2

Anterior Eye
JOHN G LAWRENSON

cornea is conventionally divided into four zones (central, para-

Introduction
A critical aspect of contact lens practice is monitoring the
ocular response to lens wear, which ranges from acceptable
physiological changes to adverse pathology. In order to do this,
practitioners must possess a thorough understanding of the
normal structure and function of the anterior eye, which is the
subject of this chapter. In the course of reading other chapters
in this book, the reader may need to refer back to this chapter
on the functional anatomy and physiology of the anterior eye
in order to develop a fuller understanding of the phenomena
being described.  mm (Doughty and Zaman, 2000), with a peripheral thickness
The Cornea
The cornea fulfils two important functions: together with the
sclera it forms a tough fibrous outer coat that encloses the
ocular tissues and protects the internal components of the
eye from injury. Significantly, the cornea also provides two-
thirds of the refractive power of the eye. It is particularly well
suited to its role: the cornea is curved and transparent, and the
air–tear interface provides a refractive surface of good optical
quality.
CORNEAL ANATOMY
Gross Anatomy
The cornea is elliptical when viewed from in front, with its long
axis in the horizontal meridian (Table 2.1). This asymmetry is
produced by a greater degree of overlap of the peripheral cornea
by opaque limbal tissue in the vertical meridian. The surface
area of the cornea is 1.1 cm2, which represents about 7% of the
surface area of the globe (Maurice, 1984). Topographically, the
central, peripheral and limbal). The central zone, which covers
the entrance pupil of the eye, is spherical, approximately 4 mm
wide, and principally determines high-resolution image for-
mation on the fovea. The paracentral zone, which lies outside
the central zone, is flatter and becomes optically important in
dim illumination when the pupil dilates. The peripheral zone
is where the cornea is flattest and most aspheric (Klyce et  al.,
1998). Due to a difference in curvature between its posterior
and anterior surfaces, the cornea shows a regional variation
in thickness. Centrally the thickness is approximately 0.54
between 11% and 19% higher than in the centre (Khoramnia
et al., 2007). 
Microscopic Anatomy
When the cornea is viewed in transverse section, five distinct
layers can be resolved: epithelium, Bowman’s layer, stroma, Des-
cemet’s membrane and endothelium (Fig. 2.1).
Epithelium. The epithelium represents approximately 10% of the
thickness of the cornea (55 μm) (Feng and Simpson, 2008). It is a
stratified squamous non-keratinized epithelium, consisting of 5–6
layers of cells (Fig. 2.2), which undergo a constant process of cyclic

TABLE Corneal Dimensions and Related

2.1 Measurements
Parameter Value
Area 1.1 cm2
Diameter
 Horizontal 11.8 mm
 Vertical 10.6 mm
Radius of curvature
  Anterior central 7.8 mm
  Posterior central 6.5 mm
Thickness
 Central 0.54 mm
 Peripheral 0.67 mm
Refractive index 1.376
Power 42 D Fig. 2.1  Transverse section through the cornea. The stroma, which
represents 90% of the thickness of the cornea, is bounded by the epi-
(Data adapted from Bron et al., 1997.) thelium (asterisk) and endothelium (arrow).
10

shedding and replacement to maintain corneal integrity. Three
distinct epithelial cell types are recognized: a single row of basal
cells, 2–3 rows of wing cells and 2–3 layers of superficial (squamous)
cells. In addition, several non-epithelial cells are present (e.g.
lymphocytes, macrophages and Langerhans cells). The epithelium
forms a permeability barrier to water, ions and hydrophilic
molecules above a certain size, as well as forming an effective
barrier to the entry of pathogens. Further epithelial specialization
enhances adhesion between cells, to withstand shearing and
abrasive forces. Furthermore, throughout the thickness of the
epithelium, adjacent cells are connected to one another by water
channels (aquaporins) that are engaged in transcellular water
transport and gap junctions to allow the transfer of ions and small
molecules between cells (Bron et al., 2015).
Superficial cells are structurally modified for their barrier
function and interaction with the tear film. Scanning elec-
tron microscopy of surface cells shows extensive finger-like
and ridge-like projections (microvilli and microplicae), which
increase the epithelial surface area. Light, medium and dark
cells can be distinguished depending on the number and pat-
tern of surface projections (Pfister, 1973). It has been sug-
gested that dark cells, which are relatively free of these surface
features, are close to being desquamated into the tear film. By
contrast, the newly arrived light cells possess a more extensive
array of surface projections. In high-power transmission elec-
tron micrographs, microvilli and microplicae show an extensive
filamentous covering known as the glycocalyx. The glycocalyx
is formed from membrane-bound mucin glycoproteins and is
important for spreading and attachment of the precorneal tear
film. In accordance with their barrier function, a complex net-
work of tight junctions links superficial cells that exclude water-
soluble dyes such as fluorescein (Bron et al., 2015).
Wing cells are so named because of their characteristic
shape, with lateral extensions and a concave inferior surface to
accommodate the apices of the basal cells. Their nuclei tend to
be spherical or elongated in the plane of the cornea. The cell
borders of the polygonal wing cells show prominent infoldings
that interdigitate with adjacent cells, and numerous desmo-
somes. This arrangement results in a strong intercellular adhe-
sion. The cytoplasm contains prominent cytoskeletal elements
(predominantly actin and cytokeratin intermediate filaments),
and although the usual complement of organelles is present they
are few in number.
%/
Fig. 2.2  Corneal epithelium (detail). Three cell types are present:
basal cells (asterisk), wing cells (arrowhead) and squamous cells (arrow).
BL = Bowman’s layer.
2  Anterior Eye 11
Basal cells consist of single-layer columnar cells with a verti-
cally oriented oval nucleus. Ultrastructurally, they are similar in
appearance to wing cells. The plasma membrane similarly shows
pronounced infolding and the cytoplasm contains prominent
intermediate filaments. A variety of cell junctions are present
including: desmosomes, which mediate adhesion between cells;
hemidesmosomes, which are involved in the attachment of basal
cells to the underlying stroma; and gap junctions, which allow for
intercellular metabolic coupling. Basal cells form the germative
layer of the cornea, and mitotic cells are often seen at this level. 
Basal Lamina and Bowman’s Layer. The basal lamina
(basement membrane) is synthesized by basal cells. It varies
in thickness between 0.5 and 1 μm, and under the electron
microscope can be differentiated into an anterior clear zone
(lamina lucida) and a posterior darker zone (lamina densa).
The basal lamina is part of a complex adhesion system, which
mediates the attachment of the epithelium to the underlying
stroma (Fig. 2.3). Hemidesmosomes link the cytoskeleton via a
series of anchoring fibrils to anchoring plaques in the anterior
stroma. The molecular components of this adhesion complex
have been identified and include type VII collagen, integrins,
laminin and bullous pemphigoid antigen (Gipson et al., 1987).
Bowman’s layer (anterior limiting membrane) varies in thick-
ness between 8 and 14 μm. With the light microscope it appears as
an acellular homogeneous zone. Ultrastructurally, it is composed
of a randomly oriented array of fine collagen fibrils, which merge
with the fibrils of the anterior stroma (Hogan et al., 1971). Fibrils
are composed primarily of collagen types I, III and V. Collagen VII,
associated with anchoring fibrils, is also present. There is evidence
that Bowman’s layer is formed and maintained primarily by the epi-
thelium, although its function is unclear. The absence of Bowman’s
layer from the cornea of most mammals, and the fact that corneas
devoid of this layer over the central cornea following photorefrac-
tive keratectomy (PRK) apparently function normally, suggest that
it is not critical to corneal integrity (Wilson and Hong, 2000). 
Stroma. The stroma is approximately 500 μm thick, and
accounts for 90% of the thickness of the cornea. It is composed
predominantly of collagen fibrils (70% dry weight) embedded in
a highly hydrated matrix of proteoglycans. A variety of collagen
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Fig. 2.3  Schematic representation of the adhesion system of the cor-
neal epithelium. Intermediate filaments in the cytoskeleton (CS) are
linked through hemidesmosomes (HD) via anchoring fibrils (AF) to an-
choring plaques (AP) in the anterior stroma. BL = basal lamina; D = des-
mosome.
12 PART 1  Introduction
Fig. 2.4  Section through the stroma. Keratocytes (arrowed) are locat-
ed between lamellae.
Fig. 2.5  Electron micrograph of stromal lamellae that cross each other
approximately at right angles. Note the regular arrangement of colla-
gen fibrils within lamellae.
types have been identified. Type I is the major fibril-forming
collagen, with lesser amounts of types III and V. Non-fibril-
forming collagens, including types VI and XII, are found in the
interfibrillar matrix (Meek and Boote, 2009). A section taken
perpendicular to the corneal surface reveals that the collagen
fibrils are arranged in 200–250 layers (lamellae) running parallel
to the surface (Fig. 2.4). Lamellae are approximately 2 μm thick
and 9–260 μm wide, and extend from limbus to limbus. Fibrils
of adjacent lamellae make large angles with each other. In the
superficial stroma the angles are less than 90°, but fibrils become
orthogonal in the deeper stroma (Hogan et al., 1971; Meek and
Boote, 2009). This preferred orthogonal orientation gradually
changes in favour of circumferentially aligned collagen at the
limbus. This particular arrangement of collagen imparts a high
tensile strength for corneal protection, which is important given
its exposed position. Within lamellae, all collagen fibrils are
parallel with uniform size and separation (Fig. 2.5). Accurate
Fig. 2.6  Flat section through the stroma stained with gold chloride.
Keratocytes (arrowed) display a stellate appearance.
physiological measurements of collagen fibre diameter and
spacing can be obtained for the hydrated cornea with the aid of
X-ray diffraction. Using this technique, the mean fibril diameter
in the human cornea is 31 nm, with an interfibrillar spacing of
55 nm (Meek and Leonard, 1993). This narrow fibril diameter
and constant separation, which is a characteristic of corneal
collagen, are necessary prerequisites for transparency.
The interfibrillar space contains a matrix of proteoglycans
(approximately 10% of dry weight). These molecules are highly
sulphated, and along with bound chloride ions create a polyan-
ionic stromal interfibrillar matrix that induces osmotic swelling.
As well as playing a major role in corneal hydration, collagen–
proteoglycan interactions are also thought to be important in
determining the size and spatial arrangement of stromal colla-
gen fibrils (Scott, 1991; Quantock and Young, 2008).
Collagen and proteoglycans are maintained by keratocytes.
These cells occupy 3–5% of stromal volume and lie between col-
lagen lamellae, flattened in the plane of the cornea (Fig. 2.6).
Keratocyte density examined by confocal microscopy and bio-
chemical methods (Møller-Pederson and Ehlers, 1995; Prydal
et al., 1998) is non-uniform. Density decreases from superficial
to deep stroma (Hollingsworth et al., 2001) and increases from
centre to periphery. Keratocytes display a large central nucleus
and long slender processes extend from the cell body. Processes
from adjacent cells sometimes make tight junctions with each
other. Cell organelles are not numerous but the usual comple-
ment of organelles, including endoplasmic reticulum, Golgi
apparatus and mitochondria, can be observed (Hogan et  al.,
1971).
Newer lamellar corneal transplantation techniques have
been developed that allow selective replacement of the diseased
corneal layers. Deep anterior lamellar keratoplasty (DALK),
which is increasingly being used to treat keratoconus and cor-
neal scarring, involves replacement of the affected stroma while
retaining the host’s healthy Descemet’s membrane and endo-
thelium. Separation between the posterior stroma and Des-
cemet’s / endothelium can be achieved by intrastromal injection
of air, viscoelastic or saline. Dua and co-workers performed a
histological examination of donor corneas using air bubble sep-
aration and claimed to have identified a novel ‘pre-Descemet’s
posterior stromal layer’, which was widely publicized (Dua et al.,
 2  Anterior Eye 13

