Cornea

• The cornea is the anterior part of the eye that covers the iris,

pupil, and anterior chamber.
• Together with the sclera it makes the Tunica Fibrosa.

• It’s a transparent, avascular,

convex structure with 0.5 mm
thickness and composed
of 5 layers.
• The limbus is the junction between the cornea and
the sclera .
• The irido-corneal angle is the acute angle between
the iris and the cornea at the periphery of the
anterior chamber of the eye.
Corneal Layers
 Corneal Layers
• The epithelium, an anterior non-keratinized squamous layer ,packed
cells for protection , thickened peripherally at the limbus where it
continues with the conjunctiva. The limbus houses its germinative cells.
• Bowman’s layer, ( anterior limiting layer) clear, tough, acellular layer.
• Corneal stroma, Composed of collagen fibrils, ground substance and
fibroblasts. The regular packing, small diameter and narrow separation
of the collagen fibrils account for corneal transparency.
• Descemet’s membrane, (posterior limiting layer)
It is homogenous and elastic layer . It is the basal
lamina of corneal endothelium.
• The endothelium, a monolayer of
non-regenerating cells which actively
pumps ions and water from the stroma
to control corneal hydration and transparency
contributes to corneal transparency .
• The difference between the regenerative capacity of the
epithelium and endothelium is important.

• Damage to the epithelial layer, by an abrasion for example, is

rapidly repaired.

• Damage to the endothelium, by disease or surgery, can NOT

be regenerated. Loss of its barrier and pumping functions
leads to overhydration, distortion of the regular packing of
collagen fibres; and so, corneal clouding.
 Functions of cornea
➢ Protection: It protects the internal ocular structures.
➢ Focusing: Together with the lens, it refracts and focuses
light onto the retina.
It accounts for approximately 2/3 of the eye's total refractive
power (which is 63 diopter) so the refractive power of the
cornea is ~ 43D.
Although the cornea contributes most of the eye's focusing
power cz it refracts between two different medias , its focus is
fixed.

while, the curvature of the lens, can be adjusted to tune the

focus depending on the object's distance (accommodation).
 Tear film
Liquid layer bathing the cornea and conjunctiva.
 Tear film
• The tear film is composed of 3 layers
(from anterior backward):
➢ Lipid layer : produced by the tarsal
meibomian glands, seals tear film
and prevents evaporation.
➢ Aqueous layer: produced by the
lacrimal gland.
➢ Mucous layer: produced by the
conjunctival goblet cells  adheres
well to the surface of the cornea by
their microvilli
The functions of the tear film:

• Protects and lubricates the eyes

• Keeps the surface of the eyes smooth and clear  imp for
refraction power .
• Washes away foreign particles from the ocular surface.
• Reduces the risk of eye infection, it has antibacterial
properties .
• it provides oxygen anteriorly to the avascular cornea.
 Nutrition of the cornea
• Since cornea is avascular, it receives nutrition supply
mainly from aqueous humor, which circulates through
the anterior chamber and bathes the posterior surface
of the cornea.
• The aqueous also supplies nutrients to the posterior
stroma, while the anterior stroma receives its oxygen
from the ambient air and diffused via tear film.
• Also the corneo-scleral junction (periphery) is rich of
limbal capillaries.
 Nerve Supply
• The cornea is one of the most sensitive tissues in the body, as it
is densely innervated with sensory nerve fibers via
the ophthalmic division of the trigeminal nerve (V1).

Corneal reflex is mediated by:

➢ Afferent: the nasociliary branch of the ophthalmic branch of
the trigeminal nerve, sensing the stimulus on the cornea.

➢ Efferent: the temporal and zygomatic branches of the 7th

cranial nerve (Facial nerve) initiating the motor response
(blinkimg) .
 Corneal disorders
• Dry eye disorders
• Infective corneal lesions:
➢ herpes simplex keratitis
➢ zoster opthalmaticus
➢ Fungal keratitis
➢ Acanthameba keratitis
➢ Bacterial keratitis

• Disorder of shape (Keratoconus).

