Principle of ophthalmoscope: Angle of incidence and angle of reflection in same line, light close to one side of the eye, reflected into it by a mirror, having a hole in the centre for eye of observer. Opacities show a dense white in transparent media: if in front of lens move with rolling of eye: if behind in opposite direction. To see fundus must use biconvex lens. Emmetropic eye: myopic: hypermetropic. Static refraction. Mydriatics: Atropine, homatropine, daturine, duboisine, hyoscyamine.
In the healthy eye, the pupil and iris, and in cataract, even the opaque anterior capsule of the lens, can be clearly seen. The reflection of the pupil, however, is dark and no object back of the iris can be observed. The reason of the difference is that the rays of light, entering through the whole cornea, are reflected at the same angle at which they strike the surface of the iris. The angle of incidence is the same as the angle of reflection. In the hollow fundus of the eye, however, the light entering through the narrow pupil, strikes the fundus at a point which is hidden from the observer, behind the iris, and being reflected by the concave fundus, in exactly the same line along which it entered, it remains invisible. To illuminate the fundus of the eye, for the observer, his line of vision must be made exactly the same as that in which the pencil of light enters the fundus. This is best effected by reflecting the light into the eye by the aid of a small plane or concave mirror having a hole in the center through which the observer looks into the pupil. The concave mirror gives the stronger illumination, but the plane article is more easily manipulated and tends to cause less active contractions of the pupil. This is the simplest form of ophthalmoscope. For careful examination of the fundus of the eye, it is best to have the subject in a dark chamber, with a single large flame of an oil lamp or gas (electric light with an obscure globe may answer). The light is held behind and on the same side as the eye to be examined, at the level of the eye and the perforated mirror and the eye of the observer are kept from 10 to 20 inches in front of the eye and also at the same level. For the horse or ox under favorable conditions in a stall, the light of day coming from a fansash over the door may serve the purpose. Nicholas assures us that it may be accomplished even under the shadow of a shed or a tree. In such a case it is better not to have too much glare of light as the reflection from cornea and lens may prevent accurate observation. A somewhat cloudy day may therefore prove advantageous.
In focusing the reflected light on the cornea, and then on the pupil and lens, any opacities in these will be shown as a grayish nebular reflection or a denser white according to their degree of opacity. The opacities in the cornea or aqueous, in front of the axis of vision in the lens move in the same direction and to the same degree as the eye rolls, while opacities on the posterior capsule or in the vitreous, move in a direction opposite to the motions of the eye, and to a degree corresponding to their distance back of the lens. Thus if the eye looks downward such opacities move upward; if it looks upward they move downward; if it looks inward they move outward; and if it looks outward they move inward.
To secure an image of the fundus of the eye, including the entrance of the optic nerve (optic papilla), the tapetum, the pigmentary surface and retina and vessels, accommodation must be made for the normal refraction of the eye of the patient, and even for that of the observer.
In the emmetropic (normal) eye, the rays leave the surface of the cornea parallel to each other and it may be possible for the observer to secure a good image on his retina, without the aid of lenses. In the myopic (short sighted) eye they assume a convergent course on leaving the cornea, and to secure a satisfactory image a biconcave or plano-concave lens must be interposed between the cornea of the patient and the eye of the observer.
In the hypermetropic (long sighted) eye, the rays diverge in leaving the cornea of the patient, and a convex lens must be interposed between this and the eye of the observer, in order that the rays may be focused on the eye of the observer.
To adapt the vision to the different eyes the modern ophthalmoscope is furnished with a series of lenses concave and convex, any one of which can be moved behind the hole in the mirror to suit the demands of the particular case.
To make a satisfactory examination the pupil should be dilated as for oblique focal illumination. A 1:200 solution of apomorphia may be instilled into the eye (a drop or two) and in 20 to 25 minutes a satisfactory dilatation will have been secured. The effect of the homatropin will usually have disappeared in twenty-four hours.
This can be best done in the lower animals by determining the strength of the lens required to render clear the image of its fundus. By knowing the refracting power of the lens, we may ascertain what deviation from the normal refraction there is in the eye under observation.
In making this test the mirror of the ophthalmoscope must be brought closely to the eye of the patient—1 to 2 inches.
If in such a case and without the use of any lens a distinct image of the fundus is obtained, and if this is rendered less distinct by interposing the lowest convex lens in front of the eye of the observer, the eye is emmetropic.
If the ophthalmoscopic mirror without a lens gives an indistinct vision of the fundus, and if the image is rendered clear by interposing one of the convex lenses, the eye is hypermetropic. The strength of the convex lens, +1, +2 or +3, dioptrics will give the measure of the hypermetropia.