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Fig. 2.7  High-powered micrograph of the posterior stroma. Des-

cemet’s membrane (DM) is located between the stroma (S) and the en-
dothelium (arrow).
Fig. 2.9  Tangential (flat) section through the corneal endothelium: a
single layer of polygonal cells with irregular borders can be observed.

N replace damaged or effete cells, there is a progressive reduction

V contains a total of approximately 500 000 cells, which represents
N
G
H progressively declines into old age. Since grafted corneas appear
Fig. 2.8  Three-dimensional representation of the posterior cornea
showing the endothelium (e), Descemet’s membrane (d) and stroma (s).
A stromal lamella has been reflected to reveal an intralamellar kerato-
cyte (k).
2013). However, the current consensus amongst corneal experts
is that this layer is not sufficiently unique to constitute a new
corneal layer (Jester et al., 2013).  cell loss. Under the electron microscope, the lateral borders of
Descemet’s Membrane. Descemet’s membrane is the basement
membrane of the corneal endothelium. It lies between the
endothelium and the overlying stroma (Fig. 2.7). At birth it is
3–4 μm thick, and increases to a thickness of 10–12 μm in the
adult. In the periphery of aged corneas, Descemet’s membrane
displays periodic sections of thickening, which are known as
Hassall–Henle warts. The anterior one-third of Descemet’s
membrane represents that part produced in fetal life and, under
the electron microscope, is characterized by a periodic banded
pattern (Fig. 2.8). The posterior two-thirds, which is formed
postnatally, has a more homogeneous granular appearance.
Descemet’s membrane has a unique biochemical composition
in contrast with other basement membranes (Lawrenson
et  al., 1998). The major basement membrane collagen type is
type IV, whereas in Descemet’s membrane type VIII collagen
predominates.  the trigeminal nerve (Ruskell and Lawrenson, 1994). There is
Endothelium. The endothelium is a monolayer of squamous
cells that lines the posterior surface of the cornea (Fig. 2.9)
and plays a critical role in maintaining corneal transparency
(Bonanno, 2012). As it has a limited capacity for mitosis to
in endothelial cell number with age. At birth the cornea
a mean density of 4500 cells / mm2. During infancy, cell loss
is particularly marked and a 26% reduction occurs in the first
year of life (Sherrard et  al., 1987). Thereafter the rate of loss
to maintain transparency and functional normality with an
endothelial cell density of less than 1000 cells / mm2, it seems
that normal cell density represents a considerable ‘physiological
reserve’ (Klyce and Beuerman, 1998). When viewed en face, for
example using a specular microscope, the endothelium appears
as a mosaic of polygonal (typically hexagonal) cells (Efron et al.,
2001). In response to pathology, trauma, age and prolonged
contact lens wear, the endothelial mosaic becomes less regular,
and shows a greater variation in cell size (polymegethism) and
shape (pleomorphism) as cells spread to fill gaps caused by
the cells are markedly convoluted and adjacent cells are linked
by tight junctions (with less-frequent gap junctions) (Hogan
et al., 1971). The complement of organelles seen in endothelial
cells reflects their high metabolic activity, with numerous
mitochondria and a prominent rough endoplasmic reticulum. 
CORNEAL INNERVATION
Source and Distribution of Corneal Nerves
The cornea is the most richly innervated surface tissue in
the body. Corneal nerves are responsible for the detection of
somatosensory stimuli and play an important role in initiating
the blink reflex, wound healing and tear secretion (see Sha-
heen et al., 2014, for a recent review). The majority of corneal
nerves are sensory and derive from the nasociliary branch of
also evidence for the existence of a modest sympathetic inner-
vation from the superior cervical ganglion (Marfurt and Ellis,
1993). Branches from the nasociliary nerve either pass directly
to the eye as long ciliary nerves or traverse the ciliary ganglion,
leaving it as short ciliary nerves that enter the eye close to the
14 PART 1  Introduction
Fig. 2.10  Whole-mount gold chloride-stained preparation of corneal
nerves (arrows) located at basal level.
optic nerve. Nerves destined for the cornea travel initially in
the suprachoroidal space, before crossing the sclera to advance
radially towards the cornea.
Most of the 50–80 precorneal nerve trunks, which contain
a mixture of myelinated and unmyelinated fibre bundles, enter
the cornea at mid-stromal level. Myelin is soon lost and the
unmyelinated nerve fibre bundles divide repeatedly and move
anteriorly to form a rich plexiform network in the anterior one-
third of the stroma. Axons are particularly dense immediately
beneath Bowman’s layer, forming an extensive subepithelial
plexus (Oliveira-Soto and Efron, 2001). From this plexus, axons
pass vertically through Bowman’s layer, losing their Schwann
cell sheath in the process. Upon entering the epithelium, axons
turn through 90° and divide into a series of fine branches that
course between basal cells (Fig. 2.10). Some branches pass into
the more superficial layers before terminating. The density of
nerve terminals is greatest centrally, corresponding to approxi-
mately 600 terminals / mm2, which results in large overlapping
receptive fields (Shaheen et al., 2014).
Corneal nerves display a complex neurochemistry. A variety
of neurotransmitters and neuromodulators have been identi-
fied, including acetylcholine, substance P, and calcitonin gene-
related peptide. However, it is unclear how these particular
neurochemicals correlate with function (Belmonte et al., 1997).  sion of the aqueous humour in the human eye lies between 30
Functional Considerations
Corneal nerves serve important sensory, reflex and trophic
functions. Interest in the sensitivity of the cornea dates back to
the 19th century (Lawrenson, 1997), when the pioneering Ger-
man physiologist von Frey concluded that pain was the only
sensation perceived by the cornea. This was consistent with his
theory of the specificity of sensory receptors, which maintained
that each sensory modality was subserved by a separate anatom-
ically distinct nerve terminal. In his experiments on the cornea,
von Frey could elicit only a sensation of pain and, as the cornea
contained exclusively free (unspecialized) nerve endings, he
concluded that free nerve endings were the exclusive receptors
for pain. Although the specificity theory has subsequently been
challenged, particularly with respect to its exclusivity, the ques-
tion as to whether pain is the only sensory modality perceived
by the cornea remains.
Modern experiments using carefully controlled corneal
stimulation, with a variety of mechanical, chemical and ther-
mal stimuli, have evoked only sensations of irritation or pain.
By contrast, electrophysiological studies of corneal afferent
neurones have identified neurones that respond to mechanical,
thermal and chemical stimulation. However, since the conscious
perception of these sensations has not been demonstrated, it
is likely that such specificity of modality is lost during central
nervous system processing. Electrophysiological recording also
allows for the mapping of receptive fields. These are often large
and overlapping, which explains the inability of the cornea to
localize a stimulus accurately (Belmonte et al., 1997). The sen-
sitivity of the cornea to mechanical stimulation is particularly
acute, and acts as a trigger for the protective blink and lacrimal
reflexes. Cold receptors may be important in signalling evapo-
rative cooling, which is a major determinant of spontaneous eye
blink frequency (Tsubota, 1998).
Corneal afferent fibres also exert important trophic influ-
ences. Damage to corneal sensory nerves by surgery, trauma or
infection produces neuroparalytic keratitis – a condition that is
characterized by progressive epithelial cell loss and oedema. The
mechanism of this trophic role is not fully understood, although
the release of neuropeptides (e.g. substance P and calcitonin
gene-related peptide) may be a factor. Sympathetic nerves also
play a role in epithelial maintenance by regulating ion transport
processes, and cell proliferation and migration during wound
healing. 
CORNEAL METABOLISM
Source of Oxygen and Nutrients
In order to perform its vital functions, the cornea requires a
constant supply of oxygen and other essential metabolites (e.g.
glucose, vitamins and amino acids). However, its avascularity
dictates that alternative routes must exist for the provision of its
metabolic needs. There are three possibilities: from the perilim-
bal vasculature, from the tear film or from the aqueous humour.
In open-eye conditions the bulk of the oxygen required for the
cornea is obtained from the atmosphere via diffusion across
the precorneal tear film. Under steady-state conditions it can
be assumed that the tears are saturated with oxygen, and there-
fore at an oxygen tension corresponding to the atmosphere (155
mmHg at sea level). It has been estimated that the oxygen ten-
and 40 mmHg (Klyce and Beuerman, 1998).
Experiments using nitrogen-filled goggles or sealed scleral
lenses have shown the corneal dependence on tear-side oxygen
to avoid oedema and maintain normal function. The reason
why the cornea swells during contact lens wear is explained in
Fig. 2.11. During eye closure the oxygen level in the tears is in
equilibrium with the palpebral vasculature (55 mmHg) (Efron
and Carney, 1979).
Significantly, corneal thickness increases by approximately
5% during sleep, and returns to baseline levels within 1 hour
of eye opening. It has been suggested that overnight swell-
ing is related to tear film tonicity rather than reduced oxygen

