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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
Last digit is the print number: 9 8 7 6 5 4 3 2 1
The
publisher’s
policy is to use
paper manufactured
from sustainable forests
Content Strategist: Russell Gabbedy

Content Development Specialist: Sharon Nash
Content Coordinator: Joshua Mearns
Project Manager: Joanna Souch
Design: Christian Bilbow
Illustration Manager: Emily Costantino
Marketing Manager: Melissa Fogarty
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
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

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,
158.3 CLAU-KLAL Modified Cincinnati Procedure Edward J. Holland, Gary S. Schwartz,
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

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,
174.3 Implantation of an Artiflex Lens Thomas Kohnen, Mehdi Shajari, Jose L. Güell,
174.4 Implantation of an ICL Thomas Kohnen, Mehdi Shajari, Jose L. Güell,
174.