THE CORNEA

dr. PETTY PURWANITA, SpM

Ophthalmology Department
Mohammad Hoesin General Hospital
 THE CORNEA
GROSS ANATOMY

Curved & Domshaped

Fibrous, Transparent & No blood vessels

Diameter : Horizontal 12mm

Vertical 11mm
Thickness: Central 0.5 - 0.6mm
Peripheral 0.8 1.0mm
Refractive Index : 1.37
Refractive Power : 42 D

( What is The LIMBUS ?)

 MINUTE ANATOMY

5 LAYERS

(1) Epithelium
St. Squamous Nonkeratinised (5-6 layers)
Surface Flat cells (2-3 layers)
Intermed. Polyhedral cells (2-3 layers)
Basal Columnar cells (one layer)

(2) Bowmans layer

Structure less (Acellular) condensation
Never regenerate
Scar
(3) THE STROMA (Substantia Propria)

- 90% of corneal thickness

- Regular arrangement
- Bundles of each layer \\ to each other
perpendicular to next layer
- Cells ( present in Lacunae )
Corneal corpuscles ( Keratoblasts )
Corneal metabolism & Healing
Leucocytes
Inflammation
- Scar

(4) DESCEMETS MEMBRANE

Homogenous, Structureless & Highly Elastic
Resistant & Easily Regenerate
(5) Endothelium
5 m
Monolayer hexagen
500 000 cells
Stop miosis
Tight junction
Pump
 CORNEAL PHYSIOLOGY
NUTRITION ( cornea is avascular )
By diffusion
Tear Film Aqueous humour Limbal capillaries

CORNEAL TRANSPARENCY ( WHY ? )

Anatomical Factors :
Cornea is avascular
Epithelium is nonkeratinized
Stromal lamellae are regular
Nerves are nonmyelinated
Precorneal tear film

Physiological Factors :
Corneal hydration
Uniform refractive indices of corneal tissue

FUNCTIONS OF THE CORNEA

Refractive 42 D
Protective ( corneal reflex )
 SIGNS OF CORNEAL DISEASE
A. Superficial
1.Punctate epithelial erosions
Tiny ,slightly depressed, epithelial defects which stain
with flourescein but not with rose Bengal
PEE are non specific and may develop in a wide variety
of keratopathies
2.Punctate epithelial keratitis
It is the hallmark of viral infections.
Swollen epithelial cells

Stains with rose bengal

3.Epithelial Oedema
Sign of
Endothelial decompensation

Severe acute elevation of IOP

4.Filaments
Small coma shaped mucus strands lined with
epithelium.
One end attached with epithelium

5.Pannus
Inflammatory or degenerative ingrowth of fibrovascular
tissue from limbus
 B. Stromal Lesions

1.Infiltrates
Focal areas of active stromal inflammation
2. Oedema
Increased corneal thickness
Decreased transparency
3. Vascularization
 C. Lesions of Descemet Membrane

1. Breaks
Corneal enlargement
Keratoconus
Birth trauma

2. Folds (Striate Keratopathy)

Surgical trauma
Ocular hypotony
Stromal oedema
CORNEAL INFECTIONS
1. Bacterial keratitis

2. Fungal keratitis

3. Acanthamoeba keratitis

4. Herpes simplex keratitis

-Epithelial
-Disciform
5. Herpes zoster keratitis
 Bacterial keratitis
Predisposing factors
Contact lens wear
Chronic ocular surface disease
Corneal hypoaesthesia

Expanding oval, yellow-white, Stromal suppuration and

dense stromal infiltrate hypopyon

Treatment - topical antibiotics

 BACTERIAL KERATITIS

Pathogens which can produce corneal infection in

intact epithelium.
1.Neisseria gonorrhoeae

2.Corynebacterium diphtheriae

3.Listeria

4.Haemophilus
 MANAGEMENT
History
Clinical examination (including staining and
sensitivity)
Hospitalization
Corneal scrapping
Treatment:
- Topical antibiotics
- Subconjunctival injections
-Systemic antibiotics
 Poor response to treatment
Wrong diagnosis
Wrong treatment
Drug toxicity
 Fungal keratitis
Frequently preceded by ocular trauma with organic matter

Greyish-white ulcer which may be Slow progression and occasionally

surrounded by feathery infiltrates hypopyon
Treatment
Topical antifungal agents
Systemic therapy if severe
Penetrating keratoplasty if unresponsive
History of vegetable matter injury
Greyish-white ulcer with indistinct margins
Surrounded by feathery infilterates
Ring infilterate
Endothelial plaque
Hypopyon
 Candida keratitis
Usually develops in pre-existing corneal disease
or immunocompromised patient
Yellow-white ulcer
Dense suppuration
 D/D of fungal keratitis
Suppurative bacterial keratitis
Herpetic stromal necrotic keratitis
 MANAGEMENT
Culture
Biopsy
Antifungal therapy
Systemic antifungal
Therapeutic penetrating keratoplasty
 Acanthamoeba keratitis
Contact lens wearers at particular risk
Symptoms worse than signs

