INTRODUCTION

ANATOMY AND PHYSIOLOGY OF THE EYE

The eye is one of the most complex organs of the human body. In the human eye, three layers
can be distinguished. The outer region consists of the cornea and the sclera. The cornea refracts
and transmits the light to the lens and the retina and protects the eye against infection and
structural damage to the deeper parts. The sclera forms a connective tissue coat that protects the
eye from internal and external forces and maintains its shape. The cornea and the sclera are
connected at the limbus. The visible part of the sclera is covered by a transparent mucous
membrane, the conjunctiva. The middle layer of the eye is composed of the iris, the ciliary body
and the choroid. The iris controls the size of the pupil, and thus the amount of light reaching the
retina; the ciliary body controls the power and shape of the lens and is the site of aqueous
production; and the choroid is a vascular layer that provides oxygen and nutrients to the outer
retinal layers. The inner layer of the eye is the retina, a complex, layered structure of neurons that
capture and process light. The three transparent structures surrounded by the ocular layers are
called the aqueous, the vitreous and the lens.

THE CORNEA

The cornea is the most anterior part of the eye, in front of the iris and pupil. It is the most densely
innervated tissue of the body, and most corneal nerves are sensory nerves, derived from the
ophthalmic branch of the trigeminal nerve ( Müller NR et al., 2005).The cornea of an adult
human eye has an average horizontal diameter of about 11.5 mm and a vertical diameter of
10.5 mm, and a curvature that remains rather constant throughout life( Majo F et al., 2008).
The optic zone (pre-pupillary cornea), which provides most of the cornea's refractive function,
has a diameter of 4 mm and is located in the centre of the cornea, anterior to the pupil, in
photopic conditions. The cornea is avascular and the branches of the anterior ciliary arteries stop
at the limbus where they form arcades that supply the peripheral cornea ( Farjo AA et al., 2009).
Therefore, the peripheral and central cornea are very distinct in terms of physiology and
pathology.

Five layers can be distinguished in the human cornea: the epithelium, Bowman's membrane, the
lamellar stroma, Desçemet's membrane and the endothelium. The surface of the corneal
epithelium is covered by the tear film, which protects the corneal surface from chemical, toxic or
foreign body damage and from microbial invasion and smoothes out micro-irregularities of the
surface of the epithelium.( Farjo AA et al., 2009). It consists of an outer lipid layer and an inner
water-mucous layer. The mucous layer interacts with the epithelial cells, allowing the tear film to
spread with each eyelid blinked.

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The corneal epithelium is composed of two to three layers of superficial cells, two to three layers
of wing cells and one layer of basal cells. The surface of the superficial epithelial cells is
irregular due to the presence of microplicae (ridge-like folds of the plasmalemma) that interact
with the overlying tear film. The cells of the corneal epithelium are renewed every 7–10 days
from a pluripotent stem cell population, which resides in the palisades of Vogt at the
corneoscleral limbus. The stem cells differentiate into transient amplifying cells when they
migrate to the central cornea. Recent research has also identified oligopotent stem cells in the
corneal epithelium of mice and pigs, suggesting that the limbus is not the only niche for corneal
stem cells.The corneal epithelium is extremely impermeable and stable due to the presence of
cell junctions. It is also anchored very strongly to the basal lamina. The latter is secreted by the
basal cells and mainly consists of type IV collagen and laminin. Because innervations are
essential for the physiology of the epithelium, practically all epithelial cells are in contact with
nerve cells.

The corneal lamellar stroma (500-µm-thick) provides structural integrity to the cornea. Stromal
keratocytes secrete collagen and proteoglycans, which are ultimately fundamental for the
transparency of the cornea and hydration. The stroma is separated from the epithelium by the
Bowman's layer, an acellular zone of 10–15 µm beneath the basal lamina. The bulk of the
stromal extracellular matrix consists of collagen fibrils arranged in 200–250 parallel lamellae
that run from limbus to limbus.The network of collagen fibrils is responsible for the mechanical
strength of the cornea and its regular organization is essential for corneal transparency. In the
pre-pupillar cornea, the fibrils are packed more compact than in the peripheral cornea, probably
contributing to the mechanical strength and dioptric stability in the cornea. The stromal collagen
fibrils are surrounded by proteoglycans consisting of keratan sufate or chondroitin
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sulfate/dermatan sulfate side chains. These proteoglycans have an important structural function
and help regulate hydration. Keratocytes are the predominant cell type in the stroma and play a
role in maintaining its organization. These stellar-shaped cells contact to each other by long
cytoplasmatic extensions (morphologic and functional syncytium) and also interact with the
corneal epithelium.

