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CORNEA
cornea
Fourth Edition

Mark J. Mannis MD FACS

Natalie Fosse Endowed Chair in Vision Science Research
Professor and Chair
Department of Ophthalmology & Vision Science
University of California Davis Eye Center
Sacramento, CA, USA

Edward J. Holland MD
Director of Cornea
Cincinnati Eye Institute
Professor of Ophthalmology
University of Cincinnati
Cincinnati, OH, USA

Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2017
© 2017, Elsevier Inc. All rights reserved.
First edition 1997
Second edition 2005
Third edition 2011

No part of this publication may be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopying, recording, or any information storage and
retrieval system, without permission in writing from the publisher. Details on how to seek
permission, further information about the Publisher’s permissions policies and our
arrangements with organizations such as the Copyright Clearance Center and the Copyright
Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by
the Publisher (other than as may be noted herein).

Csaba L Mártonyi and Mark Maio retain copyright for their original illustrations in Chapter 7.

Michael E. Snyder retains copyright for his original figures and video clips in Chapter 145.

Notices
Knowledge and best practice in this field are constantly changing. As new research and
experience broaden our understanding, changes in research methods, professional practices, or
medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein.
In using such information or methods they should be mindful of their own safety and the
safety of others, including parties for whom they have a professional responsibility.

With respect to any drug or pharmaceutical products identified, readers are advised to check
the most current information provided (i) on procedures featured or (ii) by the manufacturer
of each product to be administered, to verify the recommended dose or formula, the method
and duration of administration, and contraindications. It is the responsibility of practitioners,
relying on their own experience and knowledge of their patients, to make diagnoses, to
determine dosages and the best treatment for each individual patient, and to take all
appropriate safety precautions.

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,
assume any liability for any injury and/or damage to persons or property as a matter of
products liability, negligence or otherwise, or from any use or operation of any methods,
products, instructions, or ideas contained in the material herein.

ISBN:
Print: 978-0-323-35757-9
E-book: 978-0-323-35758-6
Inkling: 978-0-323-35759-3

Printed in China

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Content Strategist: Russell Gabbedy

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 Video Table of Contents

Clip Clip title Video contributor/s

50.1 The Application of Cryopreserved Amniotic Membrane in the Treatment Darren G. Gregory
of Acute Stevens–Johnson Syndrome: Part 1
50.2 The Application of Cryopreserved Amniotic Membrane in the Treatment Darren G. Gregory
of Acute Stevens–Johnson Syndrome: Part 2
50.3 The Application of Cryopreserved Amniotic Membrane in the Treatment Darren G. Gregory
of Acute Stevens–Johnson Syndrome: Part 3
110.1 Penetrating Keratoplasty Using the Barron Trephine and Interrupted Mauricio A. Perez, David S. Rootman
Sutures
110.2 Penetrating Keratoplasty Using the Hanna Trephine and Interrupted Mauricio A. Perez, David S. Rootman
Sutures
110.3 Penetrating Keratoplasty Using the Slipknot Technique for Suturing Clara C. Chan, Mauricio A. Perez
110.4 Penetrating Keratoplasty Using a Running Suture Mauricio A. Perez, Allan R. Slomovic
111.1 An Intraoperative Suprachoroidal Hemorrhage During Penetrating Michael C. Chen, Mark J. Mannis
Keratoplasty, which was Successfully Managed with the Assistance of a
Cobo Temporary Keratoprosthesis
112.1 Donor Preparation Marjan Farid, Roger F. Steinert, Sumit Garg,
Matthew Wade
112.2 Dissection and Suturing Marjan Farid, Roger F. Steinert, Sumit Garg,
Matthew Wade
112.3 Laser Incision Marjan Farid, Roger F. Steinert, Sumit Garg,
Matthew Wade
112.4 Femto DALK Marjan Farid, Roger F. Steinert, Sumit Garg,
Matthew Wade
117.1 Big Bubble DALK: A Video Presentation Mohammad Anwar
118.1 Techniques of Anterior Lamellar Keratoplasty: Stromal Delamination Luigi Fontana
118.2 Techniques of Anterior Lamellar Keratoplasty: ALTK 1 Luigi Fontana
118.3 Techniques of Anterior Lamellar Keratoplasty: ALTK 2 Luigi Fontana
118.4 Techniques of Anterior Lamellar Keratoplasty: Big Bubble Luigi Fontana
118.5 Techniques of Anterior Lamellar Keratoplasty: Big Bubble Using Luigi Fontana
a Cannula
118.6 Techniques of Anterior Lamellar Keratoplasty: Donor Preparation Luigi Fontana
119.1 Rupture of DM in a Keratoconus Patient Shigeto Shimmura
120.1 Cannula Big-Bubble Technique, Bubble Test, and the New Opening of Vincenzo Sarnicola, Enrica Sarnicola,
the Bubble Caterina Sarnicola
120.2 Air-Viscobubble Technique (AVB) Vincenzo Sarnicola, Enrica Sarnicola,
Caterina Sarnicola
120.3 Layer-by-Layer Manual Dissection Vincenzo Sarnicola, Enrica Sarnicola,
Caterina Sarnicola
120.4 dDALK Rupture Management Vincenzo Sarnicola, Enrica Sarnicola,
Caterina Sarnicola
120.5 Subtotal Full Thickness Circular Cut of the Recipient Bed Vincenzo Sarnicola, Enrica Sarnicola,
Caterina Sarnicola

xi
Video Table of Contents

Clip Clip title Video contributor/s

120.6 Total Full Thickness Circular Cut of the Recipient Bed Vincenzo Sarnicola, Enrica Sarnicola,
Caterina Sarnicola
120.7 Excessive Trephination and Perforation Vincenzo Sarnicola, Enrica Sarnicola,
Caterina Sarnicola
120.8 Traumatic Postoperative DM Disinsertion Vincenzo Sarnicola, Enrica Sarnicola,
Caterina Sarnicola
126.1 Eye Bank Preparation of DMEK Graft Tissue Using a Modified Mark A. Greiner, Gregory A. Schmidt,
SCUBA Technique Kenneth M. Goins
130.1 Ultrathin DSAEK Massimo Busin, Vincenzo Scorcia
131.1 DMEK Injectors Michael D. Straiko
131.2 Peripheral Iridotomy Kevin J. Shah, Michael D. Straiko,
Mark A. Greiner
132.1 Torn Donor Graft During DMEK Graft Preparation Using Dagny Zhu, Neda Shamie
SCUBA Technique
134.1 DSEK Under Top Hat PKP with Laplace Phenomenon Matthew T. Feng, Francis W. Price, Jr.,
Marianne O. Price
134.2 Suture Pull Through and Fixation Matthew T. Feng, Francis W. Price, Jr.,
Marianne O. Price
136.1 RHCIII Implantation Surgery May Griffith, Oleksiy Buznyk, Per Fagerholm
141.1 Primary Pterygium Excision and Conjunctival Autograft with Fibrin Glue Donald T.H. Tan, Elaine W. Chong
141.2 Recurrent Pterygium Excision and Extensive Tenon’s Excision with Donald T.H. Tan, Elaine W. Chong
Conjunctival Autograft Using Fibrin Glue
143.1 How to Know the Orientation of the Amniotic Membrane Jose L. Güell, Oscar Gris, Daniel Elies,
Felicidad Manero, Merce Morral
143.2 Surgical Videos of Several Cases where Amniotic Membrane Jose L. Güell, Oscar Gris, Daniel Elies,
Transplantation was Performed Felicidad Manero, Merce Morral
143.3 The Modified Gundersen Approach Consists of Four Main Steps Jose L. Güell, Oscar Gris, Daniel Elies,
Felicidad Manero, Merce Morral
143.4 Two-Step Approach to Treat Unilateral Total Limbal Stem Cell Jose L. Güell, Oscar Gris, Daniel Elies,
Deficiency Felicidad Manero, Merce Morral
145.1 Iris Oversew Michael E. Snyder, Jason H. Bell
145.2 Taco Down Fold of PCIOL for Insertion Behind 50-Series Iris Prostheses Michael E. Snyder, Jason H. Bell
145.3 CustomFlex Iris Device Injection and Capsular Bag Implantation Michael E. Snyder, Jason H. Bell
With Overfolding
151.1 KPro Assembly and Surgery Jose de la Cruz
155.1 Boston Keratoprosthesis Type 2 Surgical Techniques Duna Raoof, James Chodosh
156.1 Stage 1 OOKP Jean S.M. Chai, Donald T.H. Tan
156.2 Stage 2 OOKP Jean S.M. Chai, Donald T.H. Tan
158.1 LR-CLAU Edward J. Holland, Gary S. Schwartz,
Sheraz M. Daya, Ali R. Djalilian, Clara C. Chan
158.2 KLAL Edward J. Holland, Gary S. Schwartz,
Sheraz M. Daya, Ali R. Djalilian, Clara C. Chan
158.3 CLAU-KLAL Modified Cincinnati Procedure Edward J. Holland, Gary S. Schwartz,
Sheraz M. Daya, Ali R. Djalilian, Clara C. Chan
160.1 Combined LR-CLAL/KLAL (Cincinnati Procedure) Followed by Kevin J. Shah, Edward J. Holland,
Penetrating Keratoplasty Mark J. Mannis
165.1 LASEK Azar Flap Technique Dimitri T. Azar, Ramon C. Ghanem
166.1 Technique for Custom Femtosecond LASIK Louis E. Probst
167.1 Femtosecond LASIK Patricia B. Sierra, David R. Hardten

xii
 Video Table of Contents

Clip Clip title Video contributor/s

169.1 Anterior Chamber Gas Bubbles Blocking the Tracking of the Pupil Louis E. Probst, Clara C. Chan,
Mario J. Saldanha
171.1 Small Incision Lenticule Extraction Jodhbir Mehta
172.1 Post LASIK Ectasia – Intrastromal CXL and Ring Adimara da Candelaria Renesto,
Mauro Campos
173.1 Femtosecond Laser Astigmatic Keratotomy Zaina Al-Mohtaseb, Leela V. Raju, Li Wang,
Mitchell P. Weikert, Douglas D. Koch
174.1 Implantation of an Artisan Lens Thomas Kohnen, Mehdi Shajari, Jose L. Güell,
Daniel Kook, Rudy M.M.A. Nuijts
174.2 Implantation of a Toric Artisan Lens Thomas Kohnen, Mehdi Shajari, Jose L. Güell,
Daniel Kook, Rudy M.M.A. Nuijts
174.3 Implantation of an Artiflex Lens Thomas Kohnen, Mehdi Shajari, Jose L. Güell,
Daniel Kook, Rudy M.M.A. Nuijts
174.4 Implantation of an ICL Thomas Kohnen, Mehdi Shajari, Jose L. Güell,
Daniel Kook, Rudy M.M.A. Nuijts
174.5 Performing LASIK in a Patient with an Iris-Fixated Lens Thomas Kohnen, Mehdi Shajari, Jose L. Güell,
Daniel Kook, Rudy M.M.A. Nuijts
175.1 Implanting the Kamra Small-Aperture Inlay Richard L. Lindstrom, Jay S. Pepose,
John A. Vukich

Total video running time: 2 hours 41 minutes

xiii
 Preface

The subspecialty of cornea and external disease has under-
gone significant transformation since the last edition of
Cornea. New diagnostic technology has vastly improved our
ability to detect disease. New medications and other thera-
peutic options have changed the treatment paradigm for
many disorders. And new surgical techniques have had a
remarkable impact on surgical outcomes. Not only do these
new procedures provide better outcomes but, in addition,
we can now offer surgical options earlier in the disease
process.
This edition of Cornea consists of numerous new chapters
and extensive revisions of existing chapters, as well as many
new surgical videos in order to keep pace with the dramatic
innovation in our field. The editors and authors have strived
to provide the most current material available for residents,
fellows, clinicians, and researchers to help in the manage-
ment of patients with cornea and external disease. We hope
this edition will benefit patients for years to come.
Mark J. Mannis
Edward J. Holland

xiv
 Acknowledgements
This fourth edition of Cornea is the result of an extraordinary,
coordinated effort by many talented individuals. We cannot
thank our contributing authors and co-authors enough. We
appreciate their excellent contributions of the most current
information on the diagnosis and management of cornea
and external disease. In addition, we thank these authors for
adhering to the tight editorial requirements in order to keep
this textbook current and on time.
We have enjoyed our continued relationship with our
publisher, Elsevier, who shares our goal: to provide the
highest quality medical textbook possible both in print and
electronic format. Special thanks to Sharon Nash and Russell
Gabbedy at Elsevier, who have motivated and guided us
along this journey.
Finally, we would like to thank our families, who continue
to provide support and the considerable time needed to
produce what we hope is an outstanding textbook.
xv
We dedicate this book to patients suffering from corneal blindness that we cannot
help at this time but hope to be able to help in the future.

Mark J. Mannis
Edward J. Holland
 Acknowledgement to
the Founding Editors

Jay H. Krachmer MD
Mark J. Mannis MD FACS
Edward J. Holland MD

First published in 1997 Cornea established itself as the
market-leading comprehensive title covering fundamentals,
diagnosis, medical and surgical treatment of cornea and
related external disorders. Continually used by practitioners
and trainees throughout the world, what started out as a
three volume book-set has now evolved into a complete
multimedia resource delivering content in print, online,
ebook, and video formats. We acknowledge the founding
editorial team who brought this project to fruition through
their tireless efforts, expertise, and devotion that started out
over 20 years ago.
Elsevier

xvii
 List of Contributors

Richard L Abbott MD M Camille Almond MD Mohammad Anwar FRCSEd, FRCOphth

Thomas W. Boyden Endowed Chair in Comprehensive Ophthalmology, Cornea, Senior Consultant Ophthalmic
Ophthalmology Refractive and Ocular Surface Disease Surgeon
Health Sciences Professor Partner Cornea and External Diseases
Cornea and External Diseases BayCare Eye Specialists Magrabi Eye Hospital
UCSF Department of Ophthalmology Green Bay, WI, USA Dubai, UAE
Research Associate Chapter 103 Chapter 117
Francis I. Proctor Foundation
San Francisco, CA, USA Shomoukh Al-Shamekh MD Penny A Asbell MD, FACS, MBA
Chapter 115 Research Fellow Professor of Ophthalmology
Department of Ophthalmology Director of Cornea and Refractive Services
Nisha R Acharya MD King Saud University Director of the Cornea Fellowship Program
Professor of Ophthalmology Riyadh, Saudi Arabia Department of Ophthalmology
Director, Uveitis Service Chapter 58 Icahn School of Medicine at Mount Sinai
F.I. Proctor Foundation New York, NY, USA
University of California, San Francisco Lênio Souza Alvarenga MD, PhD Chapter 98
San Francisco, CA, USA Country Medical Director-Brazil
Chapter 101 Roche Pharmaceuticals Dimitri T Azar MD
São Paulo, Brazil B.A. Field Chair of Ophthalmologic
Anthony J Aldave MD Chapter 42 Research
Walton Li Chair in Cornea and Uveitis Professor and Head
Chief, Cornea and Uveitis Division Wallace LM Alward MD Department of Ophthalmology and
Director, Cornea and Refractive Surgery Professor Visual Science
Fellowship Frederick C. Blodi Chair in Ophthalmology Illinois Eye and Ear Infirmary
The Jules Stein Eye Institute Department of Ophthalmology and Chicago, IL, USA
Los Angeles, CA, USA Visual Sciences Chapters 164; 165
Chapter 70 University of Iowa
Carver College of Medicine Irit Bahar MD, MHA
Eduardo C Alfonso MD Iowa City, IA, USA Associate Professor
Medical Director, Ocular Microbiology Chapter 56 Ophthalmology Department
Laboratory Rabin Medical Center
Professor, Edward W D Norton Chair in Renato Ambrósio Jr MD, PhD Tel Aviv University
Ophthalmology Associate Professor of Post Graduation Tel Aviv, Israel
Bascom Palmer Eye Institute in Ophthalmology Chapter 52
University of Miami Universidade Federal de São Paulo &
Miami, FL, USA Pontific Catholic University of Rio de Annie K Baik MD
Chapter 80 Janeiro Associate Professor
Rio de Janeiro, Brazil Department of Ophthalmology
Richard C Allen MD, PhD, FACS Chapters 13; 168 University of California, Davis
Professor Sacramento, CA, USA
Section of Ophthalmology Andrea Y Ang MBBS, MPH, FRANZCO Chapter 116
Department of Head and Neck Surgery Consultant Ophthalmologist
University of Texas MD Anderson Lions Eye Insitute Neal P Barney MD
Cancer Center Royal Perth Hospital Professor
Houston, TX, USA Perth, Australia Department of Ophthalmology and
Chapter 28 Chapter 54 Visual Sciences
University of Wisconsin
Zaina Al-Mohtaseb MD Marcus Ang MBBS, MMED, MCI, FAMS, School of Medicine and Public Health
Assistant Professor; Associate Residency FRCSEd Madison, WI, USA
Program Director Consultant Chapter 47
Department of Ophthalmology Corneal and External Eye Disease Service
Baylor College of Medicine Singapore National Eye Centre
Houston, TX, USA Singapore
Chapter 173 Chapter 127

xviii
 List of Contributors

Brendan C Barry BA Joseph M Biber MD Oleksiy Buznyk MD, PhD

Clinical Research Coordinator Cornea, Cataract, and Refractive Specialist Cornea and Oculoplastic Surgeon
Ophthalmology Partner Department of Eye Burns, Ophthalmic
Icahn School of Medicine at Mount Sinai Horizon Eye Care Reconstructive Surgery, Keratoplasty and
New York, NY, USA Charlotte, NC, USA Keratoprosthesis
Chapter 98 Chapters 76; 100 Filatov Institute of Eye Diseases & Tissue
Therapy of the NAMS of Ukraine
Allon Barsam MD, MA, FRCOphth Andrea D Birnbaum MD, PhD Odessa, Ukraine
Director Cornea and Refractive Surgery Assistant Professor of Ophthalmology Chapter 136
Department of Ophthalmology Northwestern University
Luton and Dunstable University Hospital Feinberg School of Medicine J Douglas Cameron MD, MBA
UCL Partners Chicago, IL, USA Professor
UK Chapters 101; 106 Departments of Ophthalmology and Visual
Chapter 147 Neuroscience and Laboratory Medicine
Kelley J Bohm BS and Pathology
Rebecca M Bartow MD Cornea Clinical Research Fellow University of Minnesota School of Medicine
Department of Ophthalmology Department of Ophthalmology Minneapolis, MN, USA
Marshfield Clinic Weill Cornell Medical College Chapters 2; 38
Marshfield, WI, USA New York City, NY, USA
Chapter 62 Chapter 33 Mauro Campos MD
Professor
Jules Baum MD Charles S Bouchard MD, MA Department of Ophthalmology and
Research Professor John P. Mulcahy Professor and Chairman Visual Sciences
Department of Ophthalmology Department of Ophthalmology Federal University of São Paulo
Tufts University School of Medicine Loyola University Health System São Paulo, Brazil
Boston, MA, USA Maywood, IL, USA Chapter 172
Chapter 41 Chapter 5
Emmett F Carpel MD
Michael W Belin MD Jay C Bradley MD Adjunct Professor
Professor of Ophthalmology and West Texas Eye Associates Department of Ophthalmology
Vision Science Cornea, External Disease, & Refractive University of Minnesota
University of Arizona Surgery Minneapolis, MN, USA
Tucson, AZ, USA Lubbock, TX, USA Chief, Division of Ophthalmology
Chapters 13; 154; 163 Chapter 113 Minneapolis VA Health Care System
Minneapolis, MN, USA
Medical Director and Chief of Staff
Jason H Bell MD James D Brandt MD Phillips Eye Institute
Senior Resident Professor & Vice-Chair of International
Minneapolis, MN, USA
University of Cincinnati Programs and New Technology
Chapter 73
University of Cincinnati Medical Center Director, Glaucoma Service
Cincinnati, OH, USA Department of Ophthalmology &
Chapter 145 Vision Science H Dwight Cavanagh MD, PhD, FACS
University of California, Davis Professor and Vice Chair Emeritus of
Ophthalmology
Beth Ann Benetz CRA, FOPS Sacramento, CA, USA
Medical Director, Transplant Services Center
Professor Chapter 116
at UT Southwestern Medical Center
Case Western Reserve University
Dallas, TX, USA
University Hospitals Case Medical Center Cat N Burkat MD, FACS Chapter 15
Cleveland, OH, USA Associate Professor
Chapter 14 Oculoplastic, Orbital, & Facial
Cosmetic Surgery Jean SM Chai MBBS, FAMS, FRCSEd
Consultant
Roger W Beuerman PhD Department of Ophthalmology and
Corneal and External Eye Disease Service
Senior Scientific Director and Professor Visual Sciences
University of Wisconsin-Madison Singapore National Eye Centre
Singapore Eye Research Institute and
Madison, WI, USA Singapore
Duke-NUS SRP Neuroscience and
Chapter 27 Chapter 156
Behavioral Disorders
Singapore
Chapter 3 Massimo Busin MD Winston Chamberlain MD, PhD
Professor of Ophthalmology Associate Professor
“Villa Igea” Private Hospital Department of Ophthalmology
Forli, Italy Casey Eye Institute
Chapter 130 Oregon Health and Science University
Portland, OR, USA
Chapter 17

