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Objective Quantification of Fluorescence Intensity on the Corneal Surface Using a Modified Slit-lamp Technique

Tan, Bo Ph.D.; Zhou, Yixiu Ph.D.; Svitova, Tatyana Ph.D.; Lin, Meng C. O.D., Ph.D.

Eye & Contact Lens: Science & Clinical Practice: May 2013 - Volume 39 - Issue 3 - p 239–246
doi: 10.1097/ICL.0b013e31828dc7f3

Objectives: To improve the digital quantification of fluorescence intensity of sodium fluorescein instilled on corneal surface by modifying a slit lamp hardware and performing computerized processing of captured digital images.

Methods: The optics of a slit lamp were modified to remove corneal Purkinje reflection and to expand the illuminated area on the cornea, followed by postexperiment image processing to minimize the influence of uneven illumination. To demonstrate the feasibility and reliability of this new technique, we applied it to objective grading of corneal staining with sodium fluorescein. The results of computerized grading were compared with the results obtained using standard subjective grading of corneal staining. Objective digital grades, staining area, and staining pixel with manually and automatically defined threshold (SP-M and SP-A) were calculated for both original and processed images. Standard subjective grades of the original images were performed by 13 trained observers using National Eye Institute (NEI), Efron, and CCLRU grading scales. A series of linear regression analyses were performed to investigate the correlation between objective and subjective grades.

Results: Digital grades of the captured images were correlated significantly with subjective grades. After minimization of the artifact caused by the nonuniform illumination, correlations between digital and subjective grading were mostly strengthened. In some cases, digital grading of corneal staining was more sensitive than subjective grading methods when differentiating subtle differences of corneal staining.

Conclusions: Modifications performed on commercial slit-lamp hardware and the proposed digital image–processing technique have improved the quality of captured images for semiautomated quantification of fluorescein intensity on the cornea.

Clinical Research Center, School of Optometry, University of California, Berkeley, CA.

Address correspondence and reprint requests to Meng C. Lin, O.D., Ph.D., Clinical Research Center, School of Optometry, University of California, Berkeley, 360 Minor Hall, Berkeley, CA 94720-2020; e-mail:

Supported in part by the University of California at Berkeley Clinical Research Center with unrestricted funds from Carl Zeiss Vision, Cooper Vision, Roberta J. Smith research fund, and the Morton Sarver Foundation.

The original poster “Improving Objective Grading of Corneal Staining by Eliminating the Influence of Corneal Reflection and the Uneven Distribution of Fluorescence Excitation” was presented at the American Academy of Optometry Annual Meeting, in Boston, on October 14th, 2011.

The authors have no other funding or conflicts of interest to disclose.

Accepted February 17, 2013

© 2013 Contact Lens Association of Ophthalmologists, Inc.