The corneal endothelium consists of a single layer of five- to seven-sided cuboidal cells with
little or no self-renewing potential. The endothelial cell density at birth in a normal cornea is
3500–7000 cells/mm2. They secrete the Descemet's membrane that separates the endothelium
from the stroma. This elastic membrane thickens with age and is composed of an anterior layer
with a banded appearance and a posterior layer with an amorphous texture.The endothelium
possesses intracellular and membrane-bound ion transport systems that establish an osmotic
gradient from a relatively hypo-osmotic stroma to a hypertonic aqueous. The osmotic gradient
produces a net fluid flux from the stroma to the aqueous that produces a constant percentage of
water in the stroma (78% H2O), which is essential for the clarity and transparency of the cornea
(Schubert HD et al., 2009).This process is called deturgescence. Corneal oedema may develop if
deturgescence is disturbed for some reason.

Incident light on the cornea can be transmitted, absorbed or scattered. In a normal transparent
cornea, visible light is not absorbed and scattering is negligible. Only irregularities with
dimensions similar to the wavelength of visible light (400–700 nm) will affect the retinal
image. An increase of corneal scattering can arise in case of corneal oedema, the relaxation of
collagen fibrils, haze (extracellular matrix production by keratocytes) or irregularities due to
surgery ( Farjo AA et al., 2009).

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THE RETINA

The retina is the tissue that lines the inner surface of the eye, surrounding the vitreous cavity.
During embryogenesis, the vertebral retina develops from the optic cup. The latter is formed by
invagination of the optic vesicle, which is an outgrowth of the embryonic forebrain. The inner
wall of the optic cup (surrounding the vitreous cavity) ultimately becomes the neural retina; the
outer wall (surrounded by the choroid and sclera) becomes the retinal pigment epithelium (RPE).
The retina is protected and held in the appropriate position by the surrounding sclera and cornea.

The neural retina consists of six major classes of neurons: photoreceptors, bipolar cells,
horizontal cells, amacrine cells and ganglion cells, which capture and process light signals, and
the Müllerian glia, which act as the organizational backbone of the neural retina. The cells of the
neural retina are arranged in several parallel layers.The nuclei of the photoreceptor cells lie in the
outer nuclear layer, their outer segments lie proximal from the nuclei, close to the RPE. The
nuclei of the Müllerian glia, the bipolar cells, the amacrine and the horizontal cells are located in
the inner nuclear layer of the retina. The inner nuclear layer has plexiform layers at both sides. In
the outer plexiform layer, the photoreceptors connect with bipolar and horizontal cells, whereas
in the inner plexiform layer, bipolar and amacrine cells synapse with ganglion cells. The nuclei
of the ganglion cells lie in the ganglion layer, their axons in the nerve fibre layer. Processes of
the Müllerian glia extend throughout the retina. The apical processes form the outer limiting
membrane by making junctional complexes with one another and with photoreceptors. The
apposed end-feet of the vitreal processes form the inner limiting membrane. Lateral processes of
the Müllerian glia contact with blood vessels and neurons and form synapses with dendrites
within the plexiform layers and axons in the nerve fiber layer ( Daniels JT et al., 2001)

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The eyes of most vertebrates contain two types of photoreceptors: rods and cones. In humans,
rods are approximately 20 times more abundant than cones.The photoreceptors are responsible
for phototransduction, the conversion of light into an electrical signal. For this purpose, the
membranes of the outer segment discs of the photoreceptors contain pigments. Cones, which are
responsible for colour vision, have pigments with absorption peaks in the blue, green or yellow
parts of the spectrum. Pigments of the rods have an absorption peak in the blue-green part of the
spectrum. Rods are active with low light levels, and are not involved in colour vision.