xix
List of Contributors

Clara C Chan MD, FRCSC, FACS Mazen Y Choulakian MD, FRCSC Paulo Elias C Dantas MD, PhD
Assistant Professor Assistant Professor of Ophthalmology Professor of Ophthalmology
Department of Ophthalmology and Faculty of Medicine and Health Sciences Department of Ophthalmology, Corneal
Vision Sciences Université de Sherbrooke and External Disease Service
University of Toronto Sherbrooke, QC, Canada Santa Casa of São Paulo
Toronto, ON, Canada Chapters 42; 61 São Paulo, Brazil
Chapters 110; 153; 158; 169 Chapter 84
Gary Chung MD
Bernard H Chang MD Private Practice Mahshad Darvish-Zargar MDCM, MBA,
Private Practice Evergreen Eye Centers FRCSC
Cornea Consultants of Nashville Federal Way, WA, USA Assistant Professor
Nashville, TN, USA Chapter 91 Department of Ophthalmology
Chapter 87 McGill University
Joseph B Ciolino MD Montreal, QC, Canada
Edwin S Chen MD Assistant Professor of Ophthalmology Chapters 59; 62
Cornea and Anterior Segment Department of Ophthalmology
Scripps Memorial Hospital, La Jolla Massachusetts Eye and Ear Infirmary Richard S Davidson MD
La Jolla, CA, USA Boston, MA, USA Professor of Ophthalmology and Vice Chair
Chapter 129 Chapter 154 for Quality and Clinical Affairs
Cataract, Cornea, and Refractive Surgery
Michael C Chen MD Jessica Ciralsky MD University of Colorado Eye Center
Assistant Professor of Ophthalmology Assistant Professor University of Colorado School of Medicine
Penn State Eye Center Department of Ophthalmology Aurora, CO, USA
Penn State Milton S. Hershey Medical Weill Cornell Medical College Chapter 85
Center New York, NY, USA
Hershey, PA, USA Chapter 5 Sheraz M Daya MD, FACP, FACS, FRCS(Ed),
Chapter 111 FRCOphth
Maria Soledad Cortina MD Medical Director
Neil Chen BSc Assistant Professor of Ophthalmology Centre for Sight
Clinical Intern University of Illinois Eye and Ear Infirmary London, UK
Comite MD Department of Ophthalmology and Chapters 153; 158
New York, NY, USA Visual Sciences
Chapter 98 Chicago, IL, USA Ali R Djalilian MD
Chapters 90; 165 Associate Professor of Ophthalmology
Kenneth C Chern MD, MBA Department of Ophthalmology and
Managing Partner, Peninsula Alexandra Z Crawford BA, MBChB Visual Sciences
Ophthalmology Group Ophthalmology Registrar University of Illinois at Chicago
Associate Clinical Professor Department of Ophthalmology Chicago, IL, USA
Department of Ophthalmology and University of Auckland Chapters 33; 124; 153; 158; 159
Visual Sciences Auckland, New Zealand
University of California, San Francisco and Chapter 94 Eric D Donnenfeld MD, FACS
the Francis I. Proctor Foundation Clinical Professor of Ophthalmology
San Francisco, CA, USA Jose de la Cruz MD New York University Medical Center
Chapter 79 Assistant Professor Ophthalmology
Department of Ophthalmology New York, NY, USA
James Chodosh MD, MPH University of Illinois Eye and Ear Infirmary Chapters 138; 147
DG Cogan Professor of Ophthalmology Chicago, IL, USA
Massachusetts Eye and Ear Infirmary Chapter 151 Steven P Dunn MD
Harvard Medical School Professor
Boston, MA, USA Mausam R Damani MD Department of Ophthalmology
Chapters 150; 155 Cornea Fellow Oakland University William Beaumont
Department of Ophthalmology & School of Medical
Elaine W Chong MBBS, MEpi, PhD, Vision Science Rochester, MI, USA
FRANZCO UC Davis Eye Center Chapter 48
Consultant Ophthalmologist Sacramento, CA, USA
Royal Victorian Eye & Ear Hospital Chapter 108 Ralph C Eagle Jr MD
Melbourne, Victoria, Australia Director, Department of Pathology
Chapter 141 Wills Eye Hospital
Philadelphia, PA, USA
Chapter 18

xx
 List of Contributors

Allen O Eghrari MD Blake V Fausett MD, PhD Denise de Freitas MD

Assistant Professor of Ophthalmology Oculoplastics Fellow Professor
Wilmer Eye Institute Cincinnati Eye Institute Department of Ophthalmology and
Johns Hopkins University University of Cincinnati Visual Sciences
School of Medicine College of Medicine Paulista School of Medicine, São Paulo
Baltimore, MD, USA Department of Ophthalmology Hospital, Federal University of São Paulo
Chapter 11 Cincinnati, OH, USA (UNIFESP)
Chapter 28 São Paulo, Brazil
Richard A Eiferman MD, FACS Chapters 32; 123
Clinical Professor of Ophthalmology Robert S Feder MD, MBA
University of Louisville Professor of Ophthalmology Anat Galor MD, MSPH
Louisville, KY, USA Chief Cornea/External Disease Staff Physician, Associate Professor of
Chapter 138 Northwestern University Clinical Ophthalmology
Feinberg School of Medicine Bascom Palmer Eye Institute
Joseph A Eliason MD Chicago, IL, USA University of Miami
Clinical Professor of Ophthalmology Chapter 72 Miami, FL, USA
Department of Ophthalmology Chapter 80
Stanford University Vahid Feiz MD
School of Medicine Private Practice Prashant Garg MD
Palo Alto, CA, USA California Eye Clinic Consultant Ophthalmologist, Tej Kohli
Chapter 30 Walnut Creek, CA, USA Cornea Institute
Chapter 21 Senior Ophthalmologist, Tej Kohli Cornea
Daniel Elies MD Institute, Kallam Anji Reddy Campus
Cornea and Refractive Surgery Unit Sergio Felberg MD L V Prasad Eye Institute
Instituto de Microcirugía Ocular (IMO) Professor of Ophthalmology Hyderabad, India
Barcelona, Spain Department of Ophthalmology, Corneal Chapters 82; 92
Chapter 143 and External Disease Service
Santa Casa of São Paulo Sumit Garg MD
Per Fagerholm MD, PhD São Paulo, Brazil Assistant Professor
Professor Emeritus Chapter 84 Vice Chair of Clinical Ophthalmology
Department of Clinical and Experimental Gavin Herbert Eye Institute
Medicine – Ophthalmology Matthew T Feng MD University of California, Irvine
Faculty of Health Private Practice Irvine, CA, USA
University of Linköping Price Vision Group Chapters 112; 170
Linköping, Sweden Indianapolis, IN, USA
Chapter 136 Co-Medical Director William G Gensheimer MD, Maj, USAF
Indiana Lions Eye & Tissue Transplant Bank Chief of Cornea Service
Marjan Farid MD Indianapolis, IN, USA Warfighter Eye Center
Associate Professor of Ophthalmology Chapter 134 Malcolm Grow Medical Clinics and Surgery
Director of Cornea, Cataract, and Center (MGMCSC)
Refractive Surgery Luigi Fontana MD, PhD Joint Base Andrews, MD, USA
Gavin Herbert Eye Institute Director Chapter 85
University of California, Irvine Ophthalmic Unit
Irvine, CA, USA Arcispedale Santa Maria Nuova – IRCCS Elham Ghahari MD
Chapters 112; 170 Reggio Emilia, Italy Cornea Research Fellow
Chapter 118 Department of Ophthalmology and
Asim V Farooq MD Visual Sciences
Fellow in Cornea and External Disease Gary N Foulks MD University of Illinois at Chicago
Department of Ophthalmology and Emeritus Professor Chicago, IL, USA
Visual Sciences Department of Ophthalmology and Chapter 159
Washington University in St. Louis Vision Science
St. Louis, MO, USA University of Louisville David B Glasser MD
Chapter 124 Louisville, KY, USA Assistant Professor
Chapters 31; 114 Department of Ophthalmology
William J Faulkner MD Johns Hopkins University
Director School of Medicine
Urgents Clinic Baltimore, MD, USA
Cincinnati Eye Institute Chapter 26
Cincinnati, OH, USA
Chapter 9

xxi
 List of Contributors

Kenneth M Goins MD Steven A Greenstein MD Frederico P Guerra MD

Professor of Clinical Ophthalmology Cornea Fellow Medical Director of Centro Oftalmológico
Corneal and External Diseases Cornea and Laser Eye Institute – Hersh Jardim Icaraí
University of Iowa Hospitals and Clinics Vision Group Rio de Janeiro, Brazil
Iowa City, IA, USA Teaneck, NJ, USA Director of the Cornea Department of the
Chapters 9; 126 Department Ophthalmology Federal Hospital of Ipanema
Harvard Medical School Rio de Janeiro, Brazil
Kimberly K Gokoffski MD, PhD Boston, MA, USA Chapter 168
Resident Physician Chapter 148
Department of Ophthalmology & Preeya K Gupta MD
Vision Science Darren G Gregory MD Assistant Professor of Ophthalmology
Univerisity of California, Davis Associate Professor Cornea and Refractive Surgery
School of Medicine Department of Ophthalmology Duke University Eye Center
Sacramento, CA, USA University of Colorado Durham, NC, USA
Chapters 4; 35 School of Medicine Chapters 55; 114
Denver, CO, USA
Debra A Goldstein MD, FRCSC Chapter 50 M Bowes Hamill MD
Professor Professor of Ophthalmology
Director, Uveitis Service Mark A Greiner MD Cullen Eye Institute
Director, Uveitis Fellowship Assistant Professor Baylor College of Medicine
Department of Ophthalmology Cornea and External Diseases Department of Ophthalmology
Northwestern University Department of Ophthalmology and Houston, TX, USA
Feinberg School of Medicine Visual Sciences Chapters 93; 146
Chicago, IL, USA University of Iowa
Chapter 106 Carver College of Medicine Kristin M Hammersmith MD
Iowa City, IA, USA Assistant Surgeon
Jeffrey R Golen MD Chapters 9; 126; 131 Cornea Service
Assistant Professor in Cornea, External Wills Eye Hospital
Disease, and Refractive Surgery May Griffith PhD Instructor, Thomas Jefferson Medical
University of Virginia Professor of Regenerative Medicine College
Department of Ophthalmology Department of Clinical and Philadelphia, PA, USA
Charlottesville, VA, USA Experimental Medicine Chapter 18
Chapter 79 Linköping University
Linköping, Sweden Pedram Hamrah MD, FACS
Jose Gomes MD, PhD Chapter 136 Director, Center for Translational Ocular
Associate Professor & Director Immunology
Anterior Segment & Ocular Surface Oscar Gris MD Director, Anterior Segment Imaging, Boston
Advanced Center Cornea and Refractive Surgery Unit Image Reading Center
Department of Ophthalmology Instituto de Microcirugía Ocular (IMO) Cornea Service, New England Eye Center
Federal University of Sao Paulo Barcelona, Spain Tufts Medical Center
(UNIFESP/EPM) Chapter 143 Associate Professor, Department of
Sao Paulo, SP, Brazil Ophthalmology
Chapter 157 Erich B Groos Jr MD Tufts University School of Medicine
Partner Boston, MA, USA
John A Gonzales MD Cornea Consultants of Nashville Chapter 124
Assistant Professor Nashville, TN, USA
Department of Ophthalmology Chapter 87 Sadeer B Hannush MD
F.I. Proctor Foundation Attending Surgeon
University of California, San Francisco William D Gruzensky MD Cornea Service, Wills Eye Hospital
San Francisco, CA, USA Pacific Cataract and Laser Institute Department of Ophthalmology
Chapter 101 Olympia, WA, USA Sidney Kimmel Medical College of Thomas
Chapter 45 Jefferson University
John D Gottsch MD Medical Director
Lions Eye Bank of Delaware Valley
Professor of Ophthalmology Jose L Güell MD Philadelphia, PA, USA
Wilmer Eye Institute Director of Cornea and Refractive
Johns Hopkins University Chapters 109; 152
Surgery Unit
School of Medicine IMO. Instituto Microcirugia Ocular of
Baltimore, MD, USA Barcelona
Chapter 11 Associate Professor of Ophthalmology
UAB. Autònoma University of Barcelona
Barcelona, Spain
Chapters 143; 174

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 List of Contributors

David R Hardten MD Stephen Holland MD David Huang MD, PhD

Minnesota Eye Consultants Resident Peterson Professor of Ophthalmology
Director of Research, Cornea, Refractive Department of Ophthalmology Department of Ophthalmology
Surgery Loyola University Chicago Stritch School Casey Eye Institute
Department of Ophthalmology of Medicine Oregon Health and Science University
University of Minnesota & Minnesota Eye Maywood, IL, USA Portland, OR, USA
Consultants Chapter 103 Chapter 17
Minnetonka, MN, USA
Chapter 167 Augustine R Hong MD Jennifer I Hui MD, FACS
Assistant Professor Founder The Eyelid Institute
David G Heidemann MD Department of Ophthalmology (Palm Desert, CA)
Department of Ophthalmology Washington University Assistant Professor
William Beaumont Hospital St. Louis, MO, USA Department of Ophthalmology
Royal Oak, MI, USA Chapter 75 Loma Linda University School of Medicine
Chapter 48 Loma Linda, CA, USA
Marc A Honig MD Chapter 29
Peter S Hersh MD Clinical Instructor
Clinical Professor Wilmer Eye Institute, Johns Hopkins Alfonso Iovieno MD, PhD
Director, Cornea and Refractive Surgery University School of Medicine Cornea and Ocular Surface Unit
Department of Ophthalmology Clinical Assistant Professor Arcispedale Santa Maria Nuova – IRCCS
Rutgers Medical School Department of Ophthalmology and Reggio Emilia, Italy
Newark, NJ, USA Visual Sciences Chapter 118
Chapter 148 University of Maryland School of Medicine
Baltimore, MD, USA Joseph D Iuorno MD
Darren C Hill MD Chapter 137 Commonwealth Eye Care Associates
Resident Physician, PGY1 Richmond, VA, USA
Penn State College of Medicine Christopher T Hood MD Chapter 91
Hershey, PA, USA Clinical Assistant Professor
Chapter 138 Ophthalmology and Visual Sciences W Bruce Jackson MD, FRCSC
W.K. Kellogg Eye Center Professor
Ana Luisa Hofling-Lima MD University of Michigan Medical School Department of Ophthalmology
Head Professor at Ophthalmology Ann Arbor, MI, USA University of Ottawa Eye Institute
Department Escola Paulista de Medicina Chapter 65 Ottawa, ON, Canada
UNIFESP/EPM Chapter 164
São Paulo, Brazil Eliza N Hoskins MD
Chapter 149 Cornea Consultant Deborah S Jacobs MD
The Permanente Medical Group Medical Director
Edward J Holland MD Walnut Creek, CA, USA Boston Foundation for Sight
Director, Cornea Services Chapter 115 Needham, MA, USA
Cincinnati Eye Institute Associate Professor of Ophthalmology
Professor of Clinical Ophthalmology Joshua H Hou MD Harvard Medical School
University of Cincinnati Assistant Professor Boston, MA, USA
Cincinnati, OH, USA Department of Ophthalmology and Visual Chapter 97
Chapters 50; 53; 77; 108; 153; 157; 158; Neurosciences
159; 160 University of Minnesota Frederick A Jakobiec MD, DSc
Minneapolis, MN, USA Henry Willard Williams Professor Emeritus
Gary N Holland MD Chapter 2 of Ophthalmology and Pathology
Professor of Ophthalmology Former Chief and Chairman
Jack H. Skirball Chair in Ocular Kimberly Hsu MD Department of Ophthalmology
Inflammatory Diseases Clinical Fellow Massachusetts Eye and Ear Infirmary and
Cornea-External Ocular Disease Division / Department of Ophthalmology Harvard Medical School
Uveitis Service University of Illinois Eye and Ear Infirmary Director, David Glendenning Cogan
Department of Ophthalmology Chicago, IL, USA Laboratory of Ophthalmic Pathology
David Geffen School of Medicine at UCLA Chapter 151 Massachusetts Eye and Ear Infirmary
UCLA Stein Eye Institute Boston, MA, USA
Los Angeles, CA, USA Andrew JW Huang MD, MPH Chapters 36; 39
Chapter 65 Professor of Ophthalmology
Department of Ophthalmology and
Visual Sciences
Washington University
St. Louis, MO, USA
Chapter 75

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 List of Contributors

Bennie H Jeng MD, MS Robert C Kersten MD, FACS Shigeru Kinoshita MD, PhD
Professor and Chair Professor of Clinical Ophthalmology Professor and Chair
Department of Ophthalmology and University of California, San Francisco Department of Frontier Medical Science
Visual Sciences San Francisco, CA, USA and Technology for Ophthalmology
University of Maryland Chapter 27 Kyoto Prefectural University of Medicine
School of Medicine Kyoto, Japan
Baltimore, MD, USA Stephen S Khachikian MD Chapter 135
Chapters 65; 115 Cornea Fellow
Department of Ophthalmology Colin M Kirkness
James V Jester PhD Albany Medical College Formerly Tennent Professor of
Professor of Ophthalmology Albany, NY, USA Ophthalmology
Gavin Herbert Eye Institute Chapter 163 Department of Ophthalmology
University of California, Irvine Faculty of Medicine
Orange, CA, USA Rohit C Khanna MD University of Glasgow
Chapter 15 Director Gullapalli Pratibha Rao Glasgow, UK
International Centre for Advancement of Chapter 60
Madhura G Joag MD Rural Eye Care
Research Scholar Consultant Ophthalmologist, Tej Kohli Stephen D Klyce PhD, FARVO
Cornea Cornea Institute Adjunct Professor of Ophthalmology
Bascom Palmer Eye Institute L V Prasad Eye Institute Icahn School of Medicine at Mount Sinai
Miami, FL, USA Hyderabad, India New York, NY, USA
Chapter 20 Chapter 82 Chapter 12

