Cornea

The cornea is a remarkable structure; it has a high degree of transparency and excellent selfprotective and reparative properties. The cornea consists of the following histologic layers
(Fig 8-1):
epithelium with basement membrane
Bowman layer
stroma (or substantia propria)
Descemet membrane
endothelium
The human cornea has a rich afferent innervation. The long posterior ciliary nerves (branches
of V1, the ophthalmic division of cranial nerve V) penetrate the cornea in 3 planes: scleral,
episcleral, and conjunctival. Peripherally, approximately 70-80 branches of the long posterior
ciliary nerves enter the cornea and lose their myelin sheath 1-2 mm from the limbus.

Figure 8-1 Diagram of different layers of the cornea. (Reproduced with permission
from Kanski JJ Clin ica l Ophthalmology: A Systematic Approach. 3rd ed. Oxford
Butterworth-Heinemann; 1994: 100.)
A plexus posterior to the Bowman layer sends branches anteriorly into the epithelium.
Oxygen to the cornea is provided by the preocular tear film, eyelid vasculature, and aqueous
humor. The primary metabolic substrate for the epithelial cells, stromal keratocytes, and
endothelium is glucose. The stroma receives glucose primarily from the aqueous humor by
carrier-mediated transport through the endothelium; the epithelium receives glucose by
passive diffusion through the stroma. The preocular tear film and limbal vessels supply
approximately 10% of the glucose used by the cornea. Glucose is metabolized in the cornea
by all 3 metabolic pathways:
1. tricarboxylic acid (TCA) cycle
2. anaerobic glycolysis
3. hexose monophosphate (HMP) shunt
In the epithelium and endothelium, the HMP pathway breaks down 35%- 65% of the glucose,
but the keratocytes of the stroma metabolize very little glucose via this pathway. The
keratocytes appear to lack 6-phosphogluconate dehydrogenase, an important enzyme in the
HMP pathway. The TCA cycle is much more active in the endothelium than in the
epithelium. Pyruvic acid, the end product of glycolysis, is converted either to carbon dioxide

and water (via the TCA cycle under aerobic conditions) or to lactic acid (under anaerobic
conditions). Production oflactic acid increases in conditions of oxygen deprivation, as in the
case of tight-fitting contact lenses oflow oxygen permeability. Accumulation of lactic acid in
the cornea has detrimental consequences to vision, such as edema (due to an increase in an
osmotic solute load) or stromal acidosis, which can change endothelial morphology and
function.
Human corneas possess a remarkably high level of aldehyde dehydrogenase and
transketolase. Together, these 2 proteins constitute 40%-50% of the soluble proteins in
corneal stroma. Like enzyme crystallins of the lens, both aldehyde dehydrogenase and
transketolase are thought to contribute to the optical properties of the cornea. Both proteins
are also thought to protect corneal cells against free radicals and oxidative damage by
absorbing UVB irradiation.

Epithelium
The epithelium is typically approximately 50 flm thick and constitutes 5%- 10% of total
corneal thickness. It is composed of 4-6 layers, which include 1-2 layers of superficial
squamous cells, 2-3 layers of broad wing cells, and the innermost layer of the columnar basal
cells. Surface projections (microvilli and microplicae) are present on the apical surface of the
most superficial cell layer of epithelium. These projections are coated with filamentous
material known as glycocalyx. Mucin glycoproteins, the major constituents of glycocalyx, are
thought to promote both stability of the tear film and wettability of the corneal surface.
Plasma membrane proteins and the lipids of corneal epithelial cells, like those of other cell
types, are heavily glycosylated and play an important role in cell-cell adhesion as well as in
adhesion of the basal cells of the corneal epithelium to the underlying basement membrane.
The sugar residues of the plasma membrane glycoproteins and the glycolipids of corneal
epithelium also play a role in wound-healing mechanisms; they do so by mediating corneal
epithelial sheet migration over the wound surface following ocular injury. They also have a
role in pathogenesis of corneal infection by serving as attachment sites for microbes.
Hydrophilic molecules penetrate the epithelium poorly, but they may pass through
intercellular tight junctions if the polar molecule is less than 500 daltons in apparent
molecular mass. Knowing the ionic dissociation constant of a molecule is important for
determining its permeability across the cornea. To diffuse across the epithelium, organic
molecules should exist in an uncharged state. However, a charged molecule more readily
penetrates the stroma. Therefore, to penetrate the cornea and enter the anterior chamber, an
organic molecule should be able to dissociate at physiologic pH and temperature (ie, within
the stroma).
Bowman Layer
The Bowman layer, or Bowman membrane, is immediately posterior to the epithelial basal
lamina. This layer is 8- 12 ~m thick and is composed of randomly packed type I and type V
collagen fibers that are 30 nm in diameter. The fibers are enmeshed in a matrix consisting of
proteoglycans and glycoproteins. The Bowman layer is secreted during embryogenesis by the
anterior stromal keratocytes and epithelium. It is acellular, and it does not regenerate when
damaged. It is thought that this layer, by virtue of its acellularity and packing distribution,
serves to prevent exposure of stromal corneal keratocytes to growth factors secreted by
epithelial cells, such as transforming growth factor ~s (TGF-~s). This effect is notable
because, during excimer laser surgery (photorefractive keratectomy [PRK] or laser
subepithelial keratomileusis [LASEK]), the Bowman layer along with anterior corneal
stromal tissue is removed. In these procedures, corneal haze is a potentially significant