• Corneal dystrophy.
• Corneal degeneration.
Dry eye syndrome
 Dry eye syndrome
- Also known as keratoconjunctivitis sicca.
1. Decreased tear film production (from lacrimal hyposecretion)
or
2. Hyper-evaporation (unhealthy lipid layer ‘thin’)
- It is the condition of having dry eyes.
- Can be associated with other symptoms ; irritation, redness,
discharge, itchiness, and easily fatigued eyes. Blurred vision
may also occur. Foreign body sensation
- Dry eye occurs when either the eye does not produce
enough tears or when the tears evaporate too quickly. As in:
Contact lenses, Meibomian gland
dysfunction, allergies, pregnancy, Sjogren's syndrome, vitamin A
deficiency, LASIK surgery, antihistamines, hormone replacement
therapy, antidepressants .
-Multifactorial disease

Risk factors

• Old age ( mostly due to hormonal changes in

menopause )
• Female gender
• Connective tissue diseases , EX rheumatoid arthritis
• DM
• Antidepressants , antihistamines
• LASIK , PRK surgery
• Allergies
• Meibomian gland dysfunction
Diagnosis
• History ,
• assess Tear film ,
• fluorescein dye  in normal eye , it should
break after 10s , if before the pt has dry eye
Treatment is by treating the underlying
cause if found .
  - avoidance of exacerbating factors, tear
stimulation and supplementation (artificial
tears), increasing tear retention (lacrimal
plugs), and eyelid cleansing and treatment of
eye inflammation.

If left untreated it results in thickening of the

corneal surface ,
• corneal erosion
• corneal ulceration (sterile and infected)
• corneal perforation
• corneal scarring,
• corneal neovascularization
• corneal thinning.
 Herpes simplex virus keratitis
•HSV1 : common viral cause of ocular diseases.
•HSV2: which causes genital disease may occasionally cause
keratitis .
•Primary infection by HSV1 is usually acquired early in life
by close contact such as kissing the baby.
•Then, It enters a latent period in the trigeminal ganglion.

•Recurrent infection results from activation of the virus in the

ganglion by several factors :
- psychiatric diseases
- systemic illnesses
- immunocompromised patients
 Clinical manifestations
Primary infection is asymptomatic in most cases , although it can
be accompanied by:
• fever
• vesicular lid lesions
• follicular conjunctivitis
• pre - auricular lymphadenopathy
● Recurrent infection is characterized by the appearance of Dendritic ulcers
(characteristic) on the cornea which usually heal without a scar  the
florescence will attach to the abrasion on the surface of the cornea .

● If the stroma is involved, edema develops causing loss of corneal

transparency. And may lead to permanent scarring.
● Uveitis and glaucoma may accompany the disease
● Treatment  topical antiviral
The cornea may not be involved although Punctate epithelial damage / has high deferential diagnosis “
dryness , allergy , foreign body”

may be seen, and manifested by ACUTE:

-redness
-foreign body sensation
-burning
-slightly decreased vision.
-Lacrimation
-Photophobia

In history , the patient might admit a previous attack

 Disciform keratitis
• It is an immunogenic reaction to herpes antigen in
the stroma  new reaction not activation of the
virus
• Inflammation of the endothelial layer  defect in
this layer  water will accumulate in the cornea
• Presents as stromal clouding without ulceration .
• Often associated with iritis.
 Treatment
• Superficial Punctate Keratitis : treated supportively.
• Dendritic lesions: are treated with topical antivirals which
typically heal within 2 weeks. For ex. Acyclovir .
• Topical steroids must NOT be given to patients with a
dendritic ulcer since they may cause extensive corneal
ulceration.
• In patients with stromal involvement (Disciform keratitis):
topical steroids are used under ophthalmic supervision and
with antiviral cover (cz to prevent reactication , steroids can
activate the virus).
• If corneal scarring is severe: a corneal graft may be required
to restore vision.
 Herpes zoster ophthalmicus
(ophthalmic shingles)
• Caused by the varicella-zoster virus (chickenpox).
• The ophthalmic division of the trigeminal nerve is affected.
• Increase with aging (elderly)
• Unlike herpes simplex infection, there is usually a prodromal period.
• Ocular manifestations are usually preceded by the appearance of
vesicles in the distribution of the ophthalmic division of the trigeminal
nerve.
• Ocular problems are more likely if the naso-ciliary branch of the
nerve is involved (vesicles at the root of the nose).
– The infection might be affecting the cornea and inside the eye 
pt with this distribution should be referred to ophthalmologist to
exclude ocular involvement (ophthalmic shingles)
 Clinical Manifestations
• Tingling of the forehead may occur
before any other symptoms (called a
prodrome).
• The skin of the forehead and
sometimes the tip of the nose are
covered with small, extremely painful,
red blisters.
• Keratitis, iritis and uveitis.
• Glaucoma.
• Infection of the eye causes ache,
redness, light sensitivity, and eyelid
swelling.
 Continue..
Hutchinson’s Sign:
Vesicles on the tip of the nose, or
vesicles on the side of the nose,
precedes the development of
ophthalmic herpes zoster. Indicates
the involvement of  nasocilliary
branch of the trigeminal nerve.
“High incidence of intraocular
manifestations”.
 Treatment
• Systemic Antiviral drugs taken by mouth
(acyclovir, valacyclovir, or famciclovir); can reduce the duration
of the painful rash, reduces the risk of eye complications.
• Corticosteroid eye drops if the eye is inflamed.
• Eye drops to keep the pupil dilated such as atropine; to help
prevent a severe form of glaucoma, and to relieve pain.
• Antibacterial may be required to cover secondary infection .
 Fungal Keratitis
• Most common causative pathogens:
- Filamentous(aspergillus) fungi.
- Candida albicans.