David R Jordan MD, FRCSC Timothy T Khater MD, PhD Douglas D Koch MD
Professor of Ophthalmology Cornea, External Disease, Cataract, & Professor and Allen Mosbacher, and Law
University of Ottawa Eye Institute Refractive Surgery Specialist Chair in Ophthalmology
Ottawa, ON, Canada West Texas Eye Associates Cullen Eye Institute, Department of
Chapter 34 Lubbock, TX, USA Ophthalmology
Chapter 113 Baylor College of Medicine
Raageen Kanjee MD Houston, TX, USA
Ophthalmology Resident Eric J Kim BS Chapter 173
Department of Ophthalmology Research Fellow in Cataract and Refractive
University of Manitoba Surgery Thomas Kohnen MD, PhD, FEBO
Winnipeg, MB, Canada Department of Ophthalmology Professor and Chair
Chapter 106 Baylor College of Medicine Department of Ophthalmology
Houston, TX, USA Goethe University
Carol L Karp MD Chapter 12 Frankfurt, Germany
Professor of Ophthalmology Visiting Professor
Bascom Palmer Eye Institute Michelle J Kim MD Cullen Eye Institute
University of Miami Resident Physician Baylor College of Medicine
Miami, FL, USA Department of Ophthalmology Houston, TX, USA
Chapters 17; 20; 37 Duke Eye Center Chapter 174
Durham, NC, USA
Stephen C Kaufman MD, PhD Chapter 55 Noriko Koizumi MD, PhD
Professor and Vice-Chairman of Professor
Ophthalmology Stella K Kim MD Department of Biomedical Engineering
Director of Cornea and Refractive Surgery Joe M. Green Jr. Professor of Clinical Doshisha University
State University of New York – Downstate Ophthalmology Kyotanabe, Japan
Brooklyn and Manhattan, NY, USA Ruiz Department of Ophthalmology and Chapter 135
Chapter 19 Visual Science
University of Texas Health, Medical School Daniel Kook MD, PhD
Jeremy D Keenan MD, MPH Houston, TX, USA Smile Eyes Eye Clinic
Associate Professor of Ophthalmology Chapter 66 Munich Airport, Germany
Francis I. Proctor Foundation and Chapter 174
Department of Ophthalmology Terry Kim MD
University of California, San Francisco Professor of Ophthalmology Regis P Kowalski MS, M(ASCP)
San Francisco, CA, USA Duke University School of Medicine Professor
Chapter 43 Chief, Cornea and External Disease Service Department of Ophthalmology
Director, Refractive Surgery Service School of Medicine
Duke University Eye Center University of Pittsburgh
Durham, NC, USA Pittsburgh, PA, USA
Chapter 55 Chapter 10

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 List of Contributors

Friedrich E Kruse MD Yan Li PhD Timothy P Lindquist MD

Professor and Chair of Ophthalmology Research Assistant Professor Durrie Vision
Department of Ophthalmology Department of Ophthalmology Overland Park, KS, USA
University of Erlangen-Nuremberg Casey Eye Institute Clinical Instructor
Erlangen, Germany Oregon Health and Science University Department of Ophthalmology
Chapter 133 Portland, OR, USA University of Kansas
Chapter 17 Kansas City, KS, USA
Edward Lai MD Chapter 44
Assistant Professor of Ophthalmology Thomas M Lietman MD
Department of Ophthalmology Professor, Director of Francis I. Proctor Richard L Lindstrom MD
Weill Cornell Medical College Foundation Founder and Attending Surgeon, Minnesota
New York, NY, USA Departments of Ophthalmology and Eye Consultants
Chapter 5 Epidemiology and Biostatistics Adjunct Clinical Professor Emeritus
University of California, San Francisco University of Minnesota
Peter R Laibson MD San Francisco, CA, USA Department of Ophthalmology
Director Emeritus Chapter 43 Associate Director
Cornea Department Minnesota Lions Eye Bank
Wills Eye Hospital Michele C Lim MD Board Member
Philadelphia, PA, USA Professor of Ophthalmology University of Minnesota Foundation
Chapter 69 Vice Chair and Medical Director Visiting Professor
UC Davis Eye Center UC Irvine, Gavin Herbert Eye Institute
Irvine, CA, USA
Jonathan H Lass MD University of California, Davis
Chapter 175
Charles I Thomas Professor School of Medicine
Department of Ophthalmology and Sacramento, CA, USA
Visual Sciences Chapter 116 David Litoff MD
Case Western Reserve University Kaiser Permanente
University Hospitals Eye Institute Lily Koo Lin MD Chief of Ophthalmology
Cleveland, OH, USA Associate Professor Assistant Clinical Professor
Chapter 14 Department of Ophthalmology & Department of Ophthalmology
Vision Science University of Colorado
Lafayette, CO, USA
Samuel H Lee MD University of California, Davis
Chapter 24
Cornea and External Disease Health System
Sacramento Eye Consultants Sacramento, CA, USA
Sacramento, CA, USA Chapters 4; 35 Yu-Chi Liu MD, MCI
Chapter 64 Clinician
T Peter Lindquist MD Cornea and External Eye Disease Service
Singapore National Eye Centre
W Barry Lee MD, FACS Associate Medical Director, Georgia
Singapore
Medical Director, Georgia Eye Bank Eye Bank
SouthEast Eye Specialists Chapter 171
Cornea and Refractive Surgery Service
Eye Consultants of Atlanta/Piedmont Cornea, External Disease and Refractive
Hospital Surgery Eitan Livny MD
Atlanta, GA, USA Chattanooga, TN, USA Anterior Segment, Cornea and Cataract
Chapters 78; 128 Chapters 40; 128 Specialist
Department of Ophthalmology
Michael A Lemp MD Thomas D Lindquist MD, PhD Rabin Medical Center
Formerly Director, Cornea and External Petach Tiqva, Israel
Clinical Professor of Ophthalmology
Disease Service Chapter 52
Georgetown University and George
Washington University Department of Ophthalmology
Washington, DC, USA Group Health Cooperative Lorena LoVerde MD
Chapters 3; 8; 31 Bellevue, WA, USA Associate Professor
Clinical Professor Department of Ophthalmology
Department of Ophthalmology University of Cincinnati
Jennifer Y Li MD University of Washington Cincinnati, OH, USA
Associate Professor
School of Medicine Chapter 157
Department of Ophthalmology &
Seattle, WA, USA
Vision Science
University of California, Davis
Medical Director, SightLife Careen Y Lowder MD, PhD
Seattle, WA, USA Staff, Cole Eye Institute
Sacramento, CA, USA
Chapters 40; 44 Cleveland Clinic Foundation
Chapters 23; 89; 125
Cleveland, OH, USA
Chapter 65

xxv
 List of Contributors

Allan Luz MD, PhD Tova Mannis MD Woodford S Van Meter MD

Corneal Director of Hospital de Olhos Clinical Fellow Professor
de Sergipe F.I. Proctor Foundation Department of Ophthalmology
Department of Ophthalmology and University of California, San Francisco University of Kentucky School of Medicine
Visual Science San Francisco, CA, USA Lexington, KY, USA
Federal University of São Paulo Chapter 60 Chapter 110
São Paulo, Brazil
Chapter 13 Carlos E Martinez MD, MS Jay J Meyer MD, MPH
Chairman of Ophthalmology Cornea and Anterior Segment Fellow
Marian S Macsai MD Long Beach Memorial Hospital Department of Ophthalmology
Chief, Division of Ophthalmology Long Beach, CA, USA New Zealand National Eye Centre
NorthShore University HealthSystem Chapter 12 University of Auckland
Professor, University of Chicago Pritzker Auckland, New Zealand
School of Medicine Csaba L Mártonyi FOPS Chapter 94
Glenview, IL, USA Emeritus Associate Professor
Chapters 139; 144 Department of Ophthalmology and Shahzad I Mian MD
Visual Sciences Terry J. Bergstrom Professor
Mark Maio FOPS University of Michigan Medical School Associate Chair, Education
President Ann Arbor, MI, USA Residency Program Director
InVision, Inc Chapter 7 Associate Professor
Alpharetta, GA, USA University of Michigan
Chapter 7 Maite Sainz de la Maza MD, PhD Department of Ophthalmology
Associate Professor Ann Arbor, MI, USA
Jackie V Malling RN, CEBT Department of Ophthalmology Chapter 95
Chief Strategy Officer Hospital Clinic of Barcelona
Saving Sight Barcelona, Spain Darlene Miller DHSc, MPH, CIC
Kansas City, KS, USA Chapter 100 Research Associate Professor
Chapter 25 Department of Ophthalmology
Hall T McGee MD, MS Bascom Palmer Eye Institute
Amanda C Maltry MD Cornea & External Disease Specialist University of Miami
Assistant Professor Everett & Hurite Ophthalmic Association Miller School of Medicine
Department of Ophthalmology and Visual Pittsburgh, PA, USA Miami, FL, USA
Neuroscience Chapter 6 Chapter 80
University of Minnesota School of Medicine
Minneapolis, MN, USA Charles NJ McGhee MBChB, PhD, DSc, Naoyuki Morishige MD, PhD
Chapter 38 FRCS, FRCOphth, FRANZCO Associate Professor
Maurice Paykel Professor and Chair of Department of Ophthalmology
Paramdeep S Mand MD Ophthalmology Yamaguchi University
Associate Director, New Zealand National Eye Centre Graduate School of Medicine
Department of Ophthalmology Department of Ophthalmology Ube, Japan
Kaiser Permanente Faculty of Medical & Health Sciences Chapter 1
Riverside, CA, USA University of Auckland
Chapter 30 Auckland, New Zealand Merce Morral MD, PhD
Chapter 94 Anterior Segment Diseases, Cornea,
Felicidad Manero MD Cataract and Refractive Surgery Specialist
Ophthalmology Jodhbir Mehta BSc, MBBS, FRCS(Ed) Instituto Oftalmología Ocular (IMO)
IMO (Instituto de Microcirugía Ocular) Associate Professor Barcelona, Spain
Barcelona, Spain Corneal and External Disease Service Chapter 143
Chapter 143 Singapore National Eye Centre
Singapore Majid Moshirfar MD, FACS
Mark J Mannis MD, FACS Chapter 171 Professor of Clinical Ophthalmology,
Natalie Fosse Endowed Chair in Vision Co-director of Cornea & Refractive Surgery
Science Research David M Meisler MD Division
Professor and Chair Consultant, Cornea and External Diseases Department of Ophthalmology
Department of Ophthalmology & Cleveland Clinic Foundation University of California, San Francisco
Vision Science Cleveland, OH, USA San Francisco, CA, USA
University of California Davis Eye Center Chapter 65 Chapter 138
Sacramento, CA, USA
Chapters 42; 51; 60; 70; 108; 111; 125; Adam Moss MD, MBA
142; 160 McCannel Eye Clinic
Edina, MN, USA
Chapter 121

xxvi

Asadolah Movahedan MD
Resident of Ophthalmology
Department of Ophthalmology
University of Chicago
Chicago, IL, USA
Chapter 124
Parveen Nagra MD
Asssistant Surgeon
Wills Eye Hospital
Assistant Professor
Jefferson Medical College
Philadelphia, PA, USA
Chapter 18
Afshan A Nanji MD, MPH
Assistant Professor
Department of Ophthalmology
Casey Eye Institute
Oregon Health and Science University
Portland, OR, USA
Chapter 17
Leslie C Neems MD
Ophthalmology Resident Physician
Northwestern University
Feinberg School of Medicine
Chicago, IL, USA
Chapter 72
Kristiana D Neff MD
Partner
Carolina Cataract & Laser Center
Charleston, SC, USA
Chapter 53
J Daniel Nelson MD, FACS
Professor of Ophthalmology
University of Minnesota
Associate Medical Director
HealthPartners Medical Group
Minneapolis, MN, USA
Chapter 2
Jeffrey A Nerad MD
Partner, Cincinnati Eye Institute
Professor of Ophthalmology
University of Cincinnati
Cincinnati, OH, USA
Chapter 28
Marcelo V Netto MD, PhD
Department of Ophthalmology
University of São Paulo
São Paulo, Brazil
Medical Director
Instituto Oftalmológico Paulista
São Paulo, Brazil
Chapter 168
List of Contributors
Jacqueline Ng MD Karen W Oxford MD
Department of Ophthalmology Director, Cornea and Refractive Surgery
Cornea Division Pacific Eye Associates
University of California, Irvine Clinical Professor of Ophthalmology
Gavin Herbert Eye Institute California Pacific Medical Center
Irvine, CA, USA San Francisco, CA, USA
Chapter 170 Chapter 115
Lisa M Nijm MD, JD David A Palay MD
Medical & Surgical Director Associate Clinical Professor
Warrenville EyeCare and LASIK Department of Ophthalmology
Warrenville, IL, USA Emory University School of Medicine
Assistant Clinical Professor of Atlanta, GA, USA
Ophthalmology Chapter 22
University of Illinois Eye and Ear Infirmary
Department of Ophthalmology and Sotiria Palioura MD, PhD
Visual Sciences Instructor
Chicago, IL, USA Department of Ophthalmology
Chapters 88; 108 Bascom Palmer Eye Institute
University of Miami
Ken K Nischal MD, FRCOphth Miller School of Medicine
Professor of Ophthalmology Miami, FL, USA
Director of Pediatric Ophthalmology Chapter 66
Strabismus and Adult Motility
UPMC Eye Center Deval R Paranjpe MD, ScB
Children’s Hospital of Pittsburgh of UPMC Assistant Professor of Ophthalmology
University of Pittsburgh Drexel University College of Medicine
Pittsburgh, PA, USA Pittsburgh, PA, USA
Chapter 122 Chapter 60
Teruo Nishida MD, DSc Mansi Parikh MD
Professor Emeritus Assistant Professor
Department of Ophthalmology Casey Eye Institute
Graduate School of Medicine Oregon Health and Sciences University
Yamaguchi University Portland, OR, USA
Ube, Japan Chapter 56
Chapter 1
Matthew R Parsons MD
M Cristina Nishiwaki-Dantas MD Chief
Professor of Ophthalmology Corneal Service
Department of Ophthalmology, Corneal Excel Eye Center
and External Disease Service Provo, UT, USA
Santa Casa of São Paulo Chapter 88
São Paulo, Brazil
Chapter 84
Sirichai Pasadhika MD
Director of Vitreoretinal Services
Rudy MMA Nuijts MD, PhD Devers Eye Institute
Professor of Ophthalmology Legacy Health System
University Eye Clinic Maastricht Portland, OR, USA
Medical University Center Maastricht Affiliate Instructor
Maastricht, The Netherlands Casey Eye Institute
Chapter 174
Oregon Health & Science University
Portland, OR, USA
Robert B Nussenblatt MD, MPH Chapter 102
Formerly Chief, Laboratory of Immunology
National Eye Institute, NIH Dipika V Patel PhD, MRCOphth
Bethesda, MD, USA Associate Professor
Chapter 101 Department of Ophthalmology
New Zealand National Eye Centre
University of Auckland
Auckland, New Zealand
Chapter 94
xxvii
 List of Contributors

Charles J Pavlin MD, FRCS(Can) Stephen C Pflugfelder MD Christopher J Rapuano MD

Formerly Professor, University of Toronto Professor Professor, Department of Ophthalmology
Department of Ophthalmology Ophthalmology Sidney Kimmel Medical College at Thomas
Mount Sinai Hospital Baylor College of Medicine Jefferson University
Toronto, ON, Canada Houston, TX, USA Chief, Cornea Service
Chapter 16 Chapter 33 Wills Eye Hospital
Philadelphia, PA, USA
Eric S Pearlstein MD Francis W Price Jr MD Chapters 18; 137; 140
Clinical Assistant Professor President
Department of Ophthalmology Price Vision Group Jagadesh C Reddy MD
SUNY Downstate Medical Center Indianapolis, IN, USA Assistant Ophthalmologist
Brooklyn, NY, USA President of the Board Tej Kohli Cornea Institute, Kallam Anji
Chapter 99 Cornea Research Foundation of America Reddy Campus
Indianapolis, IN, USA L V Prasad Eye Institute
Jay S Pepose MD, PhD Chapter 134 Hyderabad, India
Professor of Clinical Ophthalmology and Chapter 92
Visual Sciences Marianne O Price PhD, MBA
Washington University School of Medicine Executive Director Ellen Redenbo CDOS, ROUB, CRA
St. Louis, MO, USA Cornea Research Foundation of America Imaging Center Supervisor
Chapter 175 Indianapolis, IN, USA Department of Ophthalmology
Chapter 134 UC Davis Eye Center
Robert J Peralta MD Sacramento, CA, USA
Ophthalmic Plastic and Reconstructive Louis E Probst MD Chapter 16
Surgery National Medical Director
Kaiser Permanente TLC The Laser Eye Centers James J Reidy MD
Oakland, CA, USA Chicago, IL, USA Associate Professor
Chapter 6 Chapters 166; 169 Vice Chair of Clinical Affairs
Department of Ophthalmology and
Mauricio A Perez MD Michael B Raizman MD Visual Science
Cornea, Cataract & Refractive Surgery Ophthalmic Consultants of Boston University of Chicago Medicine and
Department Associate Professor of Ophthalmology Biological Sciences
Clínica de Enfermedades de la Visión / Tufts University School of Medicine Chicago, IL, USA
Clínica Las Condes / Hospital Salvador / Boston, MA, USA Chapter 74
Fundación Imagina Chapter 100
Volunteer Faculty University of Chile Charles D Reilly MD
Santiago, Chile Leela V Raju MD Managing Partner
Chapters 110; 164 Eye Physicians and Surgeons Rashid, Rice, Flynn and Reilly Eye
Clinical Instructor Associates
Victor L Perez MD New York Eye and Ear Infirmary Clinical Assistant Professor
Professor of Ophthalmology Brooklyn, NY, USA Department of Ophthalmology
Walter G. Ross Chair in Ophthalmic Chapter 173 University of Texas Health Science Center
Research San Antonio
San Antonio, TX, USA
Bascom Palmer Eye Institute Gullapalli N Rao MD Chapters 51; 161
University of Miami Chair
Miller School of Medicine L V Prasad Eye Institute
Miami, FL, USA Hyderabad, India Adimara da Candelaria Renesto MD
Chapters 49; 66 Chapter 82 Fellow of Refractive Surgery
Department of Ophthalmology and
Alicia Perry BA Duna Raoof MD Visual Sciences
Ophthalmic Consultants of Long Island Federal University of São Paulo
Cornea, Cataract, and Refractive Surgery
New York, NY, USA Vision Institute IPEPO
Specialist
Chapter 138 São Paulo, Brazil
Harvard Eye Associates
Chapter 172
Laguna Hills, CA, USA
W Matthew Petroll PhD Clinical Instructor
Professor Harbor-University of California Los Angeles Andri K Riau MSc
Department of Ophthalmology Torrence, CA, USA Research Associate
UT Southwestern Medical Center Chapters 150; 155 Tissue Engineering and Stem Cell Group
Dallas, TX, USA Singapore Eye Research Institute
Chapter 15 Singapore
Chapter 171