If, on the contrary, the ophthalmoscopic mirror gives an indistinct image of the fundus, which is rendered even more indistinct by the interposition of a convex lens, but is cleared up and rendered definite by a concave lens, the patient is myopic. The strength of the concave lens used will give the degree of myopia, –1 dioptric, –2 dioptrics, etc.
The tendency in the horse is constantly to slight long-sightedness, but the deviation is rarely found to be serious either in this direction or in that of astigmatism.
Dilation of the pupil by mydriatics (mydriasis dilation of the pupil) is a most important means of diagnosis, and therefore a knowledge of the action of the different mydriatics is essential. The mydriatics in common use not only dilate the pupil, but also paralyze the ciliary body and the power of accommodation in ratio with the strength of the solution employed. This determines an adaptation of the eye to the farthest point of vision and holds it there until the action of the mydriatic passes off and normal power of accommodation is restored. In short it renders the subject long sighted, during its action.
Atropine the alkaloid of atropa belladonna is the most generally available and persistent of the mydriatics, and is in most common use. It is usually employed as sulphate of atropine, though some prefer the nitrate, the salicylate or the borate to obviate the danger of atropinism. This form of poisoning may show in the occurrence of conjunctivitis and in case of one attack the susceptibility to atropine is greatly to be dreaded, so that it should never again be used on the same subject. The real cause of atropinism is uncertain, it has been variously ascribed to too great acidity or alkalinity, or to micro-organisms growing in the solution. Hence the importance of using the antiseptic salts of atropine, and of testing the solution to see that it is exactly neutral before it is applied.
The strength of the solution of atropine is an important consideration. Donders found that 1:120 of water produced a full effect, while Jaarsma obtained the full effect in one hour from a drop of a solution of one to twelve hundred of water. The action on carnivora (dogs and cats) is equivalent to that on man, while on the herbivora (rabbit, horse, ox, sheep) it is somewhat less, and on birds very slight indeed. On diseased eyes a large amount may be required, and with synechia (adhesion of the iris to the capsule of the lens) dilatation may be impossible. The full effect may last 24 hours, and accommodation may remain very imperfect for 11 days.
The direct action of atropine on the eye is shown in dilatation of the pupil of the frog after the eye has been detached from all connection with heart or brain, by excision. It acts also in the normal system through reflex nervous action, since, after division of the sympathetic trunk going to the eye, that eye does not dilate so much under atropia as the opposite eye.
Atropine is usually employed by lodging a drop in the pouch of the conjunctiva (inside the lower lid), and from this it makes its way into the aqueous humor, for if that liquid is transferred to the conjunctiva of another animal it causes dilatation. Puncture of the cornea with evacuation of the aqueous humor lessens the action of the atropine. Atropine dilatation is increased by following it with cocaine which causes contraction of the iridian vessels, the antithesis of the dilatation of the vessels which occurs when the cornea is perforated and the pressure of the aqueous humor is removed.
Atropine is one of the most potent poisons and must be used with caution especially in the carnivora and omnivora. The danger lies not alone in the absorption from the conjunctiva, but also from the escape of the liquid through the lachrymo-nasal duct, to the nose and later to the actively absorbing mucosæ of the lungs and stomach.
The symptoms of general poisoning are: rapid pulse, vertigo, weakness of posterior limbs, general prostration and thirst or dryness of the throat.
Homatropine is an oily liquid produced by the action of muriatic acid on the cyanate of atropine. With hydrobromic acid it forms a readily crystallizable salt, the solution of which acts on the eye like atropine, but more promptly and transiently. One drop of a solution of one to one hundred and twenty, usually gives in twenty minutes, full pupillary dilation and complete paralysis of accommodation which lasts only for twenty-four hours. Add to this that there is little danger of constitutional disturbance and poisoning, and homatropine must be accepted as a more desirable agent than atropine. It is especially to be preferred in cases of senility with shallow anterior chambers, and in glaucoma, in which atropine tends to aggravate the lesion.
Daturine, the alkaloid of datura stramonium is a potent mydriatic, causing pupillary dilatation in a solution of one to one hundred and sixty thousand of water. It appears to be identical with atropine.
Duboisine the alkaloid of duboisia myoporoides is also a potent mydriatic. Jaarsma found that a solution of the sulphate, of one to three thousand, paralyzed accommodation for twenty-four hours. It acts more promptly than atropine but is more poisonous.
Hyoscyamin, the alkaloid of hyoscyamus niger, is also strongly mydriatic. One drop of an one to three hundred solution of the sulphate paralyzed accommodation for from seventy-five to one hundred hours. Risley found it to act more promptly than atropine, and to be less dangerous than duboisine.