• It should be considered in:

-lack of response to antibacterial therapy in corneal ulceration.
-cases of trauma with vegetable matter
-cases associated with the prolonged use of steroids.

• The corneal opacity appears fluffy and satellite lesions may be

present.
 Signs same as bacteria

• Filamentous keratitis:
gray-white fluffy borders.
It may be difficult to
differentiate from other
eye infections.

• Candidal keratitis:
yellow-white dense
infiltration .
Severe fungal keratitis involving the limbus
 Management & Progression
• Treatment requires topical antifungal drops such as
pimaricin (natamycin) 5%.
• Progression is much slower & less painful than in
bacterial.
 Acanthamoeba keratitis
History of pt used tap water to clean his lenses
 Bacterial keratitis
Bacterial keratitis is a bacterial infection of the cornea. usually
develops quickly. if Left untreated it can cause blindness.

Some of the bacteria responsible for the infection :

➢ Staphylococcus epidermidis
➢ Staphylococcus aureus
➢ pseudomonas aeruginosa
➢ Streptococcus pneumonia
➢ Coliforms
➢ Haemophilus
 Protection against infections
The cornea & conjunctiva are protected against infections by:

• blinking

• washing away of debris by the flow of tears

• entrapment of foreign particles by mucus

• the antibacterial properties of the tears

• the barrier function of the corneal epithelium

*(Neisseria gonorrhoeae is one of the microorganism that can penetrate

the intact epithelium).
 Predisposing factors
✓ Contact lens wear : a very important predisposing factor for bacterial
keratitis >> (pseudomonas)

✓ Kerato-conjunctivitis sicca (dry eye).

✓ A breach in the corneal epithelium e.g. following surgery or trauma.

✓ Prolonged use of topical steroids.

✓ Steroids

✓ Decrease immunologic defense.

 Signs and Symptoms
• severe pain of rapid onset (acute) / highly enervated .
• Conjunctival injection.
• Cilliary (limbal) injection.
• Purulent discharge.
• Hypopyon (anterior chamber reaction; accumulation of leukocytes in
the anterior chamber).
• white corneal opacity (ulcer) which can often be seen with the naked
eye.
• visual impairment (severe if the visual axis is involved).
Hypopyon

Corneal ulcer / has depth

ciliary injection
 Complications

• Corneal scar.
• Vision loss / corneal scaring .
• Thinning of cornea.
• Corneal perforation.
• Irregular astigmatism
(uneven healing ulcer)
• Endophthalmitis.
 Management
❖ Corneal Scrapings/swap are taken for Gram staining and culture.
❖ topical broad-spectrum antibiotics often dual therapy to cover most
organisms (e.g. cefuroxime against Gram positive bacteria and gentamicin
for Gram negative bacteria). Given as eye drops  adjust
❖ The use of fluoroquinolones (e.g. ciprofloxacin) as a monotherapy.
❖ In severe or unresponsive disease the cornea may get perforated. This
can be treated initially with tissue adhesives (cyanoacrylate glue) and a
subsequent corneal graft.
❖ Persistent scar may require a corneal graft to restore vision.

❖ Remember the 5 A`s;

Antibiotic, Atropine, Analgesics, Anti-glaucoma
medications, and Vitamin A.
Keratoconus
 Keratoconus
Normally, the cornea has a dome shape, like a ball. however,
the structure of the cornea is not strong enough to hold this
round shape and the cornea bulges outward and downward
like a cone. This condition is called keratoconus.
Disease of young age / puberty

Progressive thinning of the corneal center

Pathophysiology:  multifactorial
-progressive dissolution of Bowman's layer, which lies
between the corneal epithelium and stroma. As the
two come into contact, cellular and structural changes
in the cornea adversely affect its integrity and lead to
the bulging.
-corneas show signs of increased activity by proteases, a
class of enzymes that break some of the collagen cross-
linkages in the stroma, with a simultaneous
reduced expression of protease inhibitors

Whatever the process is, the damage caused by activity

within the cornea likely results in a reduction in it`s
thickness and biomechanical strength. the weakening
of the corneal tissue is associated with a disruption of
the regular arrangement of the collagen layers and
collagen fibril orientation which causes BULGING.
Signs and symptoms: progressive painless vision loss
the symptoms of keratoconus may be no different
from those of any other refractive defect of the eye.
 Can be subclinical / diagnosed by screening “family
history”
-vision deteriorates as the disease progresses
“myopia”  increase in the curvature .
-Astigmatism.
-Photophobia.
-eye straining.
-NO PAIN.
Fleischer's ring a ring of yellow-brown to
olive-green pigmentation caused by
deposition of the iron
oxide hemosiderin within the corneal
epithelium.