xxviii
 List of Contributors

Lorena Riveroll-Hannush MD Shizuya Saika MD, PhD Rony R Sayegh MD

Clinical Director Professor and Chairman Assistant Professor
Oxford Valley Laser Vision Center Department of Ophthalmology Department of Ophthalmology
Langhorne, PA, USA Wakayama Medical University University Hospitals Case Medical Center
Cornea Service School of Medicine Case Western Reserve University
Asociación Para Evitar La Ceguera Wakayama, Japan School of Medicine
Hospital Dr. Luis Sánchez Bulnes Chapter 1 Cleveland, OH, USA
Mexico City, Mexico Chapter 14
Chapters 109; 152 Mario J Saldanha DO, FRCS, FRCOphth
Cornea, External Disease and Refractive Gregory A Schmidt BS, CEBT
Allison E Rizzuti MD Surgery Fellow Iowa Lions Eye Bank
Clinical Assistant Professor Ophthalmology Coralville, IA, USA
Department of Ophthalmology Toronto Western Hospital Chapter 126
State University of New York, Downstate University of Toronto
Medical Center Toronto, ON, Canada Miriam T Schteingart MD
Brooklyn, NY, USA Chapter 169 Physician
Chapter 19 Andersen Eye Associates
James J Salz MD Saginaw, MI, USA
Danielle M Robertson OD, PhD Clinical Professor, Ophthalmoloygy Chapter 104
Associate Professor University of Southern California
Department of Ophthalmology Keck Medical School Ivan R Schwab MD, FACS
University of Texas Southwestern Los Angeles, CA, USA Professor of Ophthalmology
Medical Center Chapter 162 Department of Ophthalmology
Dallas, TX, USA University of California, Davis
Chapter 97 Virender S Sangwan MD Sacramento, CA, USA
Dr. Paul Dubord Chair in Cornea Chapters 64; 86
Ashley Rohr MD Director, Center for Ocular Regeneration
Cornea Fellow (CORE) Brian L Schwam MD
Department of Ophthalmology Director, Srujana-Center for Innovation Vice President and Chief Medical Officer
Manhattan Eye, Ear, and Throat Hospital/ Kallam Anji Reddy Campus Johnson and Johnson Vision Care
Northshore-LIJ Health System L V Prasad Eye Institute Jacksonville, FL, USA
New York, NY, USA Hyderabad, India Chapter 100
Chapters 139; 144 Chapter 92
Gary S Schwartz MD
David S Rootman MD, FRCSC Caterina Sarnicola MD Adjunct Associate Professor
Professor, University of Toronto Resident Department of Ophthalmology
Toronto Western Hospital University of Ferrara University of Minnesota
Toronto, ON, Canada Ferrara, Italy School of Medicine
Chapter 164 Chapter 120 Minneapolis, MN, USA
Chapters 53; 77; 157; 158
James T Rosenbaum MD Enrica Sarnicola MD
Chief of Ophthalmology Resident Vincenzo Scorcia MD
Devers Eye Institute University of Siena Associate Professor
Legacy Health System Siena, Italy Department of Ophthalmology
Portland, OR, USA Chapter 120 University of Magna Graecia
Professor Catanzaro, Italy
Departments of Ophthalmology, Medicine, Vincenzo Sarnicola MD Chapter 130
and Cell Biology Director
Casey Eye Institute
Oregon Health & Science University
Private Practice H Nida Sen MD, MHS
“Clinica degli occhi Sarnicola” National Eye Institute
Portland, OR, USA Grosseto, Italy National Institutes of Health
Chapter 102 Professor Bethesda, MD, USA
Department of Ophthalmology Chapter 101
Alan E Sadowsky MD University of Siena
Adjunct Assistant Professor Siena, Italy
Department of Ophthalmology Chapter 120
Boris Severinsky OD, MOptom
Contact Lens Service
University of Minnesota
Department of Ophthalmology
Fairview Medical Group Ibrahim O Sayed-Ahmed MD Hadassah University Hospital
Fridley, MN, USA Research Fellow Jerusalem, Israel
Chapter 63 Cornea Chapter 97
Bascom Palmer Eye Institute
Miami, FL, USA
Chapter 20

xxix
 List of Contributors

Kevin J Shah MD Kavitha R Sivaraman MD Anna M Stagner MD

Staff Surgeon Fellow, Cornea and External Disease Ophthalmic Pathology Fellow
Department of Ophthalmology Bascom Palmer Eye Institute David Glendenning Cogan Laboratory of
Cole Eye Institute, Cleveland Clinic University of Miami Miller Ophthalmic Pathology
Foundation School of Medicine Massachusetts Eye and Ear Infirmary
Cleveland, OH, USA Miami, FL, USA Boston, MA, USA
Chapters 77; 131; 160 Chapter 37 Chapters 36; 39

Mehdi Shajari MD Craig A Skolnick MD Christopher E Starr MD

Department of Ophthalmology President Associate Professor of Ophthalmology
Goethe University Skolnick Eye Institute Director, Cornea, Cataract & Refractive
Frankfurt, Germany Jupiter, FL, USA Surgery Fellowship
Chapter 174 Chapter 96 Director, Refractive Surgery Service
Director, Ophthalmic Education
Neda Shamie MD Allan R Slomovic MSc, MD, FRCS(C) Weill Cornell Medical College
Cornea, Refractive and Cataract Surgeon Marta and Owen Boris Endowed Chair in New York Presbyterian Hospital
Advanced Vision Care Cornea and Stem Cell Research New York, NY, USA
Los Angeles, CA, USA Professor of Ophthalmology Chapter 33
Chapter 132 University of Toronto
Research Director, Cornea Service Roger F Steinert MD
Brett Shapiro MD University Health Network Irving H Leopold Professor
Attending Ophthalmologist President, Canadian Ophthalmological Chair of Ophthalmology
Kaiser Permanente, Hawai’i Region Society Professor of Biomedical Engineering
Wailuku, Maui, HI, USA Toronto Western Hospital Director, Gavin Herbert Eye Institute
Chapter 21 Toronto, ON, Canada University of California
Chapters 52; 57 Irvine, CA, USA
Chapters 112; 170
Raneen Shehadeh-Mashor MD
Ophthalmologist, Corneal specialist Michael E Snyder MD
Department of Ophthalmology, Bnai Zion Board of Directors, Cincinnati Eye Institute Bazil TL Stoica MD
Medical Center Chair, Clinical Research Steering Oculoplastic Fellow
Institute – Technion Committee Department of Ophthalmology
Haifa, Israel Volunteer Faculty, University of Cincinnati University of Ottawa
Chapter 57 Cincinnati, OH, USA Ottawa, ON, Canada
Chapter 145 Chapter 34
Shigeto Shimmura MD, PhD
Associate Professor Renée Solomon MD Michael D Straiko MD
Department of Ophthalmology Private Practice Associate Director of Corneal Services
Keio University School of Medicine New York, NY, USA Devers Eye Institute
Tokyo, Japan Chapter 138 Legacy Health System
Chapter 119 Portland, OR, USA
Sarkis H Soukiasian MD Chapter 131
Thomas S Shute MD, MS Assistant Professor of Ophthalmology
Department of Ophthalmology and Tufts University School of Medicine Alan Sugar MD
Visual Sciences Director, Corneal and External Disease Professor and Vice-Chair
Washington University School of Medicine Department of Ophthalmology Ophthalmology and Visual Sciences
St. Louis, MO, USA Lahey Health W.K. Kellogg Eye Center
Chapter 75 Burlington, MA, USA University of Michigan Medical School
Chapter 41 Ann Arbor, MI, USA
Chapter 95
Patricia B Sierra MD
Cornea, Cataract and Refractive Surgery Luciene Barbosa de Sousa MD
Sacramento Eye Consultants Head of Cornea Section Joel Sugar MD
Sacramento, CA, USA Federal University of São Paulo Professor and Vice-Head
Chapter 167 São Paulo, Brazil Ophthalmology and Visual Sciences
Chapter 70 Illinois Eye and Ear Infirmary
University of Illinois College of Medicine
Francisco Bandeira e Silva MD
Post-graduation Student Sathish Srinivasan FRCSEd, FRCOphth, Chicago, IL, USA
FACS Chapters 67; 90
Department of Ophthalmology
Paulista School of Medicine Consultant Corneal Surgeon
Federal University of São Paulo Joint Clinical Director Christopher N Ta MD
São Paulo, Brazil Department of Ophthalmology Professor
Chapter 149 University Hospital Ayr Byers Eye Institute at Stanford
Ayr, Scotland, UK School of Medicine
Chapter 57 Palo Alto, CA, USA
Chapter 46

xxx
 List of Contributors

Khalid F Tabbara MD Elias I Traboulsi MD, MEd David D Verdier MD

Adjunct Professor Professor Clinical Professor
Department of Ophthalmology Cole Eye Institute Department of Surgery, Ophthalmology
Wilmer Institute Cleveland Clinic Lerner College of Division
Johns Hopkins University Medicine Michigan State University
Baltimore, MD, USA Case University College of Human Medicine
Medical Director Cleveland, OH, USA Grand Rapids, MI, USA
The Eye Center Chapter 58 Chapter 110
Riyadh, Saudi Arabia
Chapter 105 William Trattler MD Laura A Vickers MD
Director of Cornea Chief Resident
Donald TH Tan FRCSG, FRCSE, FRCOphth, Center for Excellence in Eye Care Duke University Eye Center
FAMS Miami, FL, USA Durham, NC, USA
Arthur Lim Professor in Ophthalmology Chapter 162 Chapter 114
Ophthalmology and Visual Sciences
Academic Clinical Program, Duke-NUS Matthew GJ Trese MA Ana Carolina Vieira MD, PhD
Graduate Medical School, Singapore Clinical Research Intern Cornea and External Diseases Specialist
Singapore National Eye Centre Department of Ophthalmology and Department of Ophthalmology
Singapore Visual Sciences State University of Rio de Janeiro
Chapters 127; 141; 156 Kellogg Eye Center, University of Michigan Rio de Janeiro, Brazil
Ann Arbor, MI, USA Chapters 86; 142
Maolong Tang PhD Chapter 95
Research Assistant Professor Jesse M Vislisel MD
Department of Ophthalmology David T Tse MD, FACS Fellow
Casey Eye Institute Professor of Ophthalmology Department of Ophthalmology and
Oregon Health and Science University Dr Nasser Ibrahim Al-Rashid Chair in Vision Science
Portland, OR, USA Ophthalmic Plastic Orbital Surgery and University of Iowa
Chapter 17 Oncology Iowa City, IA, USA
Bascom Palmer Eye Institute Chapter 9
Joseph Tauber MD Miami, FL, USA
Tauber Eye Center Chapter 29 An Vo MD
Kansas City, MO, USA Cornea and External Disease Fellow
Chapter 107 Elmer Y Tu MD Department of Ophthalmology
Professor of Clinical Ophthalmology Icahn School of Medicine at Mount Sinai
Shabnam Taylor MD Department of Ophthalmology and New York, NY, USA
Resident Physician Visual Science Chapter 98
Department of Ophthalmology University of Illinois Eye and Ear Infirmary
University of California, Davis Chicago, IL, USA Rosalind C Vo MD
Sacramento, CA, USA Chapter 81 Associate Physician
Chapter 89 Southern California Permanente Medical
Pravin K Vaddavalli MD Group
Mark A Terry MD Consultant Ophthalmologist Los Angeles, CA, USA
Director, Corneal Services, Devers Eye Tej Kohli Cornea Institute Clinical Instructor
Institute LV Prasad Eye Institute UCLA David Geffen School of Medicine
Professor, Clinical Ophthalmology Hyderabad, India Los Angeles, CA, USA
Oregon Health Sciences University Chapter 82 Chapter 70
Portland, OR, USA
Chapter 129 Felipe A Valenzuela MD John A Vukich MD
Clinical Fellow Clinical Adjunct Assistant Professor of
Howard H Tessler MD Department of Ophthalmology Ophthalmology and Visual Sciences
Professor Emeritus of Ophthalmology Bascom Palmer Eye Institute University of Wisconsin Madison
University of Illinois at Chicago University of Miami School of Medicine
Chicago, IL, USA Miller School of Medicine Madison, WI, USA
Chapters 104; 106 Miami, FL, USA Chapter 175
Chapter 49
Theofilos Tourtas MD Matthew Wade MD
Consultant Ophthalmic Surgeon Gary A Varley MD Assistant Professor of Ophthalmology
Corneal and External Disease Service Cincinnati Eye Institute Gavin Herbert Eye Institute
Department of Ophthalmology Cincinnati, OH, USA University of California
University of Erlangen-Nuremberg Chapter 9 Irvine, CA, USA
Erlangen, Germany Chapters 112; 170
Chapter 133

xxxi
 List of Contributors

Jay C Wang MD Jessica E Weinstein MD Steven E Wilson MD, FARVO

Ophthalmology Resident Resident Physician Professor of Ophthalmology
Department of Ophthalmology Department of Ophthalmology Cole Eye Institute
Massachusetts Eye and Ear Infirmary Louisiana State Health Sciences Center Cleveland Clinic
Boston, MA, USA New Orleans, LA, USA Cleveland, OH, USA
Chapter 154 Chapter 71 Chapter 168

Li Wang MD, PhD Jayne S Weiss MD Elizabeth Yeu MD

Associate Professor Professor and Chair, Department of Assistant Professor of Ophthalmology
Department of Ophthalmology Ophthalmology Eastern Virginia Medical School
Baylor College of Medicine Associate Dean of Clinical Affairs, Virginia Eye Consultants
Houston, TX, USA Herbert E Kaufman, MD Endowed Chair Cornea, Cataract, Anterior Segment and
Chapter 173 in Ophthalmology Refractive Surgery
Professor of Pharmacology and Pathology Norfolk, VA, USA
George O Waring III MD, FACS, FRCOphth Director, Louisiana State University Eye Chapter 163
Formerly Founding Surgeon Center of Excellence
InView Louisiana State University Charles Q Yu MD
Atlanta, GA, USA School of Medicine Assistant Professor
Chapter 5 New Orleans, LA, USA Illinois Eye and Ear Infirmary
Chapters 68; 71 University of Illinois Chicago
George O Waring IV MD, FACS Chicago, IL, USA
Assistant Professor of Ophthalmology Julia M Weller MD Chapter 46
Director of Refractive Surgery Cornea Fellow
Adjunct Assistant Professor of Department of Ophthalmology Dagny Zhu MD
Bioengineering University of Erlangen-Nuremberg Resident Physician
Medical University of South Carolina Erlangen, Germany Department of Ophthalmology
Clemson University Chapter 133 University of Southern California
College of Engineering and Science Los Angeles, CA, USA
Storm Eye Institute Kirk R Wilhelmus MD, PhD Chapter 132
Charleston, SC, USA Professor Emeritus
Chapter 161 Department of Ophthalmology Mohammed Ziaei MBChB (Hons),
Baylor College of Medicine FRCOphth
Michael A Warner MD Houston, TX, USA Corneal Fellow
Clinical Instructor Chapter 83 Moorfields Eye Hospital
Oregon Health and Sciences University London, UK
Portland, OR, USA Samantha Williamson MD Chapter 147
Chapters 36; 39 Clinical Fellow
Department of Ophthalmology
Mitchell P Weikert MD University of Illinois Eye and Ear Infirmary
Associate Professor Chicago, IL, USA
Department of Ophthalmology Chapters 67; 151
Baylor College of Medicine
Houston, TX, USA
Chapters 12; 173

xxxii
Part i Basic Science: Cornea, Sclera, Ocular Adnexa Anatomy, Physiology and Pathophysiologic Responses
 
Chapter 1
Cornea and Sclera: Anatomy and Physiology
Teruo Nishida, Shizuya Saika, Naoyuki Morishige
Key Concepts
• The cornea and sclera form the outer shell of the eye.
• The principal physiological role of the cornea is to allow
external light to enter the eye and to contribute to its
focusing on the retina. Transparency and refractive
power are, thus, essential for this function.
• The cornea consists of the epithelium, Bowman’s layer,
stroma, Descemet membrane, and endothelium.
• The functions of the corneal epithelium are regulated by
various biologically active agents such as growth
factors, cytokines, and chemokines in tear fluid,
whereas those of the endothelium are regulated by
factors in aqueous humor.
• Dynamic homeostasis of the corneal epithelium is
maintained by the generation of new epithelial cells
from limbal stem cells, centripetal cell movement,
differentiation of basal cells into wing cells and then
superficial cells, and cell desquamation via apoptosis.
• The corneal stroma is composed primarily of
extracellular matrix, predominantly type I collagen and
proteoglycans. Collagen fibrils are homogeneous in
diameter and are aligned at a constant distance to
maintain tissue transparency. Keratocytes are the
resident cells of the stroma, and although relatively few
in number, they play important roles in the maintenance
of stromal structure through synthesis and secretion as
well as degradation of collagen and proteoglycans.
• The cornea is one of the most sensitive tissues in the
body as a result of its abundant sensory nerve endings.
Neural regulation is, thus, another important factor in
the maintenance of corneal structure and function.
• Morphogenesis of the eye is achieved by cell lineages
of various origins including the surface and neural
ectoderm during embryonic development.
Characterization of the development of ocular tissues
during embryogenesis is important for understanding
the pathogenesis of congenital anomalies of the cornea
and anterior eye segment.
Introduction
The avascular cornea is not an isolated tissue. It forms,
together with the sclera, the outer shell of the eye, occupying
one-third of the ocular tunic. Although most of both the
cornea and sclera consists of dense connective tissue, the
physiological roles of these two components of the eye shell
differ. The cornea serves as the transparent “window” of the
eye that allows the entry of light, whereas the sclera provides
a “dark box” that allows the formation of an image on the
retina. The cornea is exposed to the outer environment,
whereas the opaque sclera is covered with the semitranspar-
ent conjunctiva and has no direct exposure to the outside.
The differences in the functions of the cornea and sclera
reflect those in their microscopic structures and biochemical
components (Fig. 1.1).
Interwoven fibrous collagen is responsible for the mechan-
ical strength of both the cornea and sclera, protecting the
inner components of the eye from physical injury and main-
taining the ocular contour.1 The corneal epithelium forms
an effective mechanical barrier as a result of the interdigita-
tion of cell membranes and the formation of junctional
complexes such as tight junctions and desmosomes between
adjacent cells. Together with the cellular and chemical
components of the conjunctiva and tear film, the corneal
surface protects against potential pathological agents and
microorganisms.
The smooth surface of the cornea contributes to visual
clarity. The regular arrangement of collagen fibrils in the
corneal stroma accounts for the transparency of this tissue.2,3
Maintenance of corneal shape and transparency is critical
for light refraction, with the cornea accounting for more
than two-thirds of the total refractive power of the eye. A
functionally intact corneal endothelium is important for
maintenance of stromal transparency as a result of regula-
tion by the endothelium of corneal hydration. The cornea
thus plays a central role in vision as a result of its transpar-
ency and refractive power, and it maintains the eye shell.
Each part of the cornea contributes to its transparency and
shape, and its anatomy is closely related to its physiology
and function.
Anatomy and Physiology
Structure of the cornea and sclera
The ocular surface is composed of the cornea, conjunctiva,
lacrimal glands, and other adnexa. The outermost portion
of the cornea and conjunctiva is an epithelium that directly
1
 CHAPTER 1
Cornea and Sclera: Anatomy and Physiology

Chapter Outline
Introduction
Anatomy and Physiology
Development of the Anterior Eye Segment

1.e1
PART i BASIC SCIENCE

 

Fig. 1.1 Anatomy of the human

cornea. (A) Slit lamp microscopic
(1) view of the cornea. (B) Histology of
(2) the cornea showing the epithelium
(1), Bowman’s layer (2), stroma (3),
Descemet membrane (4), and
endothelium (5).

