Text book of veterinary medicine, Volume 3 (of 5)

by James Law

Oblique Focal Illumination.

This is so essential to clear and definite conclusions and is so easily practiced on the domestic animals that every veterinarian should make himself familiar with the method. The method is based on the fact that when two perfectly transparent media touch each other a reflection of luminous rays takes place only at the surface. But in case any opacity exists in any part of the thickness of one of these media, it reflects the rays from its surface no matter what may be its position in the medium. Thus corneal opacities appear as gray blotches and under careful focal illumination it may be determined whether these are on the conjunctival surface, in the superficial or deeper layers of the cornea or in the membrane of Descemet. Similarly cloudiness or floating objects in the aqueous, reflect the luminous rays, and so with opacities in the lens or its capsule, or in the vitreous. In the same way the surface of the iris and corpora nigra may be carefully scrutinized. For satisfactory examination of the media, back of the iris, the pupil should be first dilated, by instillation under the lid of a drop or two of a 3 per cent. solution of atropia, and the examination proceeded with twenty minutes later. Homatropin is preferable to atropin as being less persistent in its action, and less liable to produce conjunctivitis. If it fails to produce the requisite dilatation, it may be followed by a drop of a 4 per cent. solution of hydrochloride of cocaine, which will secure a free dilatation, lasting only for one day in place of seven days as with atropin. The cocaine further removes pain and favors the full eversion of the eyelids.

The instruments required for focal illumination are a biconvex lens of 15 to 20 diopters, and a good oil lamp or movable gas jet. The light of the sun is not satisfactory. The examination ought to be conducted in a dark room, or less satisfactorily in semi-darkness. The lamp is held by an assistant at the level of the eye to be examined, either in front or behind, or first one and then the other, so that the rays of light may fall upon the eye obliquely. If the lids are kept closed it may be necessary to expose the cornea by pressing on the lids with the finger and thumb. The light is held 8 or 10 inches from the eye and the lens is interposed between it and the eye and moved nearer and more distant until the clearest illumination has been obtained of the point to be examined. In this way every accessible part of the eye may be examined in turn. The examiner may make his results more satisfactory by observing the illuminated surface through a lens magnifying three or four diameters. It is important to observe that the eye of the operator must be in the direct line of reflection of the pencil of light.

Cornea. By focusing the light in succession over the different parts of the surface of the cornea, all inflammations, vascularities, opacities, ulcers, and cicatrices will be shown and their outlines clearly defined. By illuminating the deeper layers of the cornea proper, the lesions of keratitis, opacities, ulcers and cicatrices will be shown. To complete the examination of the cornea the light should be focused upon the iris so that it may be reflected back through the cornea. This will reveal the most minute blood-vessels, any cell concretions on Descemet’s membrane, or any foreign body in the cornea which may have been overlooked.

Aqueous Humor. Unless the cornea is densely opaque, the anterior chamber can be satisfactorily explored by the oblique focal illumination. The cloudiness or milkiness of iritis or choroiditis furnishes a strong reflection from its free particles of floating matter, its blood and pus globules, and its flocculi of fibrine. The latter have usually a whitish reflection, the blood elements a red (hypohæma), and the pus a yellow (hypopion). The writhing movements of a filaria scarcely need this mode of diagnosis. Sometimes, and especially in the horse, detached flocculi of black pigment are found floating free in the aqueous and are highly characteristic.

By this illumination one can easily determine the distance of the cornea from the iris and lens (depth of anterior chamber) which is lessened by the forward displacement of iris and lens in undue tension in the vitreous (glaucoma, retinitis, tumors, bladderworms), or of the iris alone, in irido-choroiditis with accumulation of exudate in the posterior chamber of the aqueous. The depth of the anterior chamber may increase in cases of luxation or absence of the lens or softening and atrophy of the vitreous.

The adhesion of the iris to the back of the cornea may be satisfactorily demonstrated by focal illumination.

Iris. The lesions of the iris are exceedingly common in connection with recurring ophthalmia in the horse, and examinations in the intervals between attacks are of the greatest importance. The eye should be examined as already stated, at a window or door, and if available by the aid of a mirror. Any changes in form or color, or luster should be carefully noted, any tension of the eyeball, or angularity of the upper lid, and any slight blue opacity round the margin of the cornea. Then the prompt or tardy response of iris and pupil to light and darkness must be made out. To complete the test the eye should be treated with homatropin for three-quarters of an hour and with cocaine for ten or fifteen minutes, and then subjected to oblique focal illumination.

With partial posterior synechia the rest of the pupil is found dilated while the attached portion extends inward remaining fixed to the capsule of the lens. If the synechia is complete no dilatation whatever has occurred. The edges of the adherent iris extend inward as adherent projections, and any exposed portion of the lens is likely to show black points, the seat of previous adhesions that have been broken up. In such cases the periphery of the iris bulges forward from the accumulation behind it of aqueous humor or inflammatory exudate which cannot escape. The discoloration of the iris as the result of inflammation, stands out more definitely under the fuller illumination.

Crystalline lens. In exploring the crystalline lens or its capsule for opacities (cataracts) oblique focal illumination can be employed to the very best advantage, if the pupil has first been widely dilated by homatropine and cocaine. The light is concentrated on all parts of the anterior capsule in turn, then in succession on the different layers of the lens at all points and finally on the posterior capsule. The striking reflection from any points of opacity whether pigmentary, gray or pearly white is diagnostic, not only of cataract, but of its exact position—anterior or posterior, capsular or lenticular.

Purkinje-Sanson images. If the flame of a candle is passed in front of the eye, at a suitable distance, in a darkened room, and the observer looks into the eye obliquely from the opposite side, he observes three images of the flame, reflected respectively from the front of the cornea, from the anterior surface of the lens and from the back of the lens. The image from the cornea is erect, bright and clearly defined: that from the front of the lens is still erect, but larger and dimmer, because the difference between the index of refraction of the aqueous and lens is very slight: the third image, which is smaller and clearer than the last, is inverted, because the surface of reflection on the back of the lens acts as a concave mirror. The beginner may at first find it difficult to make out the image from the front of the lens but with a little care he can do so, and then by moving the light he should cause each image to pass over all parts of the reflecting surface in turn. Any unevenness or opacity at any point of the reflecting surface, will cause the image reflected from it to become blurred or diffused as it passes over it and thus, not the existence only, but the exact seat of such opacity is easily demonstrated. Opacities on the cornea cause blurring of the bright, erect image of the flame as it passes over that part: opacities on the anterior capsule of the lens blur the dim, erect image when passed over them: finally, opacities in the body of the lens or on its posterior capsule, blur the small inverted image as it passes over them.

Add to this method the oblique focal illumination and the images of the flame reflected from the three mirror surfaces (cornea, anterior and posterior lens surfaces) are made much clearer and more distinct than in any other way. To do this effectively the convex lens should be held so as to focus the flame in the air nearly in front of the cornea. The Purkinje-Sanson images are made very definite and clear. If the lens is approached nearer to the eye so as to throw the image of the flame within or behind the lens, a gray phosphorescent streak of light is seen in the depth of the pupil. This is due to the laminated structure of the lens as well as to the fact that the lens itself is not perfectly transparent even in its normal condition. The absence of the lens or its dislocation and displacement downward, below the line of vision may be inferred from the absence of this gray luminous reflection under this test.