Munson's sign highly pronounced cone can

create a V-shaped indentation in the
lower eyelid when the person's gaze is directed
downwards

Vogt's striae fine stress lines within

the cornea caused by stretching
and thinning. temporarily
disappear while slight pressure is
applied to the eyeball
oil droplet sign in
keratoconus , is
characteristic , seen in red
reflex
 Kayser-Fleischer rings ??
Diagnosis:

Corneal topography is a non-

invasive medical imaging technique for
mapping the surface curvature of
the cornea and creates a colored
“map” of it. Keratoconus causes very
distinctive changes in the appearance
of these maps.
 Continue..
Corneal pachymetry process of
measuring the thickness of
the cornea at a single point by
a pachymeter.
 Treatment
Keratoconus will stabilize between the age 30-40

Non-surgical:
-Lenses “glasses or rigid contact lenses”  to improve the
vision

Surgical:
- Cross-linking: collagen cross-linking is a developing treatment
which aims to strengthen the cornea , mild to moderate 
to stop the progression , it won't make the vision better
- Corneal graft: in advanced cases
 Corneal dystrophy
Genetic disease  affect any layer of the cornea  affect the
celerity of the cornea  affect the vision
One of the indications of corneal graft

Corneal dystroph
(granular dystrophy)
 Corneal degeneration
1. Central corneal degenerations
- Band keratopathy

2. Peripheral corneal degenerations

- Corneal thinning
-Lipid arcus / arcus senilis
– Normal in old aged people
– If found in young you should check for lipid diseases
– NO NEED FOR INTERVENTION / no effect on vision
Band keratopathy

• Is the subepithelial deposition of calcium phosphate in the

exposed part of the cornea .
• Come with blurred vision and foreign body sensation
• It is seen in eyes with chronic uveitis or glaucoma , and may cause
visual loss or discomfort if epithelial erosions form over the band.
• The cause can be systemic “elevation of Ca++” :
hyperparathyroidism , multiple myeloma

• - can be scraped surgically –excimer laser

- can be a sign of systemic hypercalcemia
• As long as the cause is present it can recur
 Corneal thinning
The peripheral corneal thinning is associated with degenerative,
autoimmune, or infective causes.

And can subsequently affect the visual acuity.

 Lipid arcus
• This is a peripheral white ring shaped lipid deposit, separated
from the limbus by a clear interval.
• It is often seen in normal, elderly people ( Arcus senilis )
• but in younger patients, under 50 years, it may be a sign of
hyperlipidemia.
• It does NOT affect vision and NO treatment is required.
 Keratoplasty
Corneal transplantation, also known as corneal grafting, is a surgical procedure where a
damaged or diseased cornea is replaced by donated corneal tissue (the graft).
When the entire cornea “full thikness” is replaced it is known as penetrating keratoplasty and
when only part of the cornea is replaced it is known as lamellar keratoplasty.

Indications
• Scared cornea
• Advanced keratoconus  end with scar
• Corneal perforation
• Corneal dystrophies
• Sever corneal keratitis that can't be controlled
Aims to
-To improve visual acuity by replacing the opaque or distorted
host tissue by clear healthy donor tissue
-To preserve corneal anatomy and integrity in patients with
stromal thinning, or to reconstruct the anatomy of the eye.
-To remove inflamed corneal tissue unresponsive to treatment
by antibiotics or anti-virals.
Complication
• Graft rejection
• Infection
• bleeding
• Cataract
• Macular edema
 REFRACTIVE SURGERY
• refractive surgery is a method for correcting or
improving your vision.
• There are various surgical procedures for correcting
or adjusting your eye's focusing ability by reshaping
the cornea, or clear, round dome at the front of
your eye.
• Other procedures involve implanting a lens inside
your eye.
• The most widely performed type of refractive
surgery is LASIK (laser-assisted in situ
keratomileusis), where a laser is used to reshape
the cornea.
Indications.
-myopia.
-hyperopia.
-astigmatism.
-age related changes “presbyopia”.
Note:
Keratoconus is an absolute contraindication for
refractive surgery.
Complications
-dry eyes.
-undercorrection/overcorrection.
-glare, halos, double vision.
- Astigmatism.
-flap problem.