(3)

(4)
A B
(5)

faces the environment. The anterior corneal surface is

covered by tear fluid, which protects the cornea from dehy-
dration and helps to maintain a smooth epithelial surface.
*
Tear fluid contains many biologically important ions and *
molecules, including electrolytes, glucose, immunoglobu-
lins, lactoferrin, lysozyme, albumin, and oxygen. Moreover,
it contains a wide range of biologically active substances
such as histamine, prostaglandins, growth factors, and cyto-
kines.4 The tear film thus serves not only as a lubricant and
source of oxygen and nutrients for the corneal epithelium
but also as a source of regulatory factors required for epithe-
lial maintenance and repair. The posterior surface of the
cornea is bathed directly by the aqueous humor. The highly
vascularized limbus, which is thought to contain a reservoir
of pluripotent stem cells, constitutes the transition zone
between the cornea and the sclera or conjunctiva. The struc-
ture and function of the corneal epithelium and endothe-
lium are, therefore, regulated by biologically active factors
present in tear fluid and aqueous humor, respectively.
The sclera, a tough and nontransparent tissue, shapes the
eye shell, which is approximately 24 mm in diameter in the
emmetropic eye. The sclera is the continuation of the corneal
A B
stroma and does not directly face the environment. The
anterior part of the sclera is covered with the bulbar con-
Fig. 1.2 Histology of the human sclera. (A) Hematoxylin-eosin staining
junctiva and Tenon’s capsule, which consists of loose con-
of a cross-section of the sclera. Blood vessels (asterisks) are largely
nective tissue and is located beneath the conjunctiva (Fig. restricted to the episclera (upper region of section). (B) Higher-
1.2). The nontransparency of the sclera prevents light from magnification view of the conjunctiva and episclera as well as of stromal
reaching the retina other than through the cornea, and, fibroblasts (arrows) in the sclera. Bar, 100 µm.
together with the pigmentation of the choroid and retinal
pigment epithelium, the sclera provides a dark box for image
formation. The scleral spur is a projection of the anterior layer contains the sieve-like structure of the lamina cribrosa.
scleral stroma toward the angle of the anterior chamber and The rigidity of the lamina cribrosa accounts for the suscep-
is the site of insertion for the anterior ciliary muscle. Con- tibility of retinal nerve fibers to damage during the develop-
traction of this muscle thus opens the trabecular meshwork. ment of chronic open-angle glaucoma. The sclera contains
At the posterior pole of the eyeball, where the optic nerve six insertion sites of the extraocular muscles as well as the
fibers enter the eye, the scleral stroma is separated into outer inputs of arteries (anterior and posterior ciliary arteries) and
and inner layers. The outer layer fuses with the sheath of outputs of veins (vortex veins) that circulate blood through
the optic nerve, dura, and arachnoid, whereas the inner the uveal tissues.

2
 CHAPTER 1
Cornea and Sclera: Anatomy and Physiology

Dimensions and optical properties of the cornea
The anterior corneal surface is convex and aspheric (Fig. 1.1),
and it is transversely oval as a result of scleralization superi-
orly and inferiorly. The adult human cornea measures 11 to
12 mm horizontally and 9 to 11 mm vertically. It is approxi-
mately 0.5 mm thick at the center, with the thickness
increasing gradually toward the periphery, where it is about
0.7 mm thick.5 The curvature of the corneal surface is not
constant, being greatest at the center and smallest at the
periphery. The radius of curvature is between 7.5 and 8.0 mm
at the 3 mm central optical zone of the cornea, where the
surface is almost spherical. The refractive power of the
cornea is 40 to 44 diopters, constituting about two-thirds of
the total refractive power of the eye.
The optical properties of the cornea are determined by its
transparency, surface smoothness, contour, and refractive
index of the tissue.3 If the diameter of (or the distance
between) collagen fibrils in the corneal stroma becomes het-
erogeneous (as occurs in fibrosis or edema), incident light
rays are scattered randomly and the cornea loses its transpar-
ency. Given that the spherocylindrical surface of the cornea
has both minor and major axes, changes in corneal contour
caused either by pathological conditions such as scarring,
thinning, or keratoconus or by refractive surgery render the
surface regularly or irregularly astigmatic.
The total refractive index of the cornea is determined by
the sum of refraction at the anterior and posterior interfaces
as well as by the transmission properties of the tissue. The
refractive indices of air, tear fluid, corneal tissue, and aqueous
humor are 1.000, 1.336, 1.376, and 1.336, respectively. The
refractive power of a curved surface is determined by the
refractive index and the radius of curvature. The refractive
power at the central cornea is about +43 diopters, being
the sum of that at the air–tear fluid (+44 diopters), tear
fluid–cornea (+5 diopters), and cornea–aqueous humor (−6
diopters) interfaces. Most keratometry and topography mea-
surements assume a standard refractive index of 1.3375.
Corneal epithelium
The corneal and conjunctival epithelia are continuous and
together form the ocular surface. They are both composed
of nonkeratinized, stratified, squamous epithelial cells. The
thickness of the corneal epithelium is approximately 50 µm,
which is about 10% of the total thickness of the cornea
(Fig. 1.1), and it is constant over the entire corneal surface.
The corneal epithelium consists of five or six layers of three
different types of epithelial cells: superficial cells, wing
cells, and columnar basal cells, the latter of which adhere
to the basement membrane adjacent to Bowman’s layer
(Figs 1.1, 1.3 and 1.4).
Although their characteristics differ, both corneal and
conjunctival epithelia cooperate to provide the biodefense
system of the anterior surface of the eye.6,7 The presence of
junctional complexes between adjacent corneal epithelial
cells prevents the passage of external agents into the deeper
layers of the cornea. Both cell–cell and cell–matrix interac-
tions are important for maintenance of the normal stratified
structure and physiological functions of the corneal epithe-
lium.8 The characteristics of the different types of junctional
complexes present in the corneal epithelium (Figs 1.4 and
1.5) are summarized in Table 1.1. Tight junctions (zonula
occludens) are present mostly between cells of the superficial
cell layers and provide a highly effective barrier to prevent
the penetration of tear fluid and its chemical constituents.

Table 1.1 Characteristics of the various types of corneal epithelial cells

Shape Layers Size Mitotic Interdigitation Junctional Cytoplasmic Keratin Microfilaments Microtubules
activity complexes organelles (actin)

Superficial Flat 2–4 40–60 µm − Entire surface Desmosomes Sparse + + +/−

cells Microvilli in diameter Tight junctions
Microplicae 4–6 µm Adherens
thick at the junctions
nucleus
2 µm thick
at the
periphery

Wing cells Winglike 2–3 − Entire surface Desmosomes Sparse +++ + +/−
processes Gap junctions
Adherens
junctions

Basal Columnar Mono- 18–20 µm + Apical surface Desmosomes More than +++ + +
cells layer high Gap junctions superficial cells
8–10 µm Adherens Large numbers
in diameter junctions of glycogen
Flat at Hemidesmosomes granules
posterior Prominent
surface mitochondria
and Golgi
apparatus

3
PART i BASIC SCIENCE
 
A B
D E
G H
Desmosomes and adherens junctions are present in all layers
of the corneal epithelium, whereas gap junctions, which
allow the passage of small molecules between cells, are
present in wing cells and basal cells; and hemidesmosomes
are localized to basal cells. After damage to the corneal epi-
thelium, actively migrating epithelial cells no longer mani-
fest junctional complexes in the wounded region lacking a
basement membrane. Re-establishment of the continuity of
the corneal epithelium is accompanied by the synthesis of
basement membrane proteins and reconstruction of the
basement membrane and by the reassembly of the various
types of junctional apparatus, suggesting that the presence
of the basement membrane may be required for re-formation
of cell–cell junctions in the corneal epithelium (Fig. 1.5).9
In corneal epithelial cells, intermediate filaments of the
cytoskeleton are formed by specific types of acidic (type I)
and basic (type II) keratin molecules. Basal cells of the
corneal epithelium express keratin 5/14, like basal epidermal
cells of the skin. However, keratin 3/12 (64-kDa keratin) is
specifically expressed in the epithelium of the cornea, not
being found in that of the conjunctiva or in the epider-
mis.10,11 Deletion of the keratin 12 gene results in fragility
of the corneal epithelium in mice.12 In humans, genetic
4
Fig. 1.3 Confocal biomicroscopy
of the human cornea.
(A–C) Superficial, wing, and basal
cell layers of the corneal epithelium,
respectively. (D) Subepithelial nerve
plexus. (E) Shallow layer of the
stroma, containing a high density of
polygonal keratocytes. (F) Mid-layer
of the stroma, containing thick,
nonbranching nerve fibers. (G) Deep
layer of the stroma, containing
C a lower density of keratocytes.
(H) Amorphous appearance
of Descemet membrane.
(I) Endothelium, comprising
hexagonal endothelial cells of
uniform size.
F
I
mutation of the keratin 12 gene is responsible for Meesmann
dystrophy of the corneal epithelium.13
Replacement of most organs or tissues by transplantation
from a genetically nonidentical individual is associated
with an immune response that may lead to rejection. In
contrast, the cornea is “immune privileged,” a characteristic
that is critical for the success of corneal transplantation.
Dendritic Langerhans cells, specialized macrophages derived
from the bone marrow that are implicated in antigen pro-
cessing, are abundant at the periphery of the corneal epithe-
lium but are not present in the central region of the normal
cornea.14,15 These cells express human leukocyte antigen
(HLA) class II molecules and are thought to function in the
afferent arm of the ocular immune response by presenting
antigens to T lymphocytes.16,17 Injury to the central cornea
results in the rapid migration of peripheral Langerhans cells
to the damaged area.
Limbal stem cells and lineage of corneal
epithelial cells
Corneal epithelial cells are renewed continuously to main-
tain the normal layered structure of the epithelium in a
 CHAPTER 1
Cornea and Sclera: Anatomy and Physiology

B D

A C E

Fig. 1.4 Transmission electron microscopy of the human corneal epithelium. (A) The epithelium comprises five or six layers of epithelial cells.
The electron-dense cell is about to undergo desquamation. (B) Basal cells. Note the numerous junctional complexes. (C) Basement membrane
and anterior portion of Bowman’s layer. Note hemidesmosomes at the basal surface of the epithelial cells. (D) Interdigitation and junctional
complexes at the lateral surface of basal epithelial cells. (E) Gap junction at the lateral surface of basal cells.

process characterized by dynamic equilibrium (Fig. 1.6).
Only the basal cells of the corneal epithelium proliferate,
with the daughter cells instead differentiating into wing cells
and subsequently into superficial cells and gradually emerg-
ing at the corneal surface.18 The differentiation process
requires about 7 to 14 days, after which the superficial
cells undergo desquamation into the tear film.19 Mechanical
friction associated with blinking, ultraviolet radiation, and
hypoxia induce apoptosis (programmed cell death) and des-
quamation of corneal epithelial cells.20–22 Thoft and Friend
proposed that an equilibrium, represented by the equation
X + Y = Z, exists between the proliferation of basal epithelial

5
PART i BASIC SCIENCE

 

A B C D

E F G H I J

AF AF AF AF
AF AF
c-AMP KF KF
Ca2+ AF
P120
AF
zo-2 DP I/II
Cx Cx PG E-cad
Ca2+ Cx Cx
7H6
PG β-ctn a-ctn
zo-1
Cx Cx Ca2+ zo-1 PG α-ctn β-ctn
7H6 PG E-cad
zo-2 DP I/II
c-AMP Ca2+ AF KF
AF KF P120 AF
Oc/Cld Dsg/Dsc Dsg/Dsc
K L AF AF M AF N
AF AF

Fig. 1.5 Intercellular junctions in the corneal epithelium. Upper panels: (A–D) Transmission electron micrographs of the human corneal epithelium.
Scale bars, 50 nm. Middle panels: (E–J) Immunofluorescence micrographs of the rat corneal epithelium stained with antibodies to the indicated
proteins. Scale bars, 20 µm. Lower panels: (K–N) Schematic representation of intercellular junctions in the corneal epithelium. GJ, gap junction;
TJ, tight junction; DS, desmosome; AJ, adherens junction; Cx43, connexin 43; Oc, occludin; Dsg 1+2, desmogleins 1 and 2; E-cad, E-cadherin;
c-AMP, cyclic adenosine monophosphate; Cld, claudin; zo-1 and -2, zonula occludens–1 and –2; 7H6, 7H6 antigen; AF, actin filament;
Dsc, desmocollin; DP I/II, desmoplakin I or II; PG, plakoglobin; KF, keratin filament; α- and β-ctn, α- and β-catenin; P120, P120 catenin. (Modified
from Suzuki K, et al. Cell–matrix and cell–cell interactions during corneal epithelial wound healing. Prog Retin Eye Res 22:113–33, 2003. Copyright
Elsevier.)

cells and their differentiation into superficial cells (X), the
centripetal movement of peripheral epithelial cells (Y), and
epithelial cell loss from the corneal surface (Z).23 This X, Y,
Z hypothesis explains well the dynamic equilibrium of epi-
thelial cells in the cornea. Given the continuous desquama-
tion of surface epithelial cells, it is essential that new
epithelial cells be supplied not only by mitosis of basal
cells but also by the emergence of epithelial cells from the
periphery.
The function of stem cells is to replenish cells lost in
normal or damaged tissue. The asymmetric division of each
stem cell generates a new stem cell and a transit amplifying
cell that initially proliferates and then gives rise to termi-
nally differentiated cells. As in other tissues, the existence of
stem cells to maintain homeostasis of the corneal epithelium
has been postulated.24–28 Whereas keratin 3/12 (64-kDa
keratin) is expressed in all layers of corneal epithelial cells,
it is present only in the suprabasal epithelial cells at the
limbus.10 The presence of slowly cycling cells in the basal
cell layer at the limbus was demonstrated by cell labeling
with [3H]thymidine,29 and basal cells at the limbus were
found to have a higher mitotic potential than those of the
central cornea in vitro.30 Centripetal movement of corneal
epithelial cells has also been well documented.31–36 These
observations suggested that stem cells for corneal epithelial
cells reside at the limbus, the transitional zone between the
cornea and conjunctiva.24,28,37
The palisades of Vogt, richly vascularized papillae at the
transition zone between the cornea and conjunctiva, have
been identified as the likely location of limbal stem cells
for corneal epithelial cells.38,39 These structures are able to
provide a protective environment for stem cells as well as to
supply them with growth factors, extracellular matrix (ECM),
and neural signals to maintain their nature as stem cells.
Limbal epithelial crypts, anatomic structures that extend
from the palisades of Vogt, have been proposed to be the
actual site of the stem cell niche.40 The putative stem cells
in the basal layer of the limbus have unique characteristics
in that they cycle slowly and therefore retain DNA labels
such as [3H]thymidine, they are poorly differentiated with
primitive cytoplasm, they have a high proliferative potential
without undergoing maturation, they are small with a high

6

Conjunctiva Limbus Cornea Terminally
differentiated
cells
Basal
Transient cells
amplifying
cells
Limbal stem cells
X
ZXY
X: Proliferation of Y: Centripetal movement of cells
basal cells (supply from limbal stem cells)
Fig. 1.6 Lineage of corneal epithelial cells. Stem cells thought to reside in the basal cell layer at the limbus proliferate asymmetrically to yield a
daughter stem cell and a transit amplifying cell, the progeny of which move centripetally toward the center of the cornea to become basal corneal
epithelial cells. These newly generated basal cells proliferate symmetrically and then differentiate consecutively into wing cells and superficial cells, the
latter of which undergo apoptosis and consequent desquamation.
nucleus-to-cytoplasm ratio, they are capable of generating a
large number of differentiated progeny, and they reside in
close contact with a subset of mesenchymal niche cells.41,42
Although many markers for limbal stem cells have been
proposed,38,43 there is no single positive marker that distin-
guishes these cells. The expression of p63 (a marker of cell
proliferative ability), α-enolase, keratin 19, and the hepato-
cyte growth factor (HGF) receptor has been shown to be
higher in the limbal epithelium than in the corneal epithe-
lium. The transporter protein ABCG2 is also expressed spe-
cifically in the basal layer of the conjunctival epithelium
at the fornix area. Although no direct evidence for the exis-
tence of limbal stem cells has been obtained to date, ABCG2
appears to be the most promising surface marker for the
identification of such cells.
Limbal stem cell deficiency has been recognized as a
complex corneal disorder resulting from functional or struc-
tural loss of the limbus. Deficiency of limbal stem cells has
been suggested to lead to impairment of corneal epithelial
homeostasis in individuals with aniridia, inflammatory dis-
orders of the ocular surface such as Stevens–Johnson syn-
drome, or severe alkali burn of the ocular surface.44 No
medical treatment for limbal stem cell deficiency is currently
available. Transplantation of stem cells is a potential
approach to the treatment of limbal stem cell deficiency.
Such an approach requires sorting of limbal stem cells from
explants of limbus tissue, however, given that the stem cells
CHAPTER 1
Cornea and Sclera: Anatomy and Physiology
Z
Centripetal
movement
Palisades of Vogt
Limbus
Z: Cell loss from the surface
(desquamation via apoptosis)
are thought to constitute less than 1% of cells in the basal
layer of the limbus. The lack of a definitive stem cell marker
has thus impeded the sorting process. Sorting based on the
presence of stem cell-associated markers (ABCG2, vimentin,
keratin 19) and the absence of differentiation markers
(keratin 3/12, connexin 43, involucrin) might be the best
current approach.38
Layered structure of the corneal epithelium
Superficial cells
The surface of the corneal epithelium contains two to four
layers of terminally differentiated superficial cells. In con-
trast to the epidermis of the skin, the corneal epithelium is
not normally keratinized, although it may become so under
pathological conditions such as vitamin A deficiency. These
cells are flat and polygonal with a diameter of 40–60 µm and
a thickness of 2–6 µm (Table 1.1). Their surface is covered
with microvilli.45 Given that superficial cells are well differ-
entiated, they do not proliferate.
Numerous glycoprotein (mucin) and glycolipid molecules
are embedded in the cell membrane of epithelial cells.
Mucins include both membrane-bound and secreted mole-
cules, with the former in humans including MUC1, MUC4,
and MUC16, all of which have been detected in surperficial
epithelial cells of the cornea and conjunctiva.46 In mice,
MUC16 is expressed in the conjunctiva but not in the
7
PART i BASIC SCIENCE
 