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Fig. 2.11  (A) Cross-section of an eye wearing a contact lens, which
impedes ingress of oxygen into, and the egress of carbon dioxide from,
the cornea. (B) The contact lens blocks oxygen supply to the cornea (1),
causing lactic acid to accumulate in the stroma (2). This draws in water
(3), leading to stromal oedema (4). (Adapted from Efron, N. (1997). Con-
tact lenses and corneal physiology. Biol. Sci. Rev., 9, 29–31.)
availability (Klyce and Beuerman, 1998). The oxygen flux into
the cornea can be measured using polarographic oxygen sen-
sors. It is in the region of 6 μl / cm2 / h for the cornea as a whole,
although the consumption rate for its composite layers is not
equal. Consumption rates have been estimated as 40 : 39 : 21 for
the epithelium, stroma and endothelium, respectively (Free-
man, 1972).
Several lines of evidence indicate that the aqueous humour is
the primary source of glucose and essential amino acids for the
cornea (Maurice, 1984). The glucose concentration of tears is
low compared with that in the aqueous humour, and the inser-
tion of nutrient-impermeable implants into the stroma results
in degeneration of the tissue lying anterior to the implant.
Although exogenous glucose is primarily utilized, glycogen
stores are present in all corneal cells to provide glucose in con-
ditions of metabolic stress.
The role of the perilimbal vasculature in the provision of
oxygen and nutrients appears limited and it is likely that it is
significant only for the corneal periphery (Maurice, 1984).  consequent loss of transparency. This raises two fundamental
Oxidative Metabolism
The cornea derives its energy principally from the oxidative
breakdown of carbohydrates (Riley, 1969). Glucose, which
is the primary substrate for the generation of adenosine tri-
phosphate (ATP), is catabolized by three metabolic pathways:
glycolysis, the tricarboxylic acid (Krebs) cycle and the hex-
ose monophosphate shunt (Fig. 2.12). Anaerobic glycolysis
accounts for the majority (85%) of glucose metabolism. In
this pathway, glucose is first oxidized to pyruvate and then
subsequently reduced to lactate, with a net yield of two mol-
ecules of ATP per mole of glucose. The TCA cycle results in
a greater energy yield (36 ATP). This pathway is most active
in the corneal endothelium, which has the greatest energy
requirement.
Metabolic waste products can be potentially damaging if
allowed to accumulate. Although carbon dioxide can readily
diffuse out of the cornea across its limiting layers, lactate is less
easily eliminated. Under normoxic conditions, lactate is able to
2  Anterior Eye 15
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Fig. 2.12  Metabolic pathways present in the cornea. HMP = hexose
monophosphate shunt; TCA cycle = tricarboxylic acid (Krebs) cycle;
ATP = adenosine triphosphate; NADPH = nicotinamide adenine dinucle-
otide phosphate (reduced form).
diffuse slowly across the endothelium into the anterior cham-
ber. However, during periods of hypoxia the proportion of glu-
cose that is metabolized anaerobically increases. The resulting
accumulation of lactate causes stromal oedema via an increased
osmotic load (Klyce, 1981) and localized tissue acidosis (Klyce
and Beuerman, 1998).
The hexose monophosphate shunt (also known as the pen-
tose phosphate shunt) plays an important role in the corneal
epithelium (Berman, 1981), where it fulfils several important
functions, including the generation of intermediates for biosyn-
thetic reactions and the prevention of oxidative damage by free
radicals. 
CORNEAL TRANSPARENCY
Under normal conditions the cornea is highly transparent,
transmitting more than 90% of incident light. Structurally, the
cornea is a typical connective tissue consisting principally of a
matrix of collagen and proteoglycans. Under normal circum-
stances such an arrangement would favour light scatter with
questions: how is transparency achieved, and how is it main-
tained? To begin to answer these questions it is necessary to
understand the spatial organization of the stromal matrix and
the importance of corneal hydration control.
Stromal Organization
Maurice (1957) explained the transparency of the cornea on the
basis of the small diameter and regular separation of the stro-
mal collagen. He suggested that the collagen fibrils of the stroma
were disposed in a regular crystalline lattice, and that light scat-
tered by the fibrils is eliminated by destructive interference in
all directions other than the forward direction. This situation
will hold as long as the axes of the collagen fibrils are arranged
in a regular lattice with a separation less than the wavelength of
light. It has been suggested, however, that the fibrillar arrange-
ment need not be in a perfect crystal lattice to maintain trans-
parency (Maurice, 1984), although disruption of short-range
order between fibrils will lead to increased scatter and a loss of
transparency.
16 PART 1  Introduction
The factors involved in the maintenance of collagen fibril size
and spatial order are not fully understood. It has been proposed
that collagen fibril diameters may be controlled by the incorpo-
ration of minor collagens (e.g. type V) into the predominantly
type I fibrils (Meek and Leonard, 1993) and that their spatial
separation is a function of proteoglycan–collagen interactions
(Scott, 1991). Proteoglycans are a family of glycoproteins that
consist of a protein core to which are attached sugar chains
of repeating disaccharide units termed glycosaminoglycans
(GAGs). These molecules are increasingly being recognized
as important prerequisites for transparency (Quantock and
Young, 2008; Hassell and Birk, 2010). Proteoglycans were origi-
nally classified according to their glycosaminoglycan composi-
tion; however, current nomenclature groups them into families
based on homologous sequences of amino acids in their protein
core. Corneal stromal proteoglycans are members of the small
leucine-rich family, which are small enough to fit in the space
between collagen fibrils. The most prevalent glycosaminoglycan
in the cornea is keratan sulphate, which is found in three types
of proteoglycan: lumican, keratocan and mimecan (Funder-
burgh et al., 1991; Funderburgh 2000). The other type of corneal
proteoglycan is decorin, which contains a hybrid chondroitin
sulphate / dermatan sulphate side chain. Evidence from several
sources has shown that lumican and decoran play important
roles in regulating collagen fibril diameter and maintaining the
spacing between fibrils once formed, which are essential for
transparency.  Na+ / H+ and Na+ / HCO3− transporters) is coupled to active
Hydration Control
The state of corneal hydration is another important determi-
nant of corneal transparency (Bonanno 2012). The hydrophilic
properties of the stroma are to a large part determined by pro-
teoglycans, which contribute to the fixed negative charge of the
stroma and produce a passive gel swelling pressure through
electrostatic repulsion (Hodson, 1997). Physiologically, corneal
hydration is maintained at approximately 78%. If the cornea is
allowed to swell ±5% of this value, it begins to scatter significant
quantities of light (Hodson, 1997).
Maintenance of physiological corneal hydration is to a large
part dependent on the corneal endothelium, which possesses
both a barrier property and a metabolically driven pump. The
endothelial barrier to the free passage of molecules from the
aqueous humour is formed principally by focal tight junctions
between adjacent endothelial cells. However, in contrast to
other barrier epithelia, these junctions are of low electrical resis-
tance and allow the passage of ions and small molecules. This
leak is offset by the metabolically driven pumping of ions out of
the stroma by the endothelium, which maintains a transcellular
potential difference (aqueous side negative) to balance stromal
swelling pressure (Maurice, 1984). Disruption of this osmotic
gradient will result in stromal fluid imbibition.
The specific endothelial ion transport mechanisms respon-
sible for the maintenance of physiological hydration are not
fully understood. A simplified model representing our cur-
rent level of knowledge is represented in Fig. 2.13. There is
compelling evidence that a flux of bicarbonate ions is the pre-
dominant component of the endothelial ion transport system
(Hodson and Miller, 1976). Subsequent studies have identified
that Cl− transporters may also be important in maintaining the
pump (Bonanno 2012). The bicarbonate is generated either
by a Na+ / HCO3− co-transporter located on the basolateral
plasma membrane or via the intercellular conversion of carbon
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Fig. 2.13  Schematic representation of the corneal endothelial pump.
CA = carbonic anhydrase; TJ = tight junction.
dioxide by the enzyme carbonic anhydrase. Bicarbonate leaves
the cell via an apical bicarbonate ion channel. The driving force
for the bicarbonate flux is generated by a sodium–potassium
ATPase that resides on the basolateral endothelial membrane.
The energy associated with subsequent sodium re-entry (via
HCO3− flux (Hodson et al., 1991).
The epithelium also contributes to corneal hydration con-
trol (Klyce and Beuerman, 1998). The tight junctions between
superficial epithelial cells form an effective permeability barrier
to ions and polar solutes. For example, the anionic molecule
sodium fluorescein does not penetrate an intact epithelium.
However, damage to the superficial cells allows fluorescein to
enter the epithelium, with resulting corneal staining. In addition
to its barrier properties, the epithelium also possesses active ion
transport systems for Na+ and Cl−. As these pumps contribute
to the tonicity of the tear film, it is likely that they are involved
in the maintenance of stromal hydration. 
Response to Oedema
When corneas swell, light scattering increases, with an ensued
transparency loss due to the disruption of the regular collagen
matrix. The collagen fibrils themselves swell very little and most
of the additional water goes into the interfibrillar spaces. Trans-
mission electron micrographs of oedematous corneas show
fibril aggregation, with the result that large areas are devoid of
collagen fibrils (Stiemke et al., 1995). There is evidence that col-
lagen aggregation occurs as a result of loss of GAGs, which pre-
viously had maintained fibre separation (Stiemke et al., 1995). 
CORNEAL EPITHELIAL WOUND HEALING
A smooth and intact corneal epithelium is necessary in order
for the cornea to maintain clear vision. However, due to its
exposed position the cornea is potentially vulnerable to a vari-
ety of external insults. It possesses several protective mecha-
nisms to avoid injury, but if tissue damage occurs it is capable
of an effective wound-healing response (Gipson and Inatomi,
1995; Nishida and Tanaka, 1996). Corneal epithelial repair is a
complex process involving an orchestrated interaction between
cells and extracellular matrix, which is coordinated by a variety

