corneaesh.gov.sy/publicfiles/file/cornea course/anatomy... · 2019. 9. 4. · of cornea •sugar...
TRANSCRIPT
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cornea
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Anatomy , physiology, corneal breaks and emergencies
By MAIS IBRAHIM M.D
SYPERVISED BY RASHA GAZALI M.D
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Anatomy
• Vertical diameter : 12 mm
• Horizontal diameter : 11 mm
• Radius of curvature : ant, 7.8mm – post, 6.5mm
• Thickness : 1mm peripherally – 0.5 mm centrally
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Anatomy
• Five layers :
• 1- Epithelium
• 2-Bowman
• 3- Stroma
• 4-Descemet Membrane
• 5-Endothelium
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anatomy
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Epithelium
• 50 micro m (5-10% )
• 1- basement membrane
• 2- columnar basal cells (single layer)
• 3-wing cells (2 to 3 layers )
• 4- surface cells
• Stem cells at the limb
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Epithelium
• Superficial cells : microvilli and microplicae
coated with “glycocalyx”
• Glycoprotein : stability of tear film and wetting of cornea
• Sugar residues of plasma membrane glycoprotein and glycolipids : wound healing ,attachment of microbes
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Epithelium
• Penetrating the epithelium : uncharged molecules
• Penetrating stroma : charged
• It should be able to dissociate at physiologic PH and temperature (biphasic)
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Bowman layer
• Collagen fibers type I and type V
• 8-10 micro m
• Acellular and packed distribution ; prevent keratocytes from growth factor
• PRK and LASEK ; corneal haze
• Can not regenerate
• Scar tissue after injury
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PRK
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LASIK flap
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Stroma
• 90% of the cornea
• 1- keratocytes (2.4 millions)
• 2- ground substances ( proteoglycans)
• 3- collagen lamellae
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Stroma
• Collagen fibers ; center to center
• Collagen type I ; 70% of stroma
• Type III ; wound healing
• Type V , VI , VII , XII , XIV
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PROTEOGLYCANS
• 10%
• Hydrophilic properties
• 1-keratan sulfate 60%
• 2-chondroitin sulfate
• 3-dermatan sulfate 40%
• Regulation of spacing between collagen fibrils
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MMPs
• Degradation of the components of the extracellular matrix
• MMT-2 ; normal cornea
• MMT-1 , MMT-3 , MMT-9 after injuiry
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Descemet membrane
• True membrane
• 10-12 micro M
• Increases with age
• Secreted by endothelium
• Type IV is the most one
• Ending peripherally at shwalbe line
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Descemet membrane
• Anterior banded zone – posterior nonbanded zone
• Resistance to the flow of solvent
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Descemet defects
• 1- descemet folds
• 2-haab’s striae
• 3-vogt striae
• 4- hydrops
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Descemet folds
• Inflammation: infection
• Inflammation after surgery : normal or complicated surgery, retained lens fragments, RD, endo
• Inflammatory conditions: belpharitis, phlyctenulosis, episcleritis, scleritis
• Trauma , injury
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Descemet folds
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Haab’s striae
• In primary congenital glaucoma
• Breaks in descemet membrane
• Stretching of the cornea
• Horizontal in CG
• Vertical or oblique : descemet’s tears in birth trauma
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Haab’s striae
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Vogt striae
• Vertical
• Keratoconus
• Disappear with compression
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Vogt striae
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Vogt striae
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Corneal hydrops
• Acute onset of corneal edema
• Break in descemet membrane
• Advanced keratoconus
• Air or gas into AC may help recovery
• Scars, corneal flattening may occur
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Hydrops
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Endothelium
• Mono layer of polygonal/hexagonal cells
• 3000/mm
• Decreases with age 0.6% per year
• 500/mm === EDEMA
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Endothelium function
• 1- permeability barrier
• 2- pump to maintain dehydration state
• 3-negative hydrostatic pressure
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After injuries
• Endothelium cells become fibroblastic
• Synthesize retrocorneal fibrous membrane (RCFM )
• Decrease in VA
• Express type I
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RCFM
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Dua’s layer
• 15 micro m
• Strong and impervious to air
• Type II air bubbles
• Optical and electron microscopy
• May improve outcomes for patients will have grafts and transplants
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CORNEAL INNERVATION
• Long posterior cilliary nerves (branches of V1 the ophthalmic division of cranial nerve V)
• Cold and pain
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CORNEAL NERVES
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Corneal nerves
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CORNEAL NUTRITION
• Oxygen : tear film, eyelid vasculature, AH
• Glucose :
Stroma; AH , carrier mediated transport through the endothelium
Epithelium; tear film and limbal blood vessels
Endothelium ; AH
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Corneal nutrition
• Glucose metabolized :
• 1-tricarboxylic acid (TCA) cycle
• 2-anaerobic glycolysis
• 3-hexose monophosphate (HMP) shunt
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• Epithelium and endothelium : HMP (35-65)%
• Keratocytes : little glucose via this way cuz they lack 6-phosphogluconate dehydrogenase
• Endothelium : TCA more than epithelium
• Pyruvic acid : TCA ; aerobic
• Lactic acid : anaerobic .. Accumulation ; edema; affect VA (contact lenses)
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Emergences
• Chemical burns
• Trauma
• Foreign body
• Corneal erosions
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Chemical burns
• Alkali, acid, alcohol .
• Alkali worse ; increased penetrating
• First aid: irrigation
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Chemical burns - signs
• Epithelial defect
• Cloudy cornea
• Conj. Hyperaemia
• Caution : if cornea limbus is blanched
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Chemical burns
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Chemical burns
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Chemical burns-after recuvery
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Chemical burns-management
• Irrigation
• Topical antibiotics, steroids, citrate and ascorbate ( buffer alkali and inhibit proteinase enzymes, support new collagen from keratocytes)
• vitamins A
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Trauma
• Laceration, perforation
• Full thickness , urgent surgery
• SEIDEL TEST
• No drops
• History, ct
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Corneal foreign body
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Foreign body removing
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FB after recovery
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Corneal abrasion/erosions/welding flash burn
• Large or small
• Chloramphenicol
• Contact lenses ?
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Flashing weld burns
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Erosions
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