cornea.47 These glycoproteins and glycolipids form floating
particles in the cell membrane that are collectively termed
the glycocalyx and which confer hydrophilic properties on
the anterior surface of the superficial epithelial cells. The
glycocalyx interacts with the mucinous layer of the tear film
and helps to maintain the layered structure of the latter.48
Loss either of the glycocalyx of corneal epithelial cells or of
goblet cells in the conjunctival epithelium results in tear film
instability and the mucin-deficiency form of dry eye.
The superficial cells of the corneal epithelium are joined
by desmosomes, adherens junctions, and tight junctions
(Figs 1.4 and 1.5), which prevent the passage of substances
through the intercellular space. Examination of fluorescein
penetration into the corneal stroma with a fluorophotome-
ter provides a measure of the barrier function of the corneal
epithelium.49
Wing cells
Beneath the superficial cells lie two or three layers of wing
cells, so called because of their characteristic wing-like shape.
Wing cells are in an intermediate state of differentiation
between basal and superficial cells and are rich in intracel-
lular tonofilaments composed of keratin (Table 1.1). The cell
membranes of adjacent wing cells are interdigitated. Numer-
ous desmosomes, adherens junctions, and gap junctions are
present between wing cells (Fig. 1.5).
Basal cells
The single layer of columnar basal cells of the corneal epi-
thelium rests on the basement membrane. Basal cells, unlike
superficial and wing cells, possess mitotic activity, and they
differentiate consecutively into wing and superficial cells
(Table 1.1). Neighboring basal cells interdigitate laterally and
are joined by desmosomes, gap junctions, and adherens
junctions (Fig. 1.5). The posterior surface of basal cells is flat
and abuts the basement membrane.
Basal cells adhere to the basement membrane via hemides-
mosomes that are linked to anchoring fibrils of type VII
collagen (Fig. 1.4).50 The anchoring fibrils penetrate the
basement membrane and course into the stroma, where
they form anchoring plaques together with type I collagen,
a major component of the stroma. The adherens junctions
are present at the lateral surface of the basal cells of the
corneal epithelium and are thought to mediate cell–cell
interaction.51
A B
Fig. 1.7 Immunofluorescence analysis of the expression of matrix proteins in the rat corneal epithelium. (A) Type I collagen. (B) Type IV collagen.
(C) Laminin. (D) Fibronectin. Bar: 50 µm.
8
Members of the integrin family of cell surface receptors
for ECM proteins exist as heterodimers of α and β subunits.52
The integrin α5β1 heterodimer, which is the major receptor
for fibronectin, is present at the surface of basal cells in the
normal corneal epithelium.53 All epithelial cells undergoing
active migration after debridement of the corneal epithelium
express integrin α5β1.54
Basement membrane
As in epithelia in other parts of the body, basal cells of the
corneal epithelium are anchored to a basement membrane.
The presence of the basement membrane between the basal
epithelium and the underlying stroma fixes the polarity
of epithelial cells. Ultrastructurally, the basement mem-
brane, which is 40–60 nm thick, is composed of a pale layer
(the lamina lucida) immediately posterior to the cell mem-
brane of the basal epithelial cells as well as an electron-dense
layer (the lamina densa) (Fig. 1.4). Type IV collagen and
laminin are major components of the basement membrane
(Fig. 1.7).55
The basement membranes of the corneal and conjuncti-
val epithelia contain different type IV collagen chains,
although the functional relevance of this difference is
unknown. Whereas collagen α5 (IV) is present in the corneal
basement membrane, collagen α2 (IV) is present in the con-
junctival basement membrane (as well as in the amniotic
membrane).56
Physiology of the corneal epithelium
Maintenance of corneal structure is crucial for the physi-
ological roles of this tissue in refraction and biodefense. A
smooth epithelium, a transparent stroma, and a functioning
endothelium are all essential for clear vision. The cornea
is vulnerable to various chemical or biological agents as
well as to physical events in the outside world. It is there-
fore equipped with an active maintenance system respon-
sible for renewal of the corneal epithelium and wound
healing.
The widespread application of corneal surgery, including
keratoplasty and refractive surgery, has necessitated a more
detailed understanding of the cellular and molecular biology
of corneal wound healing. In most parts of the body, wound
healing is initiated by the extravasation of blood constitu-
ents that accompanies disruption of blood vessels. The
C D
 CHAPTER 1
Cornea and Sclera: Anatomy and Physiology

cornea, however, is an avascular tissue. The mechanism of
wound healing in the cornea thus differs from that else-
where in the body.
Epithelial movement
Injury to the corneal surface is not uncommon and results
in an epithelial defect, the rapid resurfacing of which is
required for restoration of the continuity of the corneal
epithelium. Repair of epithelial defects occurs in three dis-
tinct phases characterized by epithelial cell migration, pro-
liferation, and differentiation, resulting in restoration of the
stratified structure of the epithelium.
Epithelial migration is thus the initial step in the resurfac-
ing of epithelial defects.57 Trauma to the corneal epithelium
induces the sliding and migration of the remaining epithe-
lial cells adjacent to the injury site toward the defective
area.58–61 Dynamic changes in cell–cell and cell–matrix
(fibronectin-integrin system) interactions, upregulation of
hyaluronan (hyaluronic acid), and modulation of the ECM
by newly expressed proteolytic enzymes play important
roles in these two types of epithelial cell movement in
response to injury. Such changes are under the overall
control of growth factors and cytokines.
Fibronectin-integrin system
The fibronectin-integrin system plays a central role in
corneal epithelial wound healing.62 Fibronectin provides a
provisional matrix during the first phase of epithelial wound
healing. It appears at the newly exposed corneal surface
soon after epithelial or stromal injury,63,64 and epithelial cells
then attach to and spread over the fibronectin matrix in an
integrin-dependent manner.53
The integrin family has been shown to include 24 differ-
ent α subunits and nine different β subunits, with the selec-
tive combination of these α and β subunits determining the
specificity of binding to ECM proteins. The integrin subunits
α2, α3, α5, α6, αv, β1, β4, and β5 have been detected in the
human cornea.65 The binding of integrins α5β1, αvβl, and
αIIβ3 to fibronectin is mediated by the RGD sequence. The
appearance and disappearance of the integrin β1 chain and
fibronectin during corneal epithelial wound healing are well
coordinated (Fig. 1.8).54

normal Integrin β1 fibronectin laminin

A B C D

12H

E F G H

1D

I J K L

1W

M N O P

1M

Q R S T

Fig. 1.8 Changes in the localization of the integrin β1 chain, fibronectin, and laminin after a nonpenetrating incision in the rat cornea. Phase-contrast
microscopy (A, E, I, M, Q) and immunofluorescence microscopy for the integrin β1 chain (B, F, J, N, R), fibronectin (C, G, K, O, S), and laminin
(D, H, L, P, T) are shown for the intact rat cornea (A–D) as well as at 12 hours (E–H), 1 day (I–L), 1 week (M–P), and 1 month (Q–T) after incision.
Immediately after the incision, fibronectin was detected at the surface of the V-shaped defect in the stroma. Epithelial cells expressing the integrin β1
subunit then began to migrate over and to fill in the defect. With the exception of that in basal cells, expression of the integrin β1 chain in epithelial
cells was downregulated coincident with the completion of wound healing. The abundance of fibronectin at the interface between the new epithelium
and the stroma also markedly decreased at this time.

9
PART i BASIC SCIENCE
 
The integrin α6β4 heterodimer is a component of hemides-
mosomes and is not related to fibronectin-mediated cell
adhesion and migration. In response to wounding of the
corneal epithelium, hemidesmosomes in the basal cell layer
are disassembled. They eventually reappear after migration
of the remaining epithelium has resulted in a recovering of
the denuded area.66
Hyaluronan
Hyaluronan is also recognized as a biological signaling
molecule and, like fibronectin, plays an important role in
inflammation and wound healing.67 Unlike other glycosami-
noglycans, a core protein for hyaluronan binding has not
yet been identified. Hyaluronan is not present in the normal
cornea, but it is transiently expressed in the rabbit cornea
during wound healing.68 These observations suggest that
hyaluronan might play a role in the late stages of corneal
wound healing. Exogenous hyaluronan also increases the
rate of corneal epithelial wound healing. The administration
of hyaluronan eyedrops thus promotes corneal epithelial
wound closure after epithelial debridement in rabbits69 and
in diabetic rats.70,71
Proteolytic enzymes
Proteolytic enzymes also play an important role in wound
healing. Cellular motility thus depends not only on the
interaction of cells with the underlying ECM but also on the
termination of such interaction by degradation of matrix
proteins. Proteases, including plasminogen activator, have
been detected in tear fluid.72,73 Mechanical wounding induces
upregulation of urokinase-type plasminogen activator at
both the protein and mRNA levels in corneal epithelial cells,
suggesting that this protease may contribute to epithelial cell
migration by degrading fibronectin during corneal epithelial
wound healing.74,75 Matrix metalloproteinases (MMPs) are
also upregulated in the migrating corneal epithelium.76
Cytokines and growth factors
The roles of various cytokines and growth factors in the
regulation of corneal epithelial migration have also been
investigated.77 In general, these molecules modulate corneal
epithelial wound healing by regulating the various healing-
related systems described above.4,78
Epidermal growth factor (EGF) was first isolated from the
mouse submaxillary gland as a factor that stimulates eye
opening and incisory tooth eruption in newborn mice.79
This 53–amino acid polypeptide is a potent stimulator of
proliferation in a variety of cell types, including corneal
epithelial cells.80,81 EGF is synthesized in lacrimal glands82,83
and is present in tear fluid.84,85 It influences the physiology
of the corneal epithelium and promotes corneal epithelial
wound closure in animals.86
The continuous exposure of the corneal epithelium to
EGF present in tear fluid suggests that the stimulatory effect
of this growth factor on epithelial cell proliferation must be
counteracted if the normal thickness and function of the
epithelium are to be maintained. In addition to its stimula-
tory effect on cell proliferation, EGF exerts a variety of other
actions in corneal epithelial cells, including promotion of
cell adhesion to a fibronectin matrix.87,88
10
Corneal epithelial cells express transforming growth
factor (TGF)–β1.83 Endogenous TGF-β also promotes corneal
epithelial cell migration.89 The stimulatory effects of EGF on
corneal epithelial cell proliferation, attachment to fibronec-
tin, and migration are modulated by TGF-β.90,91 Although
TGF-β alone inhibits corneal epithelial cell proliferation, it
has no effect on cell attachment to a fibronectin matrix in
the absence of EGF.
Basic fibroblast growth factor (bFGF) is another polypep-
tide growth factor that stimulates the proliferation of various
cell types of mesodermal or neuroectodermal origin.92 FGF
binds to heparan sulfate and is thus present in the basement
membrane of the corneal epithelium.93 The application of
recombinant human bFGF was shown to accelerate corneal
epithelial wound closure in rabbits.94 Given that FGF recep-
tors are expressed in corneal stromal cells, but not in corneal
epithelial cells, this latter effect might be mediated indi-
rectly.95 FGF is also a strong angiogenic factor in the cornea.96
Platelet-derived growth factor (PDGF) has been detected
in tear fluid.97 Rabbit corneal epithelial cells also express
both the β and α type of receptors for PDGF.98
Interleukins are cytokines that regulate the function of
the immune system, inflammation, and other reactions
of tissue to external stimuli.99 They modulate the activities
of immune or inflammatory cells both locally in tissue as
well as systemically in the circulation and in bone marrow.
Although 35 members of the interleukin family (IL-1 to
IL-35) have been identified to date, the roles of many of
these proteins in corneal wound healing remain to be inves-
tigated. For example, the corneal epithelium expresses IL-1,
and exogenous IL-1 promotes the healing of corneal epithe-
lial wounds.100 Corneal epithelial cells also express IL-6.101
Exposure of rabbit corneal epithelial cells in culture to IL-6
resulted in a marked increase in the number of cells that
attached to a fibronectin matrix. IL-6 stimulates the expres-
sion of integrin α5β1 in corneal epithelial cells, suggesting
that this cytokine may regulate corneal epithelial migration
through modulation of the fibronectin-integrin system as
well as through increase of cell proliferation.102–105
Stroma of the cornea and sclera
Bowman’s layer
An acellular, membrane-like zone known as Bowman’s layer,
or Bowman’s membrane, is detectable by light microscopy
at the interface between the corneal epithelium and stroma
in humans and certain other mammals (but not in rodents).
Given that this structure, which is 12 µm thick, is not a
membrane but rather a random arrangement of collagen
fibrils and proteoglycans, the term Bowman’s layer is prefer-
able. The collagen fibrils in Bowman’s layer are primarily
collagen types I and III. The diameter of these fibrils is
20–30 nm, which is smaller than that of the collagen fibrils
present in the corneal stroma (22.5–35 nm).
Bowman’s layer is considered to be the anterior portion
of the corneal stroma. The anterior surface of this layer,
which faces the basement membrane, is smooth. Given that
the collagen fibrils in Bowman’s layer are synthesized and
secreted by stromal keratocytes, they appear continuous
with those in the stroma.
 CHAPTER 1
Cornea and Sclera: Anatomy and Physiology

Biological functions originally attributed to Bowman’s

layer are now thought to be mediated by the basement
membrane. Bowman’s layer does not regenerate after injury.
Recent clinical experience with excimer laser photoablation
demonstrates that a normal epithelium is formed and main-
tained even in the absence of Bowman’s layer. Furthermore,
many mammals do not have a Bowman’s layer but still
exhibit a well-organized epithelial structure. The physiologi-
cal role of Bowman’s layer therefore remains unclear.

Structure of the stroma

The stroma constitutes the largest portion, more than 90%,
of the thickness of the cornea. The peripheral portion of the
cornea connects to the anterior sclera at the limbus, where
the tissue loses its transparency. Many characteristics of the
cornea, including its physical strength, stability of shape,
and transparency, are largely attributable to the anatomic
and biochemical properties of the stroma. The uniform
arrangement and continuous slow turnover (production and
degradation) of collagen fibrils in the stroma are essential for
corneal transparency.
The sclera is also composed mostly of collagen fibrils and A 5 µm
other matrix macromolecules, but nonuniformity in the
arrangement of these fibrils accounts for its lack of transpar-
ency.106 The thickness of the scleral stroma ranges from
approximately 0.5 to 1.0 mm depending on the area, with
the exception of the sites of insertion for the rectus muscle,
where the sclera is thinnest. The toughness of the scleral
stroma is essential for its role as a container of the intraocu-
lar tissues. Scleral fibroblasts are embedded within the
collagen lamellae.

Cells
The cellular components (predominantly keratocytes)
occupy only 2–3% of the total volume of the corneal
stroma,107 with the remaining portion comprising mostly
the ECM components collagen and proteoglycans. Kerato-
cytes are thought to turn over about every two to three years.
The spindle-shaped keratocytes are scattered among the
lamellae of the stroma (Fig. 1.9). These cells extend long
processes, and the processes of neighboring cells are con-
nected at their tips by gap junctions (Fig. 1.10).108 The
three-dimensional network structure of keratocytes can be
observed by light microscopy in flat preparations of the
corneal stroma, by confocal biomicroscopy, and, after diges- 1 µm
B
tion of stromal collagen, by scanning electron microscopy
(Fig. 1.10).109 Fig. 1.9 Transmission electron microscopy of the human corneal
Keratocytes are similar to fibroblasts and possess an exten- stroma. (A) A keratocyte localized between stromal lamellae. (B) A
sive intracellular cytoskeleton, including prominent actin higher-magnification view showing a keratocyte in relation to collagen
filaments. Keratocytes are thus quiescent in the normal fibrils coursing in various directions.
cornea but are readily activated and undergo transformation
into myofibroblasts, which express α–smooth muscle actin,
in response to various types of insult to the stroma.110,111 cells were found to express this marker in a mouse bone
Myofibroblasts produce ECM, collagen-degrading enzymes, marrow transplantion model.113 In response to infection or
MMPs, and cytokines for stromal tissue repair, and their injury, however, many inflammatory cells infiltrate the
ability to contract contributes to wound closure. corneal stroma from the limbal vessels surrounding the
In addition to keratocytes, bone marrow-derived cells are cornea.
present in the corneal stroma. Approximately 6% of cells Although scleral fibroblasts are not as well characterized
that reside in the normal human corneal stroma express the as keratocytes, they are thought to be similar to fibroblasts
hematopoietic cell marker CD45,112 and 7.58% of stromal in other parts of the body. As in the corneal stroma, a slow

11
PART i BASIC SCIENCE
 
1
A
B characteristics of collagen lamellae are not uniform through-
10 µm
Fig. 1.10 Electron microscopy of the corneal stroma. (A) Lamellar
structure of collagen fibrils and electron-dense gap junctions (1)
between the cellular processes of keratocytes in the human cornea.
(B) Three-dimensional view of keratocytes in the rat cornea after
digestion of collagen. Note the cellular network formed by keratocytes.
turnover of collagen fibrils by scleral fibroblasts is required
for connective tissue homeostasis. Matrix degradation by
scleral fibroblasts is promoted by prostaglandin derivatives,
which accounts in part for the increase in uveoscleral outflow
of aqueous humor and the reduction in intraocular pressure
induced by such drugs.114 Activation of scleral fibroblasts by
external stimuli, such as injury or surgery, also results in
their transdifferentiation into myofibroblasts and conse-
quent tissue fibrosis.
Collagen
Collagen constitutes more than 70% of the dry weight of
the cornea. Collagen in the corneal stroma is mostly type I,
with smaller amounts of types III, V, VI, XII, and XIV also
12
present.115–122 Proteoglycans are distributed among the major
collagen fibrils.
Both the mean diameter of collagen fibrils and the mean
distance between such fibrils in the corneal stroma are rela-
tively homogeneous and are less than half of the wavelength
of visible light (400–700 nm). This anatomic arrangement is
thought to be responsible for the fact that scattering of an
incident ray of light by each collagen fibril is canceled by
interference from other scattered rays,3,123 allowing light to
pass through the cornea. If the diameter of or the distance
between collagen fibrils becomes heterogeneous (as occurs
in fibrosis or edema), incident rays are scattered randomly
and the cornea loses its transparency.
Procollagen molecules are secreted into the extracellular
space by keratocytes, after which the pro-peptides at both
ends are cleaved to yield the mature collagen molecules. The
collagen molecules self-assemble into fibrils with a diameter
of 10–300 nm, and these fibrils subsequently further assem-
ble into collagen fibers.123 Individual collagen fibrils in the
corneal stroma can be observed by transmission electron
microscopy (Fig. 1.9). As mentioned above, both the diam-
eter of (22.5–35 nm) and distance between (41.4 ± 0.5 nm)
collagen fibrils in the corneal stroma are highly uniform,
with this regular arrangement being a major determinant of
corneal transparency.120,124–126 At high magnification, each
collagen fibril exhibits a characteristic cross-striation pattern
with a periodicity of 67 nm. In the corneal stroma, the col-
lagen fibrils align with the same orientation to form about
300 lamellae. Each lamella courses parallel to the surface of
the cornea from limbus to limbus. The collagen lamellae in
the human corneal stroma vary in width from 0.5 to 250 µm
and in thickness from 0.2 to 2.5 µm, and they interweave
with each other at various angles.120,127,128 They change direc-
tion as they course from the center to the outer zone of the
cornea.126
Three-dimensional analysis by second harmonic genera-
tion imaging microscopy has revealed that the anatomic
out the normal human corneal stroma (Fig. 1.11).128 Whereas
lamellae at the anterior stroma manifest an interwoven
structure with an angle of approximately 21° relative to Bow-
man’s layer, those in the middle and posterior regions of the
stroma are parallel.128–130 The width of collagen lamellae also
gradually increases from the anterior to posterior stroma.128
Given that dense and interwoven collagen lamellae confer
a more rigid structure compared with parallel lamellae, this
organization of stromal collagen lamellae is thought to con-
tribute to maintenance of anterior stromal curvature. The
collagen lamellae immediately below Bowman’s layer adhere
evenly to it. The width of collagen lamellae adherent to
Bowman’s layer is slightly larger than that of those located
immediately posteriorly,128,130 likely facilitating strong adher-
ence. Similar adherence of collagen lamellae to Descemet
membrane in the posterior region of the stroma has not been
observed. The turnover of collagen molecules in the cornea
is slow, requiring two to three years.131
The histological features of the scleral stroma are similar
to those of the corneal stroma, with the scleral stroma also
being composed largely of major collagen fibrils and proteo-
glycans.132 The collagen types detected in the scleral stroma
are also similar to those in the corneal stroma. In contrast,