of growth factors. The process can be divided into three phases:
(1) initial covering of the denuded area by cell migration, (2)
cell proliferation to replace lost cells and (3) epithelial differen-
tiation to re-form the normal stratified epithelial architecture.
Following a full-thickness epithelial defect, fibronectin, an
adhesive glycoprotein, is synthesized and covers the surface of
the bared stroma where it serves as a temporary matrix for cell
migration. The adhesion between fibronectin and the epithe-
lium is mediated by integrin–matrix interactions (integrins are a
family of cell surface receptors that bind to certain extracellular
matrix proteins). Several growth factors have been implicated in
the control of the wound-healing response, including epidermal
growth factor, transforming growth factor beta, platelet-derived
growth factor and fibroblast growth factor (Gipson and Ina-
tomi, 1995). Growth factors, which are produced by a variety of
sources (e.g. ocular surface epithelia and the lacrimal gland), are
able to regulate the process of epithelial migration, proliferation
and differentiation. There is evidence that epithelial–stromal
interactions play an important role in corneal wound healing
(Wilson, 2000). Epithelial injury triggers keratocyte apoptosis
(programmed cell death) in the anterior stroma, via the release
of apoptosis-inducing cytokines from epithelial cells. Kerato-
cyte apoptosis subsequently triggers a wound-healing cascade,
which influences epithelial repair.
Regeneration of the corneal epithelium is highly dependent
on the integrity of the limbus (Lavker et al., 2004). Cumulative
evidence indicates that a proportion of limbal basal epithelial
cells possess the properties of stem cells, which are ultimately
responsible for corneal epithelial replacement. Stem cells have
several unique characteristics: they are poorly differentiated,
long lived and have a high capacity for self-renewal. When these
cells divide, one of the daughter cells replenishes the stem cell
pool, whilst the other is destined to undergo further cell divi-
sions before differentiating. Such a cell is referred to as a tran-
sient amplifying cell. Transient amplifying cells undergo several
rounds of cell division before fully differentiating. These cells
play an important role in epithelial wound healing, where their
proliferative capacity is increased by shortening cycle times and
increasing the number of times that the transient amplifying
cells can divide before maturation.  open onto the upper margin, and slightly fewer (20–40) onto
The Ocular Adnexa
The ocular adnexa are those structures that support and pro-
tect the eye, and include the eyelids, conjunctiva and lacrimal
system. They play an important role in the formation of the pre-
ocular tear film and collectively defend the eye against antigenic
challenge.
EYELIDS
The eyelids are two mobile folds of skin that perform several
important functions: they act as occluders that shield the eyes
from excessive light, and through their reflex closure they afford
protection against injury. The lids also form a precorneal tear
film of uniform thickness during the upturn phase of each
blink. The action of blinking is also important for tear drainage.
Gross Anatomy
The eyelids are joined at their extremities, termed ‘the canthi’,
and when the eye is open, an elliptical space, the palpebral fis-
sure, is formed between the lid margins. In the adult, the length
2  Anterior Eye 17
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Fig. 2.14  Surface anatomy of the eyelids. (Adapted from Bron, A. J.,
Tripathi, R. C. & Tripathi, B. (1997). Wolff’s Anatomy of the Eye and Orbit
(8th ed.). London: Chapman and Hall.)
of the fissure is approximately 30–31 mm, with a vertical height
of 10–11 mm. In the primary position, the upper lid, which is
the larger and more mobile of the two, typically covers approxi-
mately the upper third of the cornea, whilst the lower lid is level
with the inferior corneal limbus (Fig. 2.14). Important differ-
ences in eyelid anatomy exist between Asian and Caucasian eyes
(Saonanon, 2014). The most obvious feature of the Asian eye is
the absent or very low lid fold and fuller upper eyelid.
The eyelid margins are about 2 mm thick from front to back.
The posterior quarter consists of conjunctival mucosa and the
anterior three-quarters is skin. The junction between the two is
referred to as the mucocutaneous junction. There has recently
been a renewed interest in the marginal zone of the human eyelid,
with the identification of the role of the inner lid border, termed
the ‘lid-wiper’ owing to the analogy to a windscreen wiper, in
the distribution of the tear film (Knop et al., 2011a, 2012). Two
or three rows of eyelashes (cilia) arise from the anterior border
of the lid margins. These are longer and more numerous in the
upper lid. The lashes receive a rich sensory nerve supply, and
their sensitivity provides an effective alerting mechanism.
The meibomian (tarsal) gland orifices emerge just anterior
to the mucocutaneous junction (Fig. 2.15). About 30–40 glands
the lower. On eversion of the lids the yellowish meibomian
acini are visible as yellow clusters through the tarsal conjunc-
tiva (Bron et al., 1991; Knop et al., 2011b). Meibomian glands
can be more clearly visualized using infrared meibography, and
instruments that use this method are now commercially avail-
able (Srinivasan et  al., 2012) (Fig. 2.16). At the medial angle,
the eyelid margins enclose a triangular space – the lacus lacri-
malis – which contains the plica semilunaris and the caruncle.
Lacrimal papillae are small elevations located 5–6 mm from the
medial canthal angle, which contains a small aperture (punc-
tum) that is the opening to the lacrimal drainage system. 
Muscles of the Eyelids
Movements of the eyelids are governed by the coordinated
action of several muscles.
Orbicularis Oculi. The orbicularis oculi is the sphincter muscle
of the eyelids, and can anatomically be divided into two main
divisions: the palpebral and the orbital (Fig. 2.17). Fibres of the
palpebral division arise from the medial palpebral ligament
and arc across the eyelids in a series of half-ellipses, meeting at
the lateral canthus to form a lateral raphe. The lateral palpebral
18 PART 1  Introduction

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Fig. 2.17  Schematic representation of the divisions of the orbicularis

oculi and the frontalis. a = pretarsal; b = preseptal; c = orbital; d = fronta-
lis. (Adapted from Bron, A. J., Tripathi, R. C. & Tripathi, B. (1997). Wolff’s
Anatomy of the Eye and Orbit (8th ed.). London: Chapman and Hall.)

ligament also acts as an anchor point. The palpebral division

% parts. The marginal part (pars ciliaris), which is also known as
Fig. 2.15  (A) Schematic representation of the eyelid margin. mcj = mu-
cocutaneous junction. (B) Gross appearance of the eyelid margin.
Openings of the meibomian glands are clearly visible (arrow). (Adapted
from Bron, A. J., Tripathi, R. C. & Tripathi, B. (1997). Wolff’s Anatomy of
the Eye and Orbit (8th ed.). London: Chapman and Hall.)
can be further subdivided into marginal, pretarsal and preseptal
Riolans muscle, is responsible for maintaining the apposition
of the lid to the cornea during lid closure. A third part of the
muscle (pars lacrimalis) is closely associated with the lacrimal
outflow pathway. The pars lacrimalis (also known as Horner’s
muscle) encloses the canaliculi and provides attachments to the
lacrimal sac and its associated fascia.
The orbital part of the orbicularis oculi lies outside the palpe-
bral division and extends for some distance beyond the orbital
margins. Muscle fibres arise predominantly from bone at the
medial orbital rim and appear to sweep around the lids without
interruption as a series of complete ellipses. However, studies
have shown that the muscle fibres of the orbital and palpebral
division of the orbicularis are relatively short (0.4–2.1 mm) and
overlapping (Lander et al., 1996). The regional divisions of the
orbicularis also show a functional distinction. The action of the
palpebral part of the muscle is to produce the reflex or voluntary
closure of the lids during blinking. Contraction of the orbital
division produces the forcible closure of the lids that occurs in
sneezing or in response to a painful stimulus. 