postoperative visual complication, presumably because stromal keratocytes are exposed to

regenerating epithelial growth factors and take on fibroblastic behaviors. On the other hand,
in laser in situ keratomileusis (LASIK), the Bowman layer is transected but still retained, and
thus central corneal haze is extremely rare.
Stroma
The stroma makes up 90% of the corneal thickness. Stromal cells are known as keratocytes.
There is loss of keratocyte density with age; therefore, depending on age, keratocytes
constitute 10%-40% of corneal volume. Usually, these cells reside between the collagen
lamellae. The stroma is made up of roughly 200 layers oflamellae, which are 1.5-2.5 ~m thick
and composed of collagen fibrils enmeshed in a matrix consisting of proteoglycans, proteins,
and glycoproteins. The stromal fibrils within each lamella are narrow and uniform in
diameter. In humans, the average fibril diameter is 30 nm.
Collagen fibrils within each lamella run parallel to each other from limbus to limbus.
Adjacent lamellae are positioned at roughly right angles to each other: less than 90 in the
anterior stroma but almost 90 in the posterior stroma. That is, alternate arrays of fibrils are
nearly perpendicular, and they are observed tangentially in electron micrographs of cross
sections of corneal stroma. Also, collagen fibrils in each lamella are regularly spaced, with a
center-to-center distance of 55-60 nm. The narrow and uniform diameter of collagen fibrils
and their regular arrangement are characteristic of collagen of the corneal stroma and are
necessary for the transparency of this tissue. Type I is the major collagen component of the
corneal stroma; it constitutes approximately 70% of the total stromal dry weight.
Immunohistochemical and biochemical studies have demonstrated that normal adult corneal
stroma also contains collagen types V, VI, VII, XII, and XIV Type III collagen production is
associated uniquely with stromal wound healing.
After collagen, proteoglycans are the second most abundant biological constituents of the
cornea; they constitute approximately 10% of the dry weight of the cornea. It is the
proteoglycans that confer hydrophilic properties to the stroma. Proteoglycans are
glycosylated proteins with at least 1 glycosaminoglycan (GAG) chain covalently bound to the
protein core. GAGs are composed of repeating disaccharides. The GAGs found in corneal
stroma include
keratan sulfate
chondroitin sulfate
dermatan sulfate
Two major proteoglycan populations have been identified in corneal stroma, one containing
keratan sulfate chains and the other containing both dermatan sulfate and chondroitin sulfate
chains. Regulation of spacing between the stromal collagen fibrils is thought to result from
highly specific interactions between the proteoglycans and the collagen fibrils. When these
interactions are disturbed, the ability of the cornea to remain transparent is profoundly
affected.
Matrix metalloproteinases (MMPs) are a family of Zn2+ -dependent enzymes responsible for
degradation of the components of the extracellular matrix (including proteoglycans and
various types of collagens) during normal development as well as in disease processes. Of
more than a dozen known metalloproteinases, only MMP-2 proenzyme has been found in the
normal healthy cornea. However, after corneal injury, additional MMPs (including MMP-1,
MMP-3, and MlV1P-9) are synthesized. The proteinase inhibitors of the cornea play a key
role in corneal protection by restricting damage during corneal inflammation, ulceration, and
wound healing. The following proteinase inhibitors have thus far been identified in the
cornea:
a 1-proteinase inhibitor

 a 1-antichymotrypsin
a 2-macroglobulin
plasminogen activator inhibitors 1 and 2
tissue inhibitors of metalloproteinases
Many of these inhibitors are synthesized by resident cells of the cornea; some are derived
from tears, aqueous humor, and limbal blood vessels.
Descemet Membrane and Endothelium
The Descemet membrane is a specialized basement membrane, 10-12 flm thick, present
between the endothelium and the posterior stroma. It is secreted by endothelium and
comprises an anterior banded portion and a posterior nonbanded portion. Type I T is the most
abundant collagen in the Descemet membrane.
The corneal endothelium is a single layer posterior to the Descemet membrane and is
composed of polygonal cells 20 flm in diameter. In young adults, the normal endothelial cell
count is approximately 3000/mm2. The number of endothelial cells decreases with age, and
there is a concomitant spreading and thinning of the remaining cells. A group of tight
junctions forms the apical junctional complex between cells that occludes the lateral
extracellular spaces from the aqueous humor. Approximately 20-30 short microvilli per cell
extend from the apical plasma membrane into the aqueous humor. The endothelium functions
as a permeability barrier between the aqueous humor and the corneal stroma and as a pump to
maintain the cornea in a dehydrated state by generating the negative hydrostatic pressure that
also serves to hold free corneal flaps ( eg, LASIK flaps) in place. In vivo, the endothelium
derives sufficient oxygen from the aqueous humor to maintain normal pump function.
If the endothelium is injured, healing occurs mainly via cell migration, rearrangement, and
enlargement of the residual cells. Substantial cell loss or damage results in irreversible edema
because human corneal endothelial cells haw a limited ability to divide after birth. Infiltration
of polymorphonuclear leukocytes in response to severe corneal injury induces endothelial
cells to become fibroblastic and to synthesize retrocorneal fibrous membrane (RCFM).
RCFM forms between the Descemet membrane and the corneal endothelium and causes a
significant decrease in visual acuity. Unlike normal corneal endothelial cells, which
accumulate little type I collagen protein, the fibroblastic cells isolated from the RCFM
predominantly express type I collagen.