A lumican, keratocan, and mimecan (osteoglycin) as keratan
B Although the roles of specific proteoglycans in the mainte-
C D
Fig. 1.11 Second harmonic generation (SHG) imaging microscopy of
the human cornea. Note the difference in alignment of collagen fibers in
anterior (A), middle (B), and posterior (C) regions of the stroma.
Reconstructed projection image of collagen lamellae in the normal
corneal stroma are also shown (D). Note that interwoven collagen
lamellae were observed at the anterior stroma. Bar: 50 µm.
the matrix components present in the spaces between the
major collagen fibrils in the scleral stroma differ from those
in the corneal stroma. This difference in the noncollagenous
matrix largely accounts for the difference in ultrastructure
between the cornea and sclera. Whereas the collagen fibrils
in the corneal stroma are highly uniform in diameter, those
in the scleral stroma range in diameter from 25 to 250 nm.
Furthermore, whereas collagen fibrils are arranged regularly
with a relatively uniform interfiber distance in the corneal
stroma, the distance between collagen fibrils in the scleral
stroma varies. The ECM of the scleral stroma, including both
collagen and noncollagenous components, is produced by
the stromal fibroblasts.
Proteoglycans
Proteoglycans, the major matrix components located in
the spaces among major collagen fibrils in the stroma of
the cornea and sclera, are composed of a core protein and
glycosaminoglycan chains and are thought to modulate
collagen fibrillogenesis.133,134 Glycosaminoglycans comprise
repeating disaccharide units and play important roles
regardless of the core protein to which they are attached.
The functions of proteoglycans can thus be considered
from the points of view of both the core protein and
glycosaminoglycans.
With the exception of hyaluronan, the glycosaminogly-
cans of the corneal stroma are present in the form of
CHAPTER 1
Cornea and Sclera: Anatomy and Physiology
proteoglycans. The most abundant glycosaminoglycan in
the cornea is keratan sulfate,135 constituting about 65% of
the total glycosaminoglycan content. The remaining glycos-
aminoglycans include chondroitin sulfate and dermatan
sulfate. Glycosaminoglycans have the ability to absorb and
retain large amounts of water.
In terms of core proteins, the corneal stroma contains
sulfate proteoglycans as well as decorin and biglycan as
chondroitin sulfate or dermatan sulfate proteoglycans (Table
1.2).136,137 These core proteins are members of the family of
small leucine-rich proteoglycans (SLRPs), which contain a
common central domain consisting of about 10 leucine-rich
repeats.138 They first accumulate as low-sulfate glycoproteins
in the embryonic stroma and subsequently bind glycosami-
noglycans to form proteoglycans typical of the adult cornea.
nance of corneal transparency or shape under physiological
conditions or in the development of corneal haziness under
pathological conditions remain unclear, spontaneous muta-
tion of a core protein gene has provided some insight. Muta-
tion of the keratocan gene was recently shown to result in
cornea plana, an anomaly characterized by abnormal corneal
curvature, but it did not affect the transparency of the
corneal stroma.139,140
Recent studies with transgenic or knockout mice have
also provided insight into the roles of proteoglycan core
proteins. A lumican-null mouse was shown to undergo
age-dependent opacification of the corneal stroma.141,142
Transmission electron microscopy revealed an irregular
arrangement of collagen fibrils in the posterior stroma of
these animals, indicating that lumican is required for the
regular organization of collagen fibrils and that its dis­
tribution is not uniform throughout the thickness of the
stroma.123 Similar to the effect of keratocan gene mutation
in humans,140 keratocan-deficient mice show a change in the
shape of the eye shell, but the transparency of the corneal
stroma is not affected.139 These observations indicate that
two major keratan sulfate proteoglycans (those based on
lumican or keratocan) do not similarly influence collagen
fibril organization in the corneal stroma.138 Mice lacking
decorin exhibit abnormal collagen fibrillogenesis in the tail
tendon but not in the corneal stroma,143 indicating that
decorin may not play an important role in maintenance of
corneal stromal transparency, despite its abundance in the
stroma. Such genetically modified mice not only shed light
on the functions of specific molecules but also provide
models of human genetic disorders of the cornea.
The main difference between the proteoglycan composi-
tion of the sclera and that of the cornea is the absence of
keratocan, a specific marker of keratocyte differentiation,137
in the sclera. However, this difference alone does not explain
the lack of uniformity in the size and arrangement of col-
lagen fibrils in the sclera. The eyeball of lumican-null mice
is larger than that of wild-type animals, whereas that of
keratocan-deficient mice is smaller.139,141,142 Although humans
with a mutated lumican gene have not yet been described,
recent studies suggest that high myopia due to an increased
axial length of the eye globe is associated with lumican gene
polymorphisms.144 The relative amounts of proteoglycan
components in the sclera are changed in an animal model
13
PART i BASIC SCIENCE
 
Table 1.2 Glycosaminoglycans and proteoglycan core proteins in the cornea
Glycosaminoglycan
Heparan sulfate
Heparin
Dermatan sulfate
Chondroitin 4,6-sulfate
Keratan sulfate
Hyaluronan
Core protein
Lumican
Keratocan
Mimecan
Decorin
In the normal cornea, proteoglycans are synthesized by stromal keratocytes. They are transiently synthesized by corneal epithelial cells during the early phase of wound
healing.
of myopia.145 Recent studies thus suggest that matrix com-
ponents of the cornea or sclera play specific roles in regula-
tion of the shape or size of the eye shell.
Physiology of the stroma
ECM and stromal repair
Structural and biochemical homeostasis of the ECM in the
corneal stroma is maintained by a balance in the synthesis
and degradation of ECM components by keratocytes. In
response to corneal injury, keratocytes transdifferentiate
into myofibroblasts and actively produce matrix compo-
nents for healing of the injured stroma, with each newly
expressed macromolecule appearing to play an important
role in the repair process.
During infectious ulceration of the corneal stroma,
enzymes that degrade the ECM of the stroma are released by
both host cells and the infecting bacteria. Furthermore,
pseudomonal elastase degrades collagen directly as well as
promoting collagen degradation by keratocytes, in part via
activation of pro-MMPs.146 There thus appear to be at least
three different pathways for the degradation of stromal col-
lagen fibrils in individuals with infectious corneal ulcer-
ation: (1) direct degradation by bacterial collagenase, (2)
degradation by MMPs released from keratocytes (or myofi-
broblasts) and activated by bacterial factors such as elastase,
and (3) degradation by proteases released from infiltrated
inflammatory cells.
Cytokines and growth factors
Both keratocytes and infiltrated cells, such as lymphocytes,
neutrophils, and macrophages, secrete cytokines and growth
14
Size (kDa) Constituent disaccharide
5–12 N-acetylgalactosamine, glucuronic acid
6–25 N-acetylgalactosamine, glucuronic acid
15–49 N-acetylgalactosamine, iduronic acid
5–50 N-acetylgalactosamine, glucuronic acid
4–19 N-acetylgalactosamine, galactose
4–8000 N-acetylgalactosamine, glucuronic acid
Glycosaminoglycan Function
Keratan sulfate Interaction with corneal epithelial cells
Keratan sulfate Mutation causes cornea plana
Keratan sulfate Unknown
Chondroitin sulfate or dermatan sulfate Wound healing
factors and thereby modulate the behavior of cells in the
healing corneal stroma. Each cytokine or growth factor acti-
vates signal transduction pathways that regulate the expres-
sion of specific genes that contribute to the inflammatory
response. Targeting of such regulation at the ligand or signal-
ing level may provide new strategies for treatment of wound-
related pathology. TGF-β is thought to play a key role in the
healing of the corneal stroma.147,148 It is expressed by both
epithelial cells and stromal cells (keratocytes or scleral fibro-
blasts) as well as by inflammatory cells that activate stromal
cells and promote their transdifferentiation into myofibro-
blasts. Myofibroblasts contribute not only to wound repair
but also to post-injury stromal scarring in the cornea and
sclera as a result of the overproduction of matrix compo-
nents. Blockade of TGF-β signaling effectively reduces the
fibrogenic reaction and consequent scarring and opacifica-
tion in a mouse model of corneal alkali burn.147,148
The proinflammatory cytokine tumor necrosis factor
(TNF)–α is also upregulated in response to injury.149 TNF-α
induces various effects in the cornea under pathological
conditions such as injury, allergy, and infection.150–153
However, the complete loss of TNF-α in the cornea of knock-
out mice results in enhancement of post-alkali burn inflam-
mation, suggesting that the role of TNF-α in the cornea
might depend on the specific condition.154
Endothelium
Descemet membrane
Descemet membrane, the basement membrane of the
corneal endothelium, gradually increases in thickness from

birth (3 µm) to adulthood (8–10 µm) in humans. Histologi-
cal analysis reveals it to be stratified into a thin (0.3 µm),
nonbanded layer adjacent to the stroma, an anterior banded
zone (2–4 µm), and a posterior, amorphous, nonbanded
zone (>4 µm), the latter of which can represent up to two-
thirds of the thickness of the membrane and is laid down
over time.155
Descemet membrane is composed primarily of collagen
types IV and VIII and laminin156 but also contains fibronec-
tin.63,64 Type VIII collagen, which is produced by the corneal
endothelium, forms a hexagonal lattice quite different from
the structure of type IV collagen in the basement membrane.
Collagen fibers in the stroma are continuous with those in
Bowman’s layer but not with those in the Descemet mem-
brane. The Descemet membrane adheres tightly to the
posterior surface of the corneal stroma and reflects any
change in the shape of the stroma. Rupture of the Descemet
membrane by physical stress, such as compression birth
injury, results in the penetration of aqueous humor into the
corneal stroma and consequent stromal edema. The Des-
cemet membrane does not regenerate after endothelial cells
re-cover the ruptured area. Diseases such as Fuchs dystrophy
are associated with an atypical striated pattern of collagen
deposition in the Descemet membrane.157 A patient with
early-onset Fuchs dystrophy was found to harbor a mutation
in COL8A2,158 which encodes the α2 chain of type VIII
collagen.
A B
D E
CHAPTER 1
Cornea and Sclera: Anatomy and Physiology
Endothelial cells
A single layer of corneal endothelial cells covers the posterior
surface of the Descemet membrane in a well-arranged mosaic
pattern (Fig. 1.12). In humans, these cells are uniformly
5 µm in thickness and 20 µm in width and are polygonal
(mostly hexagonal) in shape. The uniformity of endothelial
cell size has been evaluated by statistical analysis based on
photographs taken by a wide-field specular microscope.159 In
young adults, the cell density is about 3500 cells/mm2. The
coefficient of variation (standard deviation/mean) for cell
area is a clinically valuable marker and is about 0.25 in the
normal cornea. An increase in the variability of cell area is
termed polymegethism. Another morphometric parameter
of the state of the endothelium is hexagonality. In the
normal healthy cornea, about 70–80% of endothelial cells
are hexagonal. However, endothelial damage can result in a
decrease in the hexagonality value and an increase in the
variability of cell area (Fig. 1.12). Deviation from hexagonal-
ity is referred to as pleomorphism.
Corneal endothelial cells contain a large nucleus and
abundant cytoplasmic organelles, including mitochondria,
endoplasmic reticulum, free ribosomes, and Golgi apparatus
(Fig. 1.12), suggesting that they are metabolically active. The
endothelial cells interdigitate and contain various junctional
complexes, including zonula occludens, macula occludens,
and macula adherens. The interconnected endothelial cell
C
Fig. 1.12 Corneal endothelium observed by scanning
(A) and transmission electron microscopy (B) of the
rabbit. Immunofluorescent microscopy (C) of rabbit
endothelial cells stained for ZO-1 (green) and nucleus
(red). Note each endothelial cell is bound by tight
junctions. Specular microscopic images of the human
corneal endothelial cells of normal (D) and early stages
of bullous keratopathy (E). Cell density is lowered in
bullous keratopathy.
15
PART i BASIC SCIENCE

 

layer provides a leaky barrier to aqueous humor. In addition, the deep peripheral stroma radially and then course anteri-
gap junctions allow the transfer of small molecules and orly, forming a terminal subepithelial plexus.165 The nerve
electrolytes between the endothelial cells. fibers lose their myelination within a short distance of their
point of entry into the cornea, penetrate the Bowman’s layer,
Physiology of the endothelium and terminate at the wing cell level of the epithelium. Loss
of the superficial corneal epithelium results in exposure of
Loss of or damage to corneal endothelial cells will result in
the nerve endings and consequent severe ocular pain.
increased imbibition of water by the corneal stroma. The
Slit lamp microscopy allows observation of nerve fibers in
endothelial cells contain ion transport systems that counter-
the corneal stroma. The fibers are especially prominent at
act the imbibition of water into the stroma. An osmotic
the corneal periphery, where their diameter is relatively
gradient of Na+ is present between the aqueous humor
large. Laser-scanning confocal biomicroscopy has revealed
(143 mEq/L) and the stroma (134 mEq/L). This gradient
networks of fine nerve fibers (subepithelial nerve plexuses)
results in the flow of Na+ from the aqueous humor to the
in or below the basal cell layer of the corneal epithelium.164,166
stroma and in a flux of K+ in the opposite direction. The
The diameter of these nerve fibers increases with distance
Na+- and K+-dependent ATPase and the Na+/H+ exchanger
from the anterior corneal surface (Fig. 1.3).
are expressed in the basolateral membrane of corneal endo-
Histochemical studies have revealed the presence of
thelial cells. Carbon dioxide also diffuses into the cytoplasm
various neurotransmitters, including substance P, calcitonin
of these cells and, together with water, generates bicarbonate
gene-related peptide, neuropeptide Y, vasoactive intestinal
ions (HCO3−) in a reaction catalyzed by carbonic anhydrase.
peptide, galanin, methionine-enkephalin, catecholamines,
The HCO3− then diffuses or is transported into the aqueous
and acetylcholine, in the cornea.167–174 The cornea thus con-
humor. Coupled with this movement of HCO3− is a flux of
tains peptidergic, sympathetic, and parasympathetic nerve
water across endothelial cells into the aqueous humor.160
fibers. Sensory nerves release neuropeptides that modulate
Given that this ion transport system is partially dependent
local cell behavior and inflammation.
on cellular energy, cooling of the cornea results in its thick-
The loss of corneal sensation often results in breakdown
ening and in it becoming opaque. The return of the cornea
of corneal integrity. Trigeminal denervation is associated
to normal body temperature, however, results in the restora-
with a reduction in the abundance of substance P in the
tion of its normal thickness and clarity in a phenomenon
cornea.175 Sectioning of the trigeminal nerve results in
known as temperature reversal.
trophic or degenerative changes in the cornea as well as in
Corneal endothelial cells essentially do not proliferate in
the depletion of substance P.176–178 Substance P may therefore
humans, monkeys, and cats, but they do divide in rabbits.
contribute to maintenance of the corneal epithelium. Degen-
Endothelial cell density in the healthy human cornea
eration or dysfunction of sensory nerves (trigeminal nerve
decreases with age.161 It is important that corneal endothelial
branches) in the cornea can result in delayed healing of
cells are protected and preserved as much as possible during
corneal injuries and the development of neurotrophic ulcer
surgery and during inflammation in the anterior chamber.
or neurotrophic keratopathy, one of the most refractory
Endothelial cells are targeted by immune and inflammatory
corneal disorders.179 Persistent corneal epithelial defects or
cells that appear in the anterior chamber in association with
delayed epithelial wound healing are frequently observed in
corneal graft rejection or conditions such as anterior uveitis.
individuals with a reduced corneal sensation, such as those
Furthermore, inflammatory cytokines disturb the pumping
infected with herpes simplex or herpes zoster viruses as well
function of endothelial cells and thereby promote stromal
as those with trigeminal nerve damage due to intracranial
edema. Steroids and insulin have been found to increase
disorders or diabetes mellitus. Topical anesthetics, which are
Na+, K+-dependent ATPase activity in corneal endothelial
potentially drugs of abuse, also impair corneal epithelial
cells.162 The loss of endothelial cells for any reason results in
migration in an organ culture system.180 Furthermore, frank
enlargement of the remaining neighboring cells and their
corneal ulceration has been shown to develop in anesthe-
spreading to cover the defective area, without an increase in
tized eyes. These various observations thus implicate neural
cell number. The indexes based on specular microscopy fluc-
regulation in maintenance and repair of the corneal epithe-
tuate as endothelial damage is resurfaced by the migration
lium. The physiological role of corneal innervation in
and enlargement of the remaining endothelial cells. The
corneal epithelial wound healing remains to be fully clari-
coefficient of the variation of cell area is the most sensitive
fied, however.
index of corneal endothelial dysfunction, whereas hexago-
Substance P is thought to regulate various physiological
nality is a good index of the progress of endothelial wound
processes, including plasma extravasation, vasodilation, and
healing.
the release of histamine from mast cells.181–184 Exposure of
rabbit corneal epithelial cells in culture to the combination
Innervation of substance P and insulin-like growth factor–1 (IGF-1)
resulted in a marked increase in the number of cells that
The cornea is one of the most highly innervated and sensi- attached to a fibronectin matrix.185 The combination of sub-
tive tissues in the body. The density of nerve endings in the stance P and IGF-1 also synergistically promotes corneal
cornea is thus about 300 to 400 times greater than that in epithelial migration, with neither agent alone having an
the skin.163,164 Most of the sensory nerves in the cornea are effect on this process. Furthermore, the administration of
derived from the ciliary nerves of the ophthalmic branch of eyedrops containing IGF-1 and either substance P or a tetra-
the trigeminal nerve. The long ciliary nerves provide the peptide derived from its carboxyl terminus has been shown
perilimbal nerve ring. Nerve fibers penetrate the cornea in to be an effective treatment for persistent corneal epithelial