Levator Palpebrae Superioris. The levator palpebrae superioris

is primarily responsible for elevating the upper lid during
blinking and for maintaining an open palpebral aperture. The
levator palpebrae arises from the lesser wing of the sphenoid,
above and anterior to the optic canal, and runs forward along
the roof of the orbit above the superior rectus before terminating
anteriorly in a fan-shaped tendon (aponeurosis). Some fibres
are attached to the anterior surface of the tarsal plate, whilst the
remainder pass between fascicles of the orbicularis (Fig. 2.18).
The superior palpebral sulcus forms at the upper border of the
attachment to the orbicularis. 

Superior and Inferior Tarsal Muscles (of Müller). These

Fig. 2.16  Normal meibomian glands of the upper tarsus (top) and low-
er tarsus (bottom) of a 38-year-old woman, imaged using non-invasive
infrared meibography. (Image courtesy of Reiko Arita.)
smooth muscles arise from the lower border of the levator in the
upper lid and the inferior rectus in the lower lid, and insert into
the orbital margins of the tarsal plates. The role of the superior
tarsal muscle is to assist the levator in maintaining the width
of the palpebral aperture. A mild degree of ptosis results from
damage to its sympathetic nerve supply (Horner’s syndrome). 

D
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WP
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Fig. 2.18  Diagram showing the relations of the levator palpebrae
superioris. a = levator aponeurosis; tm = superior tarsal muscle (of Mül-
ler); t = tarsal plate; s = orbital septum. (Adapted from Gray, H., Bannis-
ter, L. H., Berry, M. M. & Williams, P. L. (1995) Gray’s Anatomy: The Ana-
tomical Basis of Medicine and Surgery (38th ed.). Edinburgh: Churchill
Livingstone.)
Control of Eyelid Movements
Movements of the eyelids occur through the coordinated action
of several muscles – the levator palpebrae, tarsal muscles, the
orbicularis oculi and the frontalis. The elevation of the upper lid
and the control of its vertical position are mediated principally
by the levator. In vertical gaze, lid position and eye movements
are closely linked. During elevation the state of contraction of
the levator is varied to maximize visibility. In extreme upgaze,
lid retraction is augmented by the action of the frontalis, which
elevates the eyebrows. In downgaze, coordinated lid move-
ments similarly occur through levator relaxation. In periodic
and reflex blinks, the levator is spontaneously inhibited prior to
orbicularis contraction in lid closure. Similarly, in lid opening
the orbicularis relaxes, followed by contraction of the levator.
Spontaneous eye-blink activity is influenced by both central and
peripheral factors (Tsubota, 1998).
Compared with the upper lid, the lower lid is relatively
immobile and has no counterpart to the levator palpebrae. The
depression of the lower lid that occurs in downgaze is due to the
attachment of the sheaths of the inferior oblique and inferior
rectus muscles to the tarsal plate via a fibrous extension.  Meibomian Glands. The tarsal plates contain the acini and ducts
Microscopic Anatomy
The histological appearance of the upper and lower lids is similar,
and in sagittal section the following six tissue layers can be resolved:
skin, subcutaneous connective tissue, muscle layer, submuscular
connective tissue, tarsal plate and palpebral conjunctiva (Fig. 2.19).
The eyelid skin is thin and very elastic. It is continuous with
the palpebral conjunctiva at the lid margin, and keratinization
is maintained up to this mucocutaneous junction. The subcu-
taneous connective tissue is composed of a loose areolar tissue
and contains hair follicles and associated glands. The muscle
layer consists of striated muscle fibres of the orbicularis oculi,
which are arranged in bundles (fascicles) separated by con-
nective tissue. The orbicularis extends throughout the lid. The
marginal part of the muscle (Riolan’s muscle) is separated from
the pretarsal portion by connective tissue that contains the eye-
lash follicles. The loose submuscular connective tissue layer lies
between the orbicularis and the tarsal plate and contains the
major nerves and vessels of the lid.
The tarsal plates (tarsi) are composed of dense fibrous con-
nective tissue and provide support and determine lid shape.
2  Anterior Eye 19
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Fig. 2.19  Sagittal section through the upper lid. TP = tarsal plate;
OOc = orbicularis oculi; R = Riolan’s muscle; EF = eyelash follicles;
PC = palpebral conjunctiva; ES = eyelid surface.
They are anchored to the orbital margins by the medial and lat-
eral palpebral ligaments. Each tarsus is approximately 25 mm
long and 1–2 mm thick. The upper tarsus is semioval with a
height of 11 mm at its midpoint, whereas the inferior tarsus is
narrower (4 mm in height). The posterior surface of the eyelid
is lined by the palpebral conjunctiva, which is firmly adherent
to the underlying tarsal plate. 
Glands of the Eyelids
of the meibomian (tarsal) glands. Ducts are vertically oriented with
respect to the lid margins, with multiple secretory acini that open
laterally onto each duct. The glands occupy nearly the full length
and width of each tarsus, and are fewer and shorter in the lower
lid. Histologically, the acini are lined by a layer of undifferentiated
basal cells that divide, and cells are displaced from the basement
membrane. As they progress towards the duct they gradually
enlarge and develop lipid droplets in their cytoplasm (Fig. 2.20).
Ultimately, cell membranes rupture and cellular debris, together
with the lipid product, is discharged into the duct.
The stimulus for meibomian gland secretion is unclear.
Although a modest autonomic innervation of the meibomian
glands has been demonstrated, there is still some doubt regard-
ing a neuromodulation of glandular secretion; it is likely that the
principal control of the glands is hormonal, and both androgens
and oestrogens have been shown to regulate meibomian secre-
tion (Sullivan et  al., 2000; Knop et  al., 2011b). A long ductal
system carries the secretion to the lid margin, and the compres-
sive action of the palpebral division of the orbicularis oculi on
the meibomian ducts facilitates the flow of lipid and its eventual
delivery onto the lid margins. 
20 PART 1  Introduction
'
Fig. 2.20  Histological section showing meibomian gland acini. Secre-
tory cells degenerate (asterisk) as they approach the duct (D).
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Fig. 2.21  Histological section through the ciliary zone of the eyelid.
Glands of Zeis (Z) discharge their contents into an eyelash follicle (EF),
which contains the remnants of an eyelash. M = gland of Moll.
Glands of Zeis and Moll. Ciliary glands of Zeis and Moll are
found in association with eyelash follicles (Takahashi et  al.,
2013) (Fig. 2.21). Zeis glands are unilobular sebaceous glands
that open directly into the follicle. The function of their oily
secretion is to lubricate the lashes to prevent them from drying
out and becoming brittle. Glands of Moll are modified sweat
glands (apocrine) consisting of an unbranched spiral tubule.
The exact function of these glands is unclear, although their
secretion is rich in IgA, which suggest a role in the immune
defence of the ocular surface (Stoeckelhuber et al., 2003).  from where it is reflected onto the globe, covering the sclera up
Blood and Nerve Supply
Nerves of the Eyelids. The levator palpebrae and orbicularis
oculi muscles are innervated by the oculomotor and facial
nerves, respectively. The sensory supply of the upper lid
derives from branches of the ophthalmic nerve (supraorbital,
supratrochlear and lacrimal). The supply to the lower lid comes
from branches of the maxillary nerve (zygomatic, infraorbital).  zone extends from a line immediately posterior to the openings
Blood and Lymphatic Supply to the Eyelids. The arterial
supply derives from branches of the ophthalmic, lacrimal
and infraorbital arteries, which contribute to two palpebral
arcades in the upper lid and one in the lower. Branches from
these arcades supply the skin, orbicularis, tarsal glands and
2
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Fig. 2.22  Schematic representation of a mid-sagittal section through
the eyelid and conjunctival sac showing the different conjunctival re-
gions. M = marginal; T = tarsal; O = orbital; B = bulbar; L = limbal; F = for-
nical.


