient was registered blind without contact lenses. With scleral lenses acuities remained good at R6/18+L6/12+. Contact lenses (impression scleral) were made with PMMA, consisting of a white transparent haptic and tinted blue RGP corneal portion. This gave much improved wearing time and relief from photophobia. The patient was able to open his eyes wider and he found placement/removal easier. Note limbal blanching at 9 o'clock. The tint falls short of overlapping the cornea at 3 o'clock and some bubbles can be observed under the haptic flange at this location indicating that tightening in this area could help. Overall, the cosmetic appearance is satisfactory.
Photographic Conditions: The condition was photographed using Fujichrome Sensia 400 on a Minolta XG 1/60sec f16 with teleplus MC7 macro lens and mecablitz flash.
177
QO
©
L~
E~ 0
PHOTOGRAPHIC COMPETITION
6. Contact Lens Fitting in Alopecia M. F. Petticrew The absence of body hair in alopecia is a relatively rarely encountered problem for contact lens practitioners. This patient has no eyebrows or lashes. Note the anterior cortical stellar lenticular opacities (A). To some degree he has developed the habit of lowering his brown (hence the sharp shadow) in compensation (B). This patient has successfully worn RGP lenses (B). His acuities are not wonderful at R6/18 L6/18, but he has managed to wear contact lenses without the protecting help of eyebrows against perspiration and eyelashes against foreign bodies.
Large amounts of astigmatism can be due to tight sutures, a tilted donor cornea, a mismatch in the size of the donor button, and possibly a changing orientation of the button between the donor and host, One suture was protruding through the epithelium resulting in the gross staining in the photograph.
Photographic Conditions: The picture was taken using a Zeiss 110 slit lamp, with a beam splitter and diffused flash. Fuji Provia film, ASA 400, was used.
9. Endothelial Dystrophy Photographic Conditions: The condition was photographed using Fujichrome Sensia 400 on a Minolta XG 1/60sec f16 with teleplus MC7 macro lens and mecablitz flash.
7. Pigment Dispersion R. W. W. Stevenson, J. McCormick, C. M. Kirkness The patient was a 35 year old male referred for assessment of suitability for contact lenses to correct myopia. The slit lamp photograph shows extensive pigment deposition on the corneal endothelium, typical of the spindle shape appearance associated with the pigment dispersion syndrome (Krukenberg spindle). Contact lenses were not contraindicated in this case but intraocular pressures should be checked on a regular basis since there is an association between the pigment dispersion syndrome and glaucoma.
Photographic Conditions: The photograph was taken with a Kowa SC1200 photo slit lamp using scleral scatter at a magnification of 25x. The film was Fuji 400.
8. Penetrating Keratoplasty A. J. Elder Smith This case is that of a male patient aged 20 years. Keratoconus was diagnosed January 1994. Contact lenses are worn during all waking hours but VA is 6/9 and comfort is never satisfactory. A right keratoplasty was performed on 28 February, 1996. In June 1996, the first visit to the practice after the operation, revealed a refraction of R -10.00/+11.50 × 15. Vision was 6/7.5.
Robert Terry A 30 year old female presented with a positive family (maternal) history of corneal dystrophy, keratoconus, and corneal graft. At the examination she was asymptomatic but endothelial cell layer assessment showed a very low cell density (800 cells/ram 2) and severe polymegethism. The slide highlights the irregular endothelial cell appearance, unevenness and presence of a black zone within each cell. A flow-like pattern in the tear film lipid layer is seen in the front surface specular reflection.
Photographic Conditions: The slide was recorded using Kodak Ektachrome 100 film at F 2.8 with a shutter speed of 1/60sec. An Olympus OM-40 camera was mounted on the eyepiece of a Nikon Photo-slit lamp. 10. Corneal Graft for Keratoconus Robert Terry A 48 year old male had a corneal graft performed at age 28 for advanced keratoconus. Subsequent to the graft he had worn PMMA at RGP lenses successfully. The slide highlights the graft in partial profile using the illumination technique of sclerotic scatter which clearly shows the irregular transition from the donor to host cornea. The suture marks are also clearly visible.
Photographic Conditions: The slide was recorded using Kodak Ektachrome 200 film with a shutter speed of 1/60sec. A Nikon FS-3 photo-slit lamp was used with a manual flash setting of 8.
179