Small, patchy anterior Perineural infiltrates

stromal infiltrates (radial keratoneuritis)

Ulceration, ring abscess Stromal opacification

& small, satellite lesions

Treatment - chlorhexidine or polyhexamethylenebiguanide

 CLINICAL FEATURES
Blurred vision and disproportionate pain
Patchy anterior stromal infilterates
Perineural infilterates (radial keratoneuritis)
Infilterates coalesce ring abcess, ulceration and
hypopyon
White satellite lesions
 MANAGEMENT
Corneal scrappings stained with calcoflour white
Corneal biopsy
Treatment with chlorhexidine,
polyhexamethylenebiguanide drops, dipropamidine and
propamidine.
Therapeutic penetrating keratoplasty
 Herpes simplex epithelial keratitis

Dendritic ulcer with terminal bulbs May enlarge to become geographic

Stains with fluorescein

Treatment
Aciclovir 3% ointment x 5 daily
Trifluorothymidine 1% drops 2-hourly
Debridement if non-compliant
 DENDRITIC ULCER
Opaque cells arranged in a course punctate or stellate
pattern
Central desquamation leads to a linear branching ulcer.
Fluorescein stain
Rose Bengal stain
Diminished corneal sensitivity
Anterior stromal infilterates
Geographical or amoeboid ulcer
 Differential diagnosis
Herpes zoster keratitis
Healing corneal abrasion
Pseudodendrites due to soft contact lens
Acanthamoeba keratitis
Drug toxicity
 TREATMENT
Antiviral therapy
Acyclovir 3% ointment
Trifluorothymidine 1% drops
Adenine arabinoside 3% ointment, 0.1% drops

Debridement (with sterile cotton-tipped bud 2mm

beyond the edge of ulcer)
 Herpes simplex disciform keratitis
Signs Associations

Central epithelial and stromal oedema Occasionally surrounded by

Folds in Descemet membrane Wessely ring
Small keratic precipitates

Treatment - topical steroids with antiviral cover

DISCIFORM KERATITIS
Antigen antibody reaction ( viral antigen )
H.S. & H.Z.
Grey disc-shaped dense opacity
Loss of corneal sensation
Drop of vision
Treatment
Corticosteroids + Antiviral drugs
Tarsorraphy
 Herpes zoster keratitis
Acute epithelial keratitis Nummular keratitis

Develops in about 50% within Develops in about 30% within

2 days of rash 10 days of rash
Small, fine, dendritic or stellate Multiple, fine, granular deposits
epithelial lesions just beneath Bowman membrane
Tapered ends without bulbs Halo of stromal haze
Resolves within a few days May become chronic

Treatment - topical steroids, if appropriate

 Herpes Zoster Ophthalmicus
Predisposing factors
Old age - Immunity
Clinical Picture :
-Lids: Dermatoblepharitis ( pain and rash )
-Keratitis : ( Hutchinsons rule )
Epithelial Keratitis ( Punctate or dendritic )
Interstitial Keratitis
Treatment:
Acyclovir tab. 800mg 5 times/ day for 7 days
Steroids + Antibiotic skin oint.
Steroids + Antibiotic eye drops
Analgesics
COMPLICATIONS OF CORNEAL ULCERS
A) Non Perforated corneal ulcer
Early Complications
(1) 2ry Iridocyclitis : ( Toxins )
(2) 2ry Glaucoma : Open angle glaucoma
(3) Descematocele : Small translucent bleb
Not seen in children or T hypopyon ulcer

Late Complications (Healing abnormalities)

(1) Corneal opacity ( Nebula, Macula or Leucoma non adherent )

(2) Corneal Facet : rapid healing of the epith.

(3) Keratectasia : ( weak corneal scar & IOP )

(4) Pseudoptregium
 B) COMP. OF PERFORATED CORNEAL ULCERS

Early Complications

(1) Iris Prolapse ( Big Para central or periph. Perforation )

(2) Anterior synechia ( Small periph. Perforation)
(3) Corneal Fistula ( Small central perforation )
Lost AC IOP River Green Sign
(4) Malposition of the Lens
Sublaxation Ant. Dislocation Extrusion
(5) Endo or Panophthalmitis
 B) COMP. OF PERFORATED CORNEAL ULCERS (cont.)

Late complications

(1) Ant.Polar Cataract (Toxins )

(2) Leucoma Adherent ( Large Peripheral Perforation )

- AC irregular
- Pupil pear shaped
- IOP may be high
- may be pigmented

(3) Ant. Staphyloma ( partial or total )

(4) 2ry Glaucoma (closed angle by PAS )
(5) Atrophia bulbi ( atrophy of the cil. processes )
 KERATOPLASTY
Aim: Replacing the opaque part by a clear cadaveric cornea
Types:
- Lamellar ( Superficial )
- Deep ( Penetrating )
NB: Both of them may be partial or total
- Tectonic : Has a specific shape according to site and indication
Indications:
- Optical a) Central corneal opacities
b) Keratoconus
- Therapeutic a) Resistant corneal ulcer
b) Corneal fistula