0
Fig. 2.23  Static dimensions of the conjunctival sac in millimetres.
M = medial canthus. (Adapted from Ehlers, N. (1965). On the size of the
conjunctival sac. Acta Ophthalmol., 43, 205–210.)
palpebral conjunctiva. Veins of the eyelids empty into veins of
the forehead and temple, and some empty into the ophthalmic
vein. Lymphatics drain to the preauricular and submandibular
lymph nodes. 
THE CONJUNCTIVA
Gross Anatomy
The conjunctiva is a thin transparent mucous membrane that
extends from the eyelid margins anteriorly, providing a lining to
the lids, before turning sharply upon itself to form the fornices,
to its junction with the cornea. It thus forms a sac that opens
anteriorly through the palpebral fissure. The conjunctiva is con-
ventionally divided into the following regions: marginal, tarsal,
orbital (these three collectively form the palpebral conjunctiva),
bulbar and limbal (Fig. 2.22).
The static dimensions of the conjunctival sac in the primary
position are illustrated in Fig. 2.23 (Ehlers, 1965). The marginal
of the tarsal glands and passes around the eyelid margin, from
where it continues on the inner surface of the lid as far as the
subtarsal fold (a shallow groove that marks the marginal edge
of the tarsal plate). The tarsal conjunctiva is highly vascular
and is firmly attached to the underlying fibrous connective tis-
sue. From the convex border of the tarsal plate, the orbital zone
 2  Anterior Eye 21

Fig. 2.24  High-power slit-lamp view of the conjunctival palisades of

Vogt (asterisks) at the lower limbus.

extends as far as the fornices. Over this region the conjunctiva is

more loosely attached to underlying tissues, and so readily folds.
Elevations of the conjunctival surface in the form of papillae
and lymphoid follicles are commonly observed in this region.
The transparency of the bulbar conjunctiva readily permits
the visualization of conjunctival and episcleral blood vessels.
Here, the conjunctiva is freely movable owing to its loose attach-
ment to Tenon’s capsule (the fascial sheath of the globe). As the
bulbar conjunctiva approaches the cornea, its surface becomes
smoother and its attachment to the sclera increases. The limbal
conjunctiva extends approximately 1–1.5 mm around the cornea.
Its junction with the cornea is ill defined, particularly in the ver-
tical meridian, owing to a variable degree of conjunctival / scleral
overlap. The limbus has a rich blood supply, and in the majority
of individuals a radial array of connective tissue elevations – the
palisades of Vogt – can be seen adjacent to the corneal margin
(Fig. 2.24). The palisades are most prominent in the vertical
meridian, and their visibility is enhanced in pigmented eyes.  Fig. 2.26  Histological section through the palisade region. Connec-
Microscopic Anatomy
In histological section, two distinct layers can be resolved: an
epithelium containing a variable number of goblet cells, and a
vascular stroma that consists of a superficial lymphoid layer and
a deep fibrous layer (Fig. 2.25). The appearance of the conjunc-
tiva shows a marked regional variability.
Epithelium. In the marginal zone, the epithelium is stratified
and squamous with relatively few goblet cells, although this has
recently been disputed following the description of intracellular
crypts lined with goblet cells lying deep within the epithelium in
the region of the so-called ‘lid wiper’ region (Knop et al., 2012).
It has been suggested that a subpopulation of epithelial cells that
lie close to the mucocutaneous junction may be acting as stem
cells for the palpebral conjunctiva (Wirtschafter et  al., 1999).
Approaching the tarsus, the epithelium thins to 2–3 layers of
cuboidal cells with scattered goblet cells. The epithelium of the
orbital zone is slightly thicker (2–4 cells) with more numerous
goblet cells. The number of goblet cells declines over the bulbar
conjunctiva and at the limbus the epithelium is again stratified
squamous, and goblet cells are absent. The limbus contains a
Fig. 2.25  Histological section through the bulbar conjunctiva. E = epi-
thelium; S = stroma. Goblet cells can be seen in the epithelium (arrows).
The stroma can be resolved into an adenoid layer (arrowhead) and a
deep fibrous layer (asterisk).
tive tissue ridges can be seen projecting into the overlying epithelium
(arrows).
unique array of connective tissue ridges (the palisades of Vogt),
which project into the overlying epithelium (Fig. 2.26). Clinical
and experimental evidence suggests that the palisades are the
repositories of stem cells and therefore act as the regenerative
organ of the corneal epithelium (Dua and Azuara-Blanco,
2000). The conjunctival epithelium additionally contains several
non-native cell types, including dendritic cells, melanocytes and
lymphocytes. 
Goblet and Other Secretory Cells. Goblet cells provide the
mucous component of the tear film. They arise in the basal
cell layers and migrate to the surface, there becoming fully
differentiated. Mature goblet cells are larger than the surrounding
epithelial cells and contain a peripherally placed nucleus. The
cytoplasm is packed with membrane-bound secretory granules
that discharge from the apical surface in an apocrine manner.
The number of goblet cells shows a marked regional variation
in density (Kessing, 1968) (Fig. 2.27), and these cells are
occasionally seen lining intraepithelial crypts (of Henle).
22 PART 1  Introduction

Fig. 2.27  Diagram showing the regional variation in goblet cell densi-
ty. Goblet cell density is greatest over the caruncle, plica semilunaris and
inferior nasal palpebral conjunctiva. (Adapted from Bron, A. J., Tripathi,
R. C. & Tripathi, B. (1997). Wolff’s Anatomy of the Eye and Orbit (8th ed.).
London: Chapman and Hall. Reproduced from Bron, 1997.)
Fig. 2.28  Histological section through a lymphoid follicle (F). Note the
modification of the overlying epithelium (asterisk).
The apices of many surface epithelial cells of the conjunc-
tiva contain numerous carbohydrate-containing secretory
vesicles, which are seen to migrate to the cell surface where
they fuse with the plasma membrane (Dilly, 1985). It is likely
that this represents a mechanism for recycling the cell sur-
face glycocalyx rather than a secondary source of secretory
mucin. 

Conjunctival Stroma. The conjunctival stroma (substantia

propria) is variable in thickness. It can be resolved into
two distinct layers: a superficial adenoid layer and a deeper
fibrous layer (see Fig. 2.25). The adenoid layer contains
numerous lymphocytes with local accumulations in the form
of lymphoid follicles (Fig. 2.28). Follicles represent aggregates
of predominantly B cells, which form part of the so-called
conjunctiva-associated lymphoid tissue (Knop and Knop,
2005). The adenoid layer also contains a large number of mast
cells, which play a major role in ocular allergy (McGill et  al.,
1998). The deep fibrous layer is generally thicker than the
adenoid layer and contains the majority of conjunctival blood
vessels and nerves.  from two sources: palpebral branches of the nasal and lacrimal
Innervation and Blood Supply
Nerves. The conjunctiva receives nerves from sensory,
sympathetic and parasympathetic sources. Sensory nerves,
which are trigeminal in origin, reach the conjunctiva via
branches of the ophthalmic nerve. The principal function
of these fibres is to equip the conjunctiva with the ability
to detect a variety of sensations – for example, touch, pain,
warmth and cold. Sensory nerve terminals include both
free (unspecialized) nerve endings and the more complex
corpuscular endings (classically referred to as Krause end
bulbs) (Lawrenson and Ruskell, 1991). Conjunctival blood
vessels receive a dual autonomic innervation. Parasympathetic
fibres issuing from the pterygopalatine ganglion and
sympathetic fibres from the superior cervical ganglion
are responsible for vasodilation and vasoconstriction,
respectively.  tortuous path.
Fig. 2.29  High-power slit-lamp photograph showing the limbal vascu-
lar arcades. (Courtesy of Eric Papas.)
Blood Vessels and Lymphatics. The arterial supply derives
arteries, and anterior ciliary arteries.
Palpebral vessels serve two vascular arcades within the eye-
lid. The inferior (marginal) arcade sends branches through the
tarsal plate to the eyelid margin and tarsal conjunctiva. The
superior (palpebral) arcade supplies the tarsal, orbital, fornix
and bulbar conjunctiva. The limbal zone, in contrast, is served
by anterior ciliary arteries. The anterior ciliary arteries travel
along the tendons of the rectus muscles and give off branches
at episcleral level prior to dipping down into the sclera to link
with the major iridic circle. Episcleral branches pass forward
and loop back a few millimetres short of the cornea to become
conjunctival vessels. Forward extensions of these vessels form
the limbal arcades (limbal loops), which are a complex net-
work of fine capillaries (Fig. 2.29). Conjunctival veins are more
numerous than arteries. They can be readily differentiated from
arteries owing to their larger calibre, darker colour and more
 
 2  Anterior Eye 23

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Fig. 2.31  Low-power light micrograph of the lacrimal gland. Acini are
arrowed. Adipose connective tissue (asterisks) extends across the gland.

Fig. 2.30  Lateral view of the orbit showing the position of the lacrimal
gland. The levator aponeurosis (LA) partially divides the gland into an
orbital (OD) and palpebral (PD) division. (Adapted from Kronfeld, P. C.,
McHugh, S. L. & Polyak, S. L. (1943). The Human Eye in Anatomical
Transparencies. Rochester, NY: Bausch & Lomb.)