The density of rods and cones varies between different regions of the retina. In humans, about
50% of the cones are located in the central 30% of the visual field, roughly corresponding with
the macula. The macula lutea refers to an area in the retina between the temporal vascular
arcades containing xanthophylls pigment. Histologically, the macula has several layers of
ganglion cells, whereas in the surrounding peripheral retina the ganglion cell layer is only one-
cell thick. The excavation near the centre of the macula is called the fovea. This area of the retina
is responsible for sharp central vision and contains the largest concentration of cones in the eye
(Schubert HD et al., 2009). Visual acuity is highest in the foveola, the thin, avascular bottom of
the fovea, which contains only densely packed cone cells. Due to the high density of cone cells
in the foveola, the cone synaptic terminals and the ganglion cells to which they connect are
pushed away from its centre, resulting in elongations between the nuclei and synaptic terminals
of the cone cells, called Henle's fibres ( Millar NR et al., 2005). At the level of the internal
nuclear layer, the foveola is surrounded by a circular system of capillaries, the vascular arcades.
No photoreceptor cells are present at the optic disc or optic nerve head where the axons from the
ganglion cells exit the eye to form the optic nerve.

VISUAL PATHWAYS

That enters the eye via its anterior components travels through the different layers of transparent
neurons of the retina where it is captured by the photoreceptors at the back of the retina. As
visual images are inverted as they pass through the lens, the right half of the image is projected
on the nasal retina of the right eye (and the temporal retina of the left eye), whereas the left half
of the image is projected on the temporal retina of the right eye (and the nasal retina of the left
eye).

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The neurons of the neural retina translate the visual information into nerve impulses, which
travel through the optic nerve to the brain. The photoreceptors, the bipolar cells and the ganglion
cells form a direct pathway to the brain.The horizontal and amacrine cells form lateral pathways
that modify and control the signal that passes through the direct pathway ( Schubert HD et al.,
2009). The axons of the ganglion cells first travel towards the nerve fibre layer at the vitreal
surface and then towards the optic disc, where they make a sharp turn to the optic nerve. The
optic nerve extends from the eye to the optic chiasm. The next synapses lie deep in the brain, in
the lateral geniculate nuclei (LGN) ( Millar NR et al., 2005). Both LGN receive information
from both eyes, but only from one half of the visual field. This is due to a hemidecussation of
both optic nerves in the optic chiasm, before they reach the LGN. Neurons from the LGN send
their axons to the ipsilateral primary visual cortex. The left primary visual cortex receives
information from the right visual field, and vice versa.

A lesion in one or both optic nerves will result in visual loss in one or both eyes, respectively.
This will be apparent in the optic disc, which may become swollen or develop pallor (optic
atrophy). Increased intracranial pressure results in the swelling of both optic discs
(papilloedema) that may cause optic atrophy when untreated. The hallmarks of chiasmal lesions
are defects that affect the temporal visual field in each eye. A lesion behind the optic chiasm is
characterized by homonymous visual field defects occurring in both eyes (e.g. the temporal field
in one eye and the nasal field in the other eye).

OCULAR BARRIERS

The transport of fluids and solutes in the eye is controlled by several membranes and barriers.
These barriers can hamper the delivery of topical ocular drugs (i.e. eye drops) and systemically
(i.e. orally or intravenously) administered drugs.
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Topical ocular drugs, mostly given as eyedrops, are the most frequently used dosage forms for
treating ocular diseases. The first barrier to cross for these drugs is the tear film, which rapidly
removes instilled compounds from the eye, resulting in low bioavailability. Other membranous
barriers are located in the cornea, the conjunctiva, the iris–ciliary body and the retina. Depending
on the physiochemical characteristics of the compounds, delivery of drugs can occur through the
corneal route and/or the conjunctival/scleral route. The corneal route is the main route for
delivery of drugs to the anterior chamber. Permeation of hydrophilic drugs and macromolecules
through the corneal epithelium is limited by the presence of tight junctions between adjacent
outer superficial epithelial cells (Farjo AA et al., 2009).The abundant presence of hydrated
collagen in the stroma may hamper the diffusion of highly lipophilic agents. The endothelium is
more permeable and allows the passage of hydrophilic drugs and macromolecules between the
aqueous and the stroma due to the presence of ‘leaky tight junctions’ called desmosomes or
macula adherens. The passage of topical ocular drugs through the corneal route depends on their
lipophylicity, molecular weight, charge and degree of ionization. Particularly small lypophilic
drugs can easily permeate through the cornea. After crossing the cornea, the drug diffuses into
the aqueous and to the anterior uvea.