16

defects in individuals with neurotrophic keratopathy or dia-
betic neuropathy.186–188
Nerve growth factor (NGF), first discovered by Levi-
Montalcini in the early 1950s,189 is a polypeptide that stimu-
lates the regeneration of peripheral nerve fibers.190 Eye drops
containing NGF also promote resurfacing of persistent
corneal epithelial defects in animals and humans.190–194
Although the role of calcitonin gene-related peptide in
homeostasis of the corneal epithelium remains unknown,
the finding that this peptide stimulates the proliferation of
keratinocytes suggests that it might also modulate corneal
epithelial cell behavior.195 Members of the family of transient
receptor potential (TRP) cation channels have been shown
to modulate inflammation and tissue repair by promoting
the secretion of neuropeptides in nonocular tissues.196
Studies of mutant mice with deletions in genes for members
of this family have revealed that loss of specific channels
inhibits corneal inflammation in response to alkali expo-
sure197,198 or retards corneal epithelial wound healing.199
The short and long posterior ciliary nerves, which are
branches of the trigeminal nerve, penetrate the sclera and
provide fine sensory branches to the scleral stroma. In addi-
tion, nerve fibers are also present in the episclera.200 These
fibers include those of vasodilator and vasoconstrictor nerves
and are thought to regulate blood flow and volume in the
episcleral vessels for modulation of episcleral venous pres-
sure and outflow facility. Cells in the scleral spur are also
thought to contribute to the regulation of intraocular pres-
sure. Axons of presumably parasympathetic origin are
present in the scleral spur of humans. On the other hand,
cholinergic innervation of scleral spur cells appears to be rare
or absent.201
Vascular system
The cornea is one of the few avascular tissues in the body.
Although the normal cornea does not contain blood vessels,
factors derived from the blood play important roles in corneal
metabolism and wound healing. The anterior ciliary artery,
which is derived from the ophthalmic artery, forms a vascular
arcade in the limbal region that anastomoses with vessels
derived from the facial branch of the external carotid artery.
The cornea is thus supplied with blood components by both
internal and external carotid arteries. In certain pathological
conditions, new vessels enter the corneal stroma from the
limbus and result in a loss of corneal transparency.
In contrast to the cornea, the episclera is highly vascular-
ized. The episcleral vasculature shows a specialized morphol-
ogy characterized by the absence of capillaries, numerous
arteriovenous anastomoses, and a muscle-rich venous
network, which is thought to play an important role in the
regulation of intraocular pressure. Such vascularization is
also apparent in the loose connective tissue of Tenon’s
capsule. The scleral stroma contains few blood vessels, with
the exception of the input and output of the vessels of the
choroidal circulation.
Oxygen and nutrient supply
Corneal epithelial and endothelial cells are metabolically
active. Cellular activities require ATP as an energy source,
CHAPTER 1
Cornea and Sclera: Anatomy and Physiology
with catabolism of glucose by glycolysis and the citric acid
cycle generating ATP under aerobic conditions. A supply of
glucose and oxygen is thus essential to maintain the normal
metabolic functions of the cornea.202–205 The cornea is sup-
plied with glucose by diffusion from the aqueous humor. In
contrast, oxygen is supplied to the cornea primarily by dif-
fusion from tear fluid, which absorbs oxygen from the air.
Direct exposure of tear fluid to the atmosphere is thus
essential for oxygenation of the cornea. Disruption of the
oxygen supply to the cornea, such as that resulting from the
wearing of contact lenses with low gas permeability, can lead
to corneal hypoxia and consequent stromal edema.206–208
Closure of the eyelids during sleep also reduces the amount
of oxygen that reaches the cornea. Corneal metabolism
therefore changes from aerobic to anaerobic (with conse-
quent accumulation of lactate) during sleep.209
Development of the Anterior Eye Segment
Characterization of the development of ocular tissues during
embryogenesis is important for understanding the patho-
genesis of congenital anomalies of the cornea and anterior
eye segment (Fig. 1.13).210,211 Morphogenesis of the eye is
achieved by cell lineages of various origins including the
surface and neural ectoderm during embryonic develop-
ment. Epithelial cells of the cornea are derived from the
epidermal ectoderm, whereas keratocytes, scleral fibroblasts,
and endothelial cells are of neural crest (neuroectodermal)
origin. The surface ectoderm above the neuronal optic cup
invaginates to form the crystalline lens. After the lens vesicle
has separated from the surface ectoderm, the epithelium on
the immature lens differentiates into the corneal epithelium.
Neural crest–derived mesenchymal cells migrate in the space
between the lens and primitive corneal epithelium and
develop into the corneal stroma, endothelium, iris, and
trabecular meshwork. Many anomalies of the anterior eye
segment result from impaired differentiation of these neural
crest-derived tissues.
The surface ectoderm above the optic cup invaginates
during the fifth week of gestation in humans, and the primi-
tive corneal epithelium develops junctional complexes by
the sixth week. Most scleral fibroblasts differentiate from
neural crest cells that surround the optic cup during the
sixth week. Mesodermal cells also contribute to develop-
ment of the sclera and the extraocular muscles. The neural
crest cell-derived mesenchyme migrates into the space
between the primitive corneal epithelium and lens vesicle in
three waves during the seventh week. The first wave of
migration results in formation of the corneal endothelium
and trabecular endothelium; the second wave of cells dif-
ferentiates into keratocytes; and the third wave gives rise to
the iris. During the eighth week, the keratocytes form five
to eight layers of collagen lamellae and the corneal endothe-
lium starts to form the Descemet membrane. Defects in the
migration of neural crest–derived mesenchymal cells are
responsible for anomalies of the cornea and anterior eye
segment including Peters anomaly. Several genes, including
those encoding TGF-β2 and the transcription factor FOXC,
have been implicated in the differentiation of neural crest
cells into the primitive corneal stroma in mice.212
17
PART i BASIC SCIENCE

 

A B

Fig. 1.13 Ocular histology of C57BL/6 mouse embryos as revealed by hematoxylin-

eosin staining. (A) The lens vesicle has separated from the surface ectoderm, which
will develop into the corneal epithelium, in an embryo at E12.5. Neural crest cells,
which will form the corneal stroma, are present between the lens capsule and
surface ectoderm. (B) The corneal endothelium has separated from the lens capsule
to form the anterior chamber in an embryo at E18.5. The ocular surface is covered
with the eyelids, which are fused to each other. A few cells are apparent in the
vitreous cavity. (C) Stratification of the corneal epithelium is not well developed at
E18.5, but the endothelium has matured. The density of keratocytes is higher than
that observed in the adult mouse cornea. Bars: 500 µm (A, B) and 50 µm (C).

The spaces among collagen fibrils in the embryonic
corneal stroma become occupied by proteoglycans that are
formed as a result of the binding of glycosaminoglycan
chains to previously accumulated core proteins. Studies with
mice have shown that the composition of proteoglycans in
the corneal stroma changes markedly during embryonic
development.213 Even by the sixth month of gestation, the
human cornea is still not fully mature. The epithelium has
only three or four layers of cells, and keratan sulfate proteo-
glycans continue to accumulate. By the seventh month,
however, the cornea is well developed, with the epithelium
consisting of four or five layers with readily recognizable
basal, wing, and superficial cells. The stroma is also almost
fully developed at this time, with the accumulation of
keratan sulfate proteoglycans among collagen fibrils being
virtually complete. Hyaluronan is a major glycosaminogly-
can in the corneal stroma during the early stages of embry-
onic development, but its abundance declines concomitantly
with the increase in that of keratan sulfate, chondroitin
sulfate, and dermatan sulfate, giving rise to a glycosamino-
glycan composition similar to that of the adult stroma.214
Recent advances in transgenic and gene knockout tech-
nologies in mice have provided important insight into the
role of specific genes in the development and homeostasis
of corneal tissue as well as into congenital anomalies in
humans.214,215 Interpretation of such studies also depends
on an understanding of the normal process of eye develop-
ment in the mouse (Fig. 1.13). The surface ectoderm invagi-
nates into the optic cup at embryonic day (E) 10.5 in mice.
At E12.5, the primitive lens has already separated from the
surface ectoderm, which will become the corneal epithe-
lium, and the neural crest-derived mesenchyme has begun
to migrate into the space between the primitive corneal
epithelium and lens. In contrast to the human embryo,
the neural crest-derived cells migrate into this space in
a single wave. At E14.5, the embryo has already developed
the epithelium, stroma, and endothelium of the cornea,
and at E18.5 the corneal stroma has increased in thickness
as a result of the synthesis of matrix macromolecules.
Eyelid morphogenesis is orchestrated by signaling networks
activated by growth factors and other morphogenesis-
related molecules.216 The palpebral conjunctiva develops in

18
Another random document with
no related content on Scribd:
hän tytön sisään, sanoi jotenkin tuimasti hyvää yötä laivurille ja sulki
oven jälkeensä.

Pää aivan pyörällä illan moninaisista vaiheista, kiiruhti laivuri

takaisin kuunariinsa. Tultuaan lähemmäksi laituria, alkoi hän juosta.
Samoin näkyi tekevän vastapäiseltä suunnalta tuleva pieni olentokin.

"Sinä kuljeksija", huohotti laivuri ja tarttui samaan aikaan kuunarin

sivulle saapuvaa poikaa kaulukseen.

"No? Minähän teen vaan kuten tekin", sanoi Henry.

"Heittäkää yli syrjän", sanoi perämies, joka melun kuultuaan oli

uudestaan tullut kannelle.

Pimeän suojassa vilkasi Henry tähän herraan sanomattoman

halveksivasti, ja katseella, mikä selvään ilmaisi hänellä olevan
tärkeän asian takanaan, alkoi hän kertoa matkastaan, sovitellen
siten että juttu kävi hiljalleen yhä jännittävämmäksi. Molemmat
kuulijansa eivät kuitenkaan olleet tyytyväisiä tällaiseen
kertomistapaan, vaan selittivät kiihkeinä asianomaiselle, mikä hyöty
oli asiallisesta ja lyhyestä kertomistavasta.

"Minä en ymmärrä hölyn pölyä", sanoi laivuri, kun kertoja

kuuntelijoiden mieliksi oli pilannut koko historiansa. "Joku on
peloittanut häntä; parasta sentään, että lähdemme heti perässä."

"Ne purjehtivat kello yhdeltä", sanoi perämies. "Ja ajatelkaa mitä

teette, ellei hän tulekaan sovinnolla takaisin, — ja jos mies ei
olekaan tytön isä. Kirotun sekasotkuinen koko juttu."

"En todellakaan ymmärrä mitä tekisin", sanoi laivuri. "En ollenkaan

ymmärrä mikä olisi viisainta."
 "Niin, minua ei asia tietystikään koske", sanoi Henry
välinpitämättömästi, "mutta kyllä minä tietäisin tehtäväni."

Molemmat miehet kumartuivat uteliaana. "Minä tietysti olen

katukuleksija", sanoi Henry, nauttien tavattomasti voimansa
tuntemisesta. "Se minä ehkä olenkin. Minut tietysti joku irvistelevä
joukko kantaa kojuun. — Minä tietysti…"

"Mitä sinä tekisit?" kysyi laivuri rauhallisena.

"Noutaisin miss Gethingin takaisin laivaan", sanoi poika, "ja sillä

olisi koko asia autettu."

"Tuhat tulimmaista, poika on oikeassa", huudahti perämies.

"Kunhan vaan ehdittäisi." Mutta laivuri oli jo matkalla. "Sinä olet kiltti
poika, Henry", sanoi perämies. "Juokse nyt uudestaan ja pidä
tarkkaa tähystystä 'Febestä'. Heti kun huomaat sen aikovan
purjehtia, kiiruhda takaisin ilmoittamaan. Jos se purjehtii sivutse
ennenkuin laivuri on tullut, koitan minä jollakin tavalla ottaa selvän,
mitä tämä kaikki merkitsee." Laivuri oli tällä aikaa juossut, henki
kurkussa, Overcourtiin. Numero viisi oli pimeän peitossa, mutta kun
laivuri hetkisen moukaroitsi ovea, ilmestyi valoa ikkunaan.

"Kuka siellä? Mitä te tahdotte?" kuului kimakka, kiukkuinen ääni ja

äskeisen vaimoihmisen pää pisti ulos avatusta ikkunasta.

"Tahdon tavata sen nuoren naisen, jonka hetkinen sitten saatoin

tänne", sanoi laivuri. "Heti!"

"Mitä? Näin myöhään yöllä?" sanoi vaimo. "Olkaa toki järkevä,

nuori mies, niin rakastunut kuin lienettekin."

"Asiani on erittäin tärkeä", sanoi laivuri kärsimättömästi.

 "Ettekö saata minulle sitä ilmoittaa?" kysyi eukko, joka välttämättä
tahtoi saada uteliaisuutensa tyydytetyksi.

"Olen saanut tietoja hänen isästään", sanoi laivuri, koettaen pysyä

rauhallisena.

Pää katosi ja ikkuna suljettiin. Hetken perästä, mikä laivurista

tuntui ijankaikkisuudelta, kuului askeleita eteisessä, ovi aukeni ja
Annis seisoi hänen edessään.

Lähdettiin takaisin satamaan ja laivuri kertoi matkalla tietonsa. Tie

oli pitkä ja Annis tunsi väsyvänsä, mutta kieltäytyi kuitenkin ylpeästi
nojautumasta seuraajansa käsivarteen — liiaksikin hyvin muistaen
edellisen matkansa samalla tiellä. Päästyään laiturille näkivät he
perämiehen tulevan juosten vastaan. Laivuri sai ankaran
sydämentykytyksen.

"Sinne ei enään kannata mennä", sanoi perämies. "'Febe' on jo

matkalla.
Huudammeko kun se menee ohitse?"

Laivuri unohti Anniksen laiturille, hyppäsi laivaan ja tirkisti jokea

ylös. Yö oli tähtikirkas ja hetkisen katseltuaan eroitti hän epäselvästi
pienen kuunarin, joka hiljalleen lähestyi.

"Vetäkää ylös pari merkkilyhtyä, Jack, ja ajakaa miehet kojusta",

huusi hän perämiehelle.

"Miksi niin?" kysyi tämä ihmeissään.

"Tehkää kuten käskin", huusi laivuri kiukkuisesta "Henry, auta

näiden luukun kansien nostamisessa."
 Perämies sytytti lyhdyt ja juoksi keulaan herättämään miehistöä.
"Febe" oli enään parikymmentä metriä peränpuolella.

"Ohoii! Kuunari, ohoi!" huusi Wilson ja juoksi syrjälle.

"Halloo", kuului käheä ääni.

"Onko teillä täysi lasti?" kysyi "Merilokin" kapteeni.

"Ei."

"Laskekaa sitten ankkuri ja tulkaa viereen", huusi Wilson. "Meidän

pitää vielä viikon päivät viipyä täällä ja ruumassa on pari tusinaa
sillitynnöreitä, joiden välttämättä pitää olla Lontoossa tällä viikolla."

"Febe" oli nyt aivan "Merilokin" rinnalla; laivuri pidätti henkeään

levottomuudesta.

"Ette siinä viivy jos puolen tuntia", huusi hän huolestuneena.

Ankkurin kolina oli musiikkia hänen korvilleen ja tuskin luottaen

silmiinsä, näki hän "Feben" miesten korjaavan juuri ylös saatuja
purjeita. Kymmenen minuutin kuluttua keinuivat kuunarit vieretysten.

"Merilokin" lastiruuman luukut olivat auki ja keinuva merkkilyhty

märssyssä levitti heikkoa valoaan miehistön unisille kasvoille.
Perämies seisoi kajuutan seinän nojalla ja supatti ohjeita Anniksen
korvaan.

"Rientäkää", sanoi "Feben" laivuri, "otan ne vaan kannelle kun

matka ei ole pitempi."

Toimekkaana riensi hän syrjälle ohjaamaan lastin siirtoa ja tarkasti

uteliaana toimitusta katselevaa tyttöä.
 "Kaunis laiva", sanoi Annis. "Saanko tulla katsomaan sinne?"

"Kernaasti, ellette vaan tule tielle", kuului vastaus.

Käyttäen hyväkseen tätä ehdollista lupausta, astui Annis "Febeen"

ja kuljeskeli ympäri sen kantta. Saavuttuaan kajuutan rappusille, hän
pysähtyi ja katseli ympärilleen. Kaikki olivat toimissaan, eikä kukaan
näyttänyt enempää kiinnittäneen huomiotansa häneen. Tyttö epäili
silmänräpäyksen ja astui sitten pimeään kajuuttaan.

"Oletteko se te, kapteeni?" kuului ääni. "Minkätähden

pysähdyimme?"
Annis ei vastannut.

"Kuka se on?" kuului ääni uudestaan, tällä kertaa jyrkemmin.

"Hiljaa", sanoi Annis.

"Mikä hätänä?" kysyi herra Tillotson.

Annis säpsähti ja koetti kuunnella toista ääntä. Mutta ainoastaan

heikko hengitys oli kaikki mitä hän saattoi eroittaa.

"Isä!" huudahti hän yht'äkkiä. "Se olen minä, — Annis! Missä sinä
olet?"

Kuului huudahdus toiselta puolen kajuuttaa ja Annis näki jonkun

hypähtävän pystyyn ja lähestyvän häntä. Se tarttui hänen
vyötäisiinsä ja partaset kasvot koskettivat hänen hienoa hipiäänsä.
Vuoroin nauraen, vuoroin itkien, kiersi Annis käsivartensa isänsä
kaulaan ja puristi häntä suonenvedontapaisesti.

"Kas niin! — kas niin, lapseni", sanoi lopulta kapteeni Gething.

 "Oli kerrassaan ihme, että onnistuimme pysäyttää teidät", sanoi
Annis innoissaan. "'Merilokki' on aivan vieressä, enkä minä ymmärrä
miksi sinä uudestaan aiot mennä matkaasi."

"Sitä en itsekään ymmärrä", sanoi Gething väsyneesti.

"Voit toki käsittää, etten minä johda sinua mihinkään vaaraan. Ota
takki päällesi ja tule mukaan."

Sanomatta sanaakaan teki kapteeni Gething mitä käskettiin ja

seurasi tytärtään kannelle.

"En tulekaan mukaan, kapteeni", sanoi hän, tavatessaan "Feben"

laivurin nostamassa sillitynnöreitä.

"Vai niin", vastasi tämä lyhyesti, "mutta rahoja ette enää saa
takaisin."

Häpeissään ja pitäen tyttärensä käsivarresta, astui kapteeni

Gething "Merilokkiin" ja pudisti Wilsonin kättä. Saavuttuaan
kertomuksensa ja selvityksensä puoliväliin sai laivuri ihmeellisen
halun kohdata Tillotsonia, mutta Annis sai hänet sentään estettyä, ja
kun "Febe" oli saanut lastattua sillinsä, liukui se hiljalleen,
toivotettuaan ystävällisesti hyvää yötä, jokea ulos ulapalle.
"Merilokin" miehistö pääsi jatkamaan häirittyä untansa.

"Oletteko tyytyväinen nyt?" kysyi laivuri Annikselta, kun kapteeni

Gething väsyneenä oli mennyt kajuuttaan.

"Täydellisesti", vastasi Annis.

"Mutta minä en ole", sanoi Wilson merkitsevällä äänenpainolla.

 Miss Gething hymyili ja nojautui laivan syrjälle katselemaan
tummaa vettä ja nukkuvaa kaupunkia. Hän ei liikahtanut, kun Wilson
asettui hänen viereensä ja kun tämä tarttui hänen käteensä ei hän
estellyt.

"Minä en ole tyytyväinen — — vielä", sanoi Wilson ja vei tytön

käden huulilleen.

Samassa huomasi hän merkkilyhtyjen loistavan liian kirkkaasti.

Hän laski ne alas ja puhalsi sammuksiin. Vaan yht'äkkiä kuului
pidätettyä naurua, laivuri kääntyi ympäri — silmänräpäystä liian
myöhään. Annis Gething katosi kajuutan rappusista.
 *** END OF THE PROJECT GUTENBERG EBOOK LAIVURI ON
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