2 Fundamentals and Principles

of Ophthalmology

2022–2023
BCSC
Basic and Clinical
®

Science Course™

Editorial Committee
Vikram S. Brar, MD, Chair
Simon K. Law, MD
Jennifer L. Lindsey, MD
David A. Mackey, MD
Robert L. Schultze, MD
Evan Silverstein, MD
Ravi S. J. Singh, MD
 The American Academy of Ophthalmology is accredited by the Accreditation Council for Con­
tinuing Medical Education (ACCME) to provide continuing medical education for physicians.

The American Academy of Ophthalmology designates this enduring material for a maximum of

™
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the extent of their participation in the activity.

Originally released June 2019; reviewed for currency August 2021; CME expiration date: June 1, 2023.

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AMA PRA Category 1 Credits may be claimed only once between June 1, 2019, and the expiration date.

®
BCSC volumes are designed to increase the physician’s ophthalmic knowledge through study and
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™
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Cover image: From BCSC Section 12, Retina and Vitreous. Confocal scanning laser ophthalmoscopy
multicolor fundus image (30° field of view) of a healthy eye. (Courtesy of Lucia Sobrin, MD.)

Copyright © 2022 American Academy of Ophthalmology. All rights reserved. No part of

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Printed in China.
48 ● Fundamentals and Principles of Ophthalmology

Topographic Features of the Globe

The eyeball, or globe, is not a true sphere. The radius of curvature of the prolate (polar
radius greater than equatorial radius, or “pointy”) cornea is 8 mm, smaller than that of the
sclera, which is 12 mm. This makes the globe an oblate “squashed” spheroid (equatorial
radius greater than polar radius). The anteroposterior diameter of the adult eye is approxi-
mately 23–25 mm. The average transverse diameter of the adult eye is 24 mm (Fig 2-1).
The eye contains 3 compartments: the anterior chamber, the posterior chamber, and
the vitreous cavity. The anterior chamber, the space between the iris and the cornea, is
filled with aqueous fluid. Anterior chamber depth varies among individuals and in re-
gional populations; the average depth is 3.11 mm. The average volume of the anterior
chamber is 220 μL. The posterior chamber is the anatomical portion of the eye posterior
to the iris and anterior to the lens and vitreous face. It is also filled with aqueous fluid and
has an average volume of 60 μL. The largest compartment is the vitreous cavity, which
makes up more than two-thirds of the volume of the eye (5–6 mL) and contains the vit-
reous gel (also called vitreous, vitreous body, or vitreous humor). The total volume of the
average adult eye is approximately 6.5–7.0 mL (Table 2-1).
The eyeball is composed of 3 concentric layers: an outer protective layer, a middle
vascular layer, and an inner neural layer. The outermost layer consists of the clear cornea
anteriorly and the opaque white sclera posteriorly. This corneoscleral layer is composed of
collagen and protects the internal ocular tissues.

Cornea
Anterior chamber
Iris
3.11 mm Anterior chamber angle
Posterior chamber
Lens
Ciliary body
Zonular fibers
Ora serrata
23–25 mm

Lens capsule
24 mm

Vitreous cavity

Neural retina
Choroid
Sclera
Optic disc
Optic nerve

Figure 2-1Sagittal section of the eye with absent vitreous and major structures identified.
Dimensions are approximate and are average for the normal adult eye. (Illustration by Christine Gralapp.)
 ChaPter 2: the eye ● 49

Table 2-1 Dimensions and Contents of the Adult Eye

Anterior Chamber Posterior Chamber Vitreous Cavity Eye as a Whole
Average depth 3.11 mm (ranges 0.52 mm 16.5 mm 23.5 mm (ranges
(emmetropic from 1.5a to from 19.5 to
eye) 4 mm) 26.5 mm)
Volume 220 μL 60 μL 5 to 6 mL 6.5 to 7 mL
Contents aqueous aqueous Vitreous

a
Below 2.5 mm the risk of angle closure increases.

The cornea occupies the center of the anterior pole of the globe. Because the sclera
and conjunctiva overlap the cornea anteriorly, slightly more above and below than medi-
ally and laterally, the cornea appears elliptical when viewed from the front. The limbus,
which borders the cornea and the sclera, is blue-gray and translucent.
The middle layer of the globe, the uvea, consists of the choroid, ciliary body, and
iris. Highly vascular, it serves nutritive and supportive functions, supplying oxygen to the
outer retina and producing aqueous humor.
The innermost layer is the retina. This photosensitive layer contains the photorecep-
tors and neural elements that initiate the processing of visual information.
Other important surface features of the globe, such as the vortex veins, the posterior
ciliary artery and nerves, and extraocular muscle insertions are discussed in Chapter 1;
the optic nerve and its surrounding meningeal sheaths are discussed in Chapter 3.

Precorneal Tear Film

The exposed surfaces of the cornea and bulbar conjunctiva are covered by the precor-
neal tear film, which was formerly described as having 3 layers: lipid (from meibomian
glands), aqueous (from the lacrimal gland), and mucin (primarily from goblet cells). It is
now thought of as a lipid layer with underlying uniform gel consisting of soluble mucus
(secreted by conjunctival goblet cells), mixed with fluids and proteins (secreted by the
lacrimal glands). A glycocalyx mediates the interaction of the mucoaqueous layer with
surface epithelial cells of the cornea.
Maintenance of the precorneal tear film is vital for normal corneal function. The tear
film does the following:
• provides lubrication for the cornea and conjunctiva
• facilitates the exchange of solutes, including oxygen
• contributes to the antimicrobial defense of the ocular surface
• serves as a medium to remove debris
Further, the air–tear film interface at the surface of the cornea constitutes a major re-
fractive element of the eye, because of the difference in the refractive index of air and that
of the tear film. Aberrations in the tear film result from a variety of diseases (eg, dry eye,