Functional Considerations
The conjunctiva contributes the mucin component of the pre-
ocular tear film and plays an important role in the defence of
the ocular surface against microbial infection. Mucins are a
family of high-molecular-weight glycoproteins that include
membrane-bound and secretory varieties (Corfield et al., 1997;
Gipson and Inatomi, 1997; Hodges and Dartt, 2013). Goblet
cells are the primary source of secretory mucin, whilst sur-
face epithelial cells of both the conjunctiva and cornea possess
mucin-like molecules within their glycocalyx. The conjunctiva
also forms part of a common mucosal defence system, which
is an important component of the defence of the human body
against microorganisms (McClellan, 1997; Knop and Knop,
2005). The conjunctiva possesses the immunological capacity
for antigen processing, and cell-mediated and humoral immu-
nity. Humoral immunity is provided by specific antibodies (par-
ticularly immunoglobulin A [IgA]) produced by transformed B
cells (plasma cells) in the stroma. T lymphocytes form the basis
of cell-mediated immunity.  Microscopic Anatomy. The lacrimal gland is tubuloacinar in
LACRIMAL SYSTEM
The lacrimal apparatus provides for the production and main-
tenance of the preocular tear film. The normal function of this
system is essential for the integrity of the ocular surface and the
provision of a smooth refractive surface. The lacrimal apparatus
comprises a secretory system that includes the main and acces-
sory lacrimal glands, and a drainage system that consists of the
paired puncta and canaliculi, the lacrimal sac and the nasolac-
rimal duct.
Lacrimal Gland
Gross Anatomy. The main lacrimal gland is the key provider
of the aqueous component of the tears. The gland is located in a
shallow depression of the frontal bone behind the superolateral
orbital rim (Fig. 2.30). It is partially split by the aponeurosis
of the levator palpebrae into an upper larger orbital lobe and
Fig. 2.32  Electron micrograph of part of a lacrimal acinus showing
light and dark secretory cells.
a lower palpebral lobe, which can often be visualized through
the conjunctiva upon lid eversion (Bron, 1986). The gland is
pinkish in colour, with a lobulated surface. Between 6 and 12
ducts leave the gland through the palpebral lobe and discharge
into the conjunctival sac at the upper lateral fornix. 
form (Fig. 2.31). Its secretory units (acini) contain secretory
cells surrounded by myoepithelial cells (Ruskell, 1975). Acinar
secretory cells show extensive folding of their plasma membrane
and apical microvilli. Adjacent cells are linked by tight junctions
that restrict diffusion between cells. The most prominent feature
of these cells is the presence of abundant secretory granules.
Two principal secretory cell subtypes have been identified on
the basis of their granule content (Fig. 2.32). The majority of
cells contain dark granules (dark cells), with a smaller number
of cells containing light granules (light cells). The functional
significance of this heterogeneity is uncertain at present. Ducts
consist of a single layer of cuboidal cells that lack secretory
granules. Myoepithelial cells are dendritic cells that are closely
associated with the perimeter of acini and ducts. It is likely that
these contractile cells play a role in the expulsion of tears from the
gland. The interstices of the gland contain numerous blood vessels
and nerves. A large population of immune cells (particularly IgA-
secreting plasma cells) are also found between acini. 
24 PART 1  Introduction
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Fig. 2.33  Diagram showing the role of the gastrointestinal tract gen-
erating specific immunoglobulin A (IgA) in the lacrimal gland. Antigens
which challenge the ocular surface ultimately drain to the gastrointes-
tinal (GI) tract where they stimulate B cells in Peyer’s patches (gut-as-
sociated lymphoid tissue). Sensitized B cells then pass to the lacrimal
gland via the circulation. SC = secretory component. (Adapted from Al-
lansmith, M. R. (1992). The Eye and Immunology. Maryland Heights, MO:
Mosby. Copyright Elsevier 2002.)
Blood and Nerve Supply. The arterial supply to the lacrimal
gland is provided by the lacrimal artery, which enters the posterior
border of the gland. Venous drainage occurs via the lacrimal
vein. A rich autonomic innervation includes secretomotor
(parasympathetic) fibres that issue from the pterygopalatine
ganglion and sympathetic (vasomotor) fibres from the carotid
plexus. The lacrimal nerve traverses the gland to provide a sensory
innervation to the conjunctiva and lateral aspect of the eyelid.  the puncta of the upper and lower lids. Each punctum is a small
Accessory Lacrimal Glands. Numerous small accessory
lacrimal glands, which include the eponymous glands of
Wolfring and Krause, are found within the conjunctival stroma.
They have a particular predilection for the upper fornix and
above the tarsal plate, and, on the basis of proportion of total
lacrimal tissue, it has been estimated that they contribute
5–10% of aqueous tear volume. Structurally, they have a similar
appearance to the lacrimal gland proper. However, true acini are
absent and glands consist of elongated tubules that connect with
ducts opening onto the conjunctival surface (Seifert et al., 1993).  extends for about 15 mm, passing through a bony canal in the
Functional Considerations. In addition to its role as the principal
provider of the aqueous phase of the tear film, the lacrimal gland
is also a major component of the ocular sensory immune system,
which acts as the first line of defence against microbial infection
(Sullivan and Sato, 1994). The secretory immune system is
mediated through secretory IgA. The lacrimal gland is the main
source of tear IgA and the gland contains a large number of IgA-
producing plasma cells. The mechanism by which an antigenic
challenge of the ocular surface induces a lacrimal antibody
response is not fully understood. However, as the administration
of an antigen by a gastrointestinal route raises specific IgA levels
in tears, one suggested mechanism is that ocular antigens – after
drainage through the nasolacrimal duct – stimulate B cells in
gut Peyer’s patches. These sensitized B cells then populate the
lacrimal gland where they transform into plasma cells (Fig. 2.33).
/6
3
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1/'
Fig. 2.34  Illustration of the lacrimal drainage system. C = canaliculi;
LS = lacrimal sac; P = punctum; NLD = nasolacrimal duct. (Adapted from
Kronfeld, P. C., McHugh, S. L. & Polyak, S. L. (1943). The Human Eye in
Anatomical Transparencies. Rochester, NY: Bausch & Lomb.)
It has been demonstrated that the lacrimal gland also
secretes into the tears growth factors that are important for the
maintenance of the ocular surface and epithelial wound healing
(Pflugfelder, 1998). Prominent amongst these growth factors are
epidermal growth factor and transforming growth factor beta. 
Lacrimal Drainage System
Tears collect at the medial canthal angle, where they drain into
oval opening approximately 0.3 mm in diameter that is located
at the summit of an elevated papilla. From each punctum the
canaliculus passes first vertically for about 2 mm and then turns
sharply to run medially for about 8 mm (Fig. 2.34). At the angle,
a slight dilation, the ampulla, can be seen. The canaliculi con-
verge towards the lacrimal sac, usually forming a common can-
aliculus before entry. The lacrimal sac occupies a fossa formed
by the maxillary and lacrimal bones. It measures 1.5–2.5 mm in
diameter and approximately 12–15 mm in vertical length. From
the lacrimal sac tears drain into the nasolacrimal duct, which
maxillary bone, to an opening in the nose beneath the inferior
nasal turbinate. A fold of mucosa is often observed at the ter-
mination of the duct: this has been termed ‘the valve of Hasner’,
although there is no strong evidence that it functions as a valve.
The process of tear drainage is an active process mediated
by the contraction of the orbicularis during blinking (Doane,
1981). Tears enter the canaliculi principally by capillary action.
During the early part of the blink the puncta are occluded as
the orbicularis further contracts. The canaliculi and lacrimal
sac are also compressed, forcing fluid into the nose. An alterna-
tive hypothesis has been proposed whereby orbicularis contrac-
tion dilates the sac, creating a negative pressure, which draws
in the tears from the canaliculi (Jones, 1961). An investigation
by Paulsen et al. (2000) described a vascular plexus embedded
in the wall of the lacrimal sac and duct that may influence tear
outflow. It is postulated that opening and closing of the lumen of
 2  Anterior Eye 25

TABLE Physical Properties of the Preocular Tear

2.2 Film
Parameter Value 3URWHLQ
LRQV
Osmolarity 302 (±6.3) mOsm/l + 2
pH 7.45 3URWHLQ
Thickness 3 μl LRQV
+2
Volume 7.0 (±0.2) μl &RQMXQFWLYDO
Rate of production HSLWKHOLXP
 Unstimulated 1–2 μl / min
 Stimulated >100 μl / min /DFULPDO
Refractive index 1.336 JODQG
$FFHVVRU\
ODFULPDO
JODQGV
the lacrimal passages can be achieved by regulating blood flow
within this plexus. 

The Preocular Tear Film

7HDUILOP
FUNCTION AND PROPERTIES OF THE 0HLERPLDQ
PREOCULAR TEAR FILM JODQGV

The tear film is a complex fluid that covers the exposed parts of the
ocular surface framed by the eyelid margins. The physical charac-
teristics of this fluid are summarized in Table 2.2. Classically, the
tear film has been regarded as a trilaminar structure with a super-
ficial lipid layer secreted by the meibomian glands, which overlies
an aqueous phase derived from the main and accessory lacrimal
glands, and an inner mucinous layer consisting of membrane-
spanning mucins of the ocular surface epithelium and secretory
mucins produced mainly by conjunctival goblet cells. The tear
film performs several important functions, which can be broadly
classified as optical, metabolic support, protective and lubrication.
By smoothing out irregularities of the corneal epithelium, the
tear film creates an even surface of good optical quality that is re-
formed with each blink. The air–tear interface forms the principal
refractive surface of the optical system of the eye and provides two-
thirds (43 D) of its total refractive power. As the cornea is avascular
it is dependent on the tear film for its oxygen provision. When the
eye is open the tear film is in a state of equilibrium with the oxygen
in the atmosphere, and gaseous exchange takes place across the
tear interface. The constant turnover of the tear film also provides
a mechanism for the removal of metabolic waste products.
Tears play a major role in the defence of the eye against
microbial colonization. The washing action of the tear fluid
reduces the likelihood of microbial adhesion to the ocular sur-
face. Moreover, the tears contain a host of protective antimicro-
bial proteins. The tear film acts as a lubricant, smoothing the
passage of the lids over the corneal surface and preventing the
transmission of damaging shearing forces. To facilitate this, tear
fluid displays non-Newtonian behaviour with respect to shear
(Tiffany, 1991). Newtonian fluids maintain a constant viscosity
with increasing shear rates. By contrast, tear fluid has a rela-
tively high viscosity between blinks to aid stability, and with
increasing shear rates during the blink process the viscosity falls
dramatically, thereby easing the movement of the lids over the
ocular surface.
Tear Production
Jones (1966) first used the terms ‘basic (basal)’ and ‘reflex’ to
describe tear flow. He proposed that the accessory lacrimal glands
were the basic (minimal flow) secretors, and that reflex secretion
(\HOLG
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&RQMXQFWLYDO
0XFXV HSLWKHOLXP
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Fig. 2.35  Schematic representation of the orbital glands, which contrib-
ute the various components of the preocular tear film. (Adapted from Dartt,
D. A. (1992). Physiology of tear production. In M. A. Lemp & R. Marquardt
(eds) The Dry Eye: A Comprehensive Guide. Berlin: Springer-Verlag.)
(i.e. in response to strong physical or emotional stimulation) is
mediated by the main lacrimal gland. However, Jordan and Baum
(1980) questioned the concept of basic and reflex secretion, and
suggested that it is more accurate to think of tear output as a con-
tinuum, whereby the rate of production is proportional to the
degree of sensory or emotive stimulation (Dartt, 2009). This con-
cept would also mean that a functional distinction between main
and accessory lacrimal glands, in terms of basal and reflex tear
production, is unnecessary. Rather, it is more likely that tear flow
is the combination of contributions from both glands, although
the output from the accessory glands alone is sufficient to main-
tain a stable tear layer (Maitchouk et al., 2000). 
SOURCES AND COMPOSITION
Tears are composed of a complex secretion that combines the
products of several glands (Fig. 2.35). Although the precise com-
position of tear fluid varies with collection method, flow rate and
time of day, it can be considered as a watery secretion containing
electrolytes and proteins, with lesser amounts of lipid and mucin.
26 PART 1  Introduction