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The non-corneal or conjunctival/scleral route is usually less efficient for drug delivery, but may
be used for the delivery of hydrophilic and larger molecules, which cannot easily diffuse through
the corneal epithelium. Unlike the cornea, the conjunctiva has a rich vasculature and a large
amount of the administered drug crossing it is removed by the systemic circulation. The
remaining drug penetrates through the sclera, which is more permeable than the cornea, but less
permeable than the conjunctiva. The passage of drugs from the anterior to the posterior segments
of the eye is not very efficient due to the aqueous turnover. Therefore, ocular surface
administered drugs usually do not reach the posterior segments of the eye (retina, vitreous,
choroid) in sufficient therapeutic concentrations.

Intravenous and intravitreal administrations appear to be the main strategies for treating posterior
segment infections/diseases. However, intravenous administration has limited success primarily
due to the exclusion of the eye from the systemic circulation. Of the ocular barriers, the BRB
selectively controls traverse of substances and pharmaceuticals after systemic and periocular
administration to the retina. Despite some similarity, the BRB differs from the blood–brain
barrier (BBB) by the functional presence of its outer barrier that is formed by the RPE. The inner
barrier is formed by the endothelial cells of retinal vessels ( Millar NR et al., 2005). Both barriers
display restricted tight junctions, by which the permeation/transfer of hydrophilic substances and
macromolecules can selectively be regulated in inward and outward directions, that is, blood to
vitreous and vice versa.26 Transcellular passive permeation is the main route for the
inward/outward traverse of small molecules across the BRB, whereas the paracellular
permeability of RPE is quite low. Besides, there exists an inverse correlation between the
molecular weight and permeability. For example, in isolated bovine RPE choroids, the inward
permeability differs between dextrans with various molecular weights (i.e. 2.36, 0.46 and 0.27
× 10−7 cm/s for 4, 40 and 80 kDa macromolecules) ( Dua HS et al., 2005). The following
equation represents overall flux of drug across the BRB: J = C × P × S = C ×
CL, with J (µg/min), C (µg), P (cm/s) and S (cm2) representing the overall flux of the drug, the
concentration gradient of the drug, the permeability in the barrier and the surface area of the
barrier. CL represents the drug clearance into the tissue ( Daniels JT et al., 2001).

Ocular manifestations in the MPS

Membrane-bound vacuoles containing GAG deposits have been found in almost all ocular
tissues in MPS patients, where they can alter the cellular shape and tissue ultrastructure.5, 37
Therefore, both the anterior and posterior segments of the eye can be affected. Characteristic
ocular features in patients with MPS include corneal clouding, glaucoma, retinopathy, optic disc
swelling and optic atrophy.2-5 Corneal clouding develops as a result of the intracellular and
extracellular deposition of GAG in the cornea, which can affect keratocyte size and disrupt the
regular network of collagen fibrils in the stroma (Majo F et al., 2008). Narrowing of the angle
secondary to GAG accumulation within the cornea can result in raised intraocular pressure and
subsequent chronic or acute angle closure glaucoma.39 GAG deposition in the trabeculocytes
and subsequent outflow obstruction can lead to open-angle glaucoma (Ashworth JL et al.,2006)
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Retinopathy results from GAG deposition in the RPE and the inter-photoreceptor matrix, leading
to retinal degeneration and photoreceptor loss.4 Optic disc swelling and secondary optic atrophy
can have several causes. Optic disc swelling can arise due to chronic elevation of intracranial
pressure (papilloedema), impingement of the optic nerve due to thickening of the sclera or as a
result of GAG deposition within ganglion cells ( Collins MLZ et al., 1990).

Ocular problems in patients with MPS can ultimately result in visual impairment or blindness
( Ashworth JL et al., 2006). As many patients with MPS first present with ocular features, it is
important that ophthalmologists are aware of the typical clinical features of MPS and can
recognize them as being of metabolic origin, so that they can refer the patients to paediatricians
for further diagnosis. The severity of the ocular findings differs between MPS types.

CONCLUSION

The anatomy and function of the eye is extremely complex and pathological events can lead to a
wide range of ocular disease manifestations that may occur. MPS patients may present with a
variety of ocular diseases in both the anterior and posterior components of the eye, resulting from
GAG accumulation in various tissues. The treatment of these ocular features warrants the
investigation of methods to circumvent various ocular barriers that hamper drug delivery.

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