is a constitutively secreted lacrimal protein whose rate of secre-

TABLE Biochemical Composition of the Preocular tion is independent of flow rate. During sleep, the levels of IgA
2.3 Tear Film increase as secretory IgA production continues and as acinar
Component Concentration secretion declines (Sack et  al., 1992). IgA plays an important
role in the defence of the ocular surface against microbial infec-
ELECTROLYTES*
tion by preventing bacterial and viral adhesion, and inactivating
Na+ 135 mEq / l
Cl− 131 mEq / l
bacterial toxins. Other immunoglobulins (e.g. IgG and IgM) are
K+ 36 mEq / l present in tears at much lower levels.
HCO3− 26 mEq / l Lysozyme, lactoferrin and lipocalin, in contrast, originate
Ca2+ 0.46 mEq / l from acinar cells and their rate of secretion roughly matches
Mg2+ 0.36 mEq / l flow rate. Lysozyme is a well-known bacteriolytic protein that
MAJOR PROTEINS* has the ability to lyse the cell wall of several Gram-positive bac-
Lysozyme 2.07 g / l teria. Lactoferrin serves an important bacteriostatic function by
Secretory IgA 3.69 g / l binding iron and making it unavailable for bacterial metabo-
Lactoferrin 1.65 g / l lism. It also acts as a free radical scavenger, thereby reducing
Lipocalin 1.55 g / l
Albumin 0.04 g / l free-radical-mediated cell damage (Tiffany, 1997). Lipocalins
IgG 0.004 g / l are a family of lipid-binding proteins with an affinity for a broad
LIPIDS† array of lipids, including fatty acids, phospholipids and choles-
Wax esters 41% terol. It has been suggested that tear lipocalins act as scavengers
Cholesteryl esters 27.3% for a wide range of meibomian lipids, which could spill onto
Polar lipids 14.8% the corneal surface and perturb its wettability (Glasgow et al.,
Hydrocarbons 7.5% 2000). Furthermore, lipocalin may promote lipid solubility at
Diesters 7.7% the aqueous–lipid interface to facilitate the formation of a thin
Triacylglycerides 3.7%
Fatty acids 2.0% layer of lipid on the surface of the tear film. 
Free sterols 1.6%
Mucins
MUCIN‡
MUC1 nd
Mucins are a family of high-molecular-weight glycoproteins, of
MUC5AC nd which sugars contribute up to 85% of their dry weight. Structur-
MUC4 nd ally, they consist of a polypeptide backbone to which chains of
MUC16 nd sugar molecules attach via O-linkages to the amino acids serine
(Data adapted from Tiffany, 1997.) and threonine. Mucins are a heterogeneous group of molecules
Sources: that can be subdivided into secretory and integrated-membrane
*Main and accessory lacrimal glands. varieties (Corfield et al., 1997; Hodges and Dartt, 2013). So far,
†Meibomian glands.
‡Epithelial cells / goblet cells.
modern molecular biology techniques have identified up to
nd  = not determined.
20 mucin (MUC) genes, although only four of these (MUC1,
MUC5AC, MUC4 and MUC16) are expressed on the human
ocular surface (Gipson and Inatomi, 1997; McKenzie et al., 2000;
Electrolytes Pflugfelder et al., 2000; Mantelli and Argüesco, 2008). The epithelia
Human tears contain approximately the same range of electro- of the cornea and conjunctiva express the transmembrane mucins
lytes as found in plasma (Tiffany, 1997). Table 2.3 gives typi- MUC1, and to a lesser extent MUC4 and MUC16, which attach
cal values for the ionic composition of human tears. However, to apical microvilli where they form a hydrophilic base to facilitate
as the electrolyte content of tears varies with flow rate, there is the spreading of the goblet-cell-derived mucin MUC5AC. Mucins
significant variation in measured values. During the process play a major role in stabilizing and spreading the tear film and
of secretion by the lacrimal gland, there is a process of active provide protection against desiccation and microbial invasion
electrolyte transport that is coupled to the passive movement of (Gipson and Inatomi, 1997; Hodges and Dartt, 2013). 
water by an osmotic process. Acinar-derived fluid is essentially
an isotonic ultrafiltrate of plasma. Its composition is altered as Lipids
it passes along the ductal system, where further chloride and The source of lipids in the tear film is the meibomian glands
potassium ions are secreted. A variety of ion transport proteins embedded within the tarsal plates of each lid. The blinking pro-
have been identified in acinar cells, including sodium–potas- cess is an important mechanism in the expulsion of the secre-
sium ATPase and potassium and chloride channels.  tion from the glands (Tiffany, 1995). Meibomian lipid (also
known as meibum) is delivered directly as a clear oil onto the lid
Proteins margins and is spread over the tear film from the inner edge of
Tear proteins are thought to originate from three main sources: the lid margins with each blink. The thickness of the lipid layer
the lacrimal gland, ocular surface epithelia and conjuncti- is variable (mean thickness 42 nm, range 15–157 nm; King-
val blood vessels. The major lacrimal proteins include secre- Smith et al., 2000, 2010), and depending on thickness gives rise
tory IgA, lysozyme, lactoferrin and lipocalin (formerly known to characteristic interference patterns when viewed in specular
as tear-specific prealbumin) (see Table 2.3). IgA, which is reflection (Fig. 2.36) (Guillon, 1998). Meibomian secretion con-
the major immunoglobulin in tears, is secreted as a dimer by sists of a complex mixture of lipids (Table 2.3), including wax
plasma cells in the interstices between lacrimal acini. It then and cholesteryl esters (which together constitute approximately
binds to a receptor on the basolateral aspect of acinar cells, and 70% of meibum), fatty acids and fatty alcohols (Tiffany, 1995;
is transcytosed across the cell and secreted into tear fluid. IgA Butovich, 2013). The primary functions of this secretion are to
 2  Anterior Eye 27

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Fig. 2.36  Lipid layer of the preocular tear film viewed in specular re-
flection. A ‘wave’ appearance can be seen, which represents the most
commonly observed lipid pattern in the population.
provide a hydrophobic barrier at the lid margin to prevent over-
spill of tears, and to cover the surface of the tear film to retard
evaporation (Craig and Tomlinson, 1997). 
MODELS OF TEAR FILM STRUCTURE
The classical trilaminar model of tear film structure in terms of
a superficial lipid layer, a middle aqueous layer and deep mucin
layer, first proposed by Wolff and subsequently modified by
Holly and Lemp (1977), has received broad acceptance. How-
ever, the results of recent studies have led to a re-evaluation of
the nature of the aqueous and mucinous layers. Several pieces of
evidence have suggested that the mucin contribution to the tear
film is much greater than was previously thought (Prydal et al.,
1992), and an alternative tear film model, which possesses a
substantial mucinous phase, has been proposed (Fig. 2.37). The
nature of the mucinous phase has not been fully established, but
08&
0LFURYLOOL
(SLWKHOLXP
Fig. 2.37  Diagram showing the composition of the preocular tear
film. Insets show details of the glycocalyx and lipid–aqueous interface.
(Adapted from Corfield, A. P., Carrington, S. D., Hicks, S. J. et al. (1997).
Ocular mucins: purification, metabolism and functions. Prog. Retin. Eye
Res., 16, 627–656.)
is thought to consist of a mixture of soluble and gel-forming
mucins (Hodges and Dartt, 2013). 
Conclusion
It is clear from the above account that our understanding of the
structure and function of the anterior eye is far from complete,
which places certain limits on our understanding of clinical,
contact-lens-related phenomena. It is essential, therefore, that
future research continues to focus on fundamental aspects of
ocular anatomy and physiology, as well as on the more applied
clinical applications that are described in the remainder of this
book.
Access the complete references list online at
http://www.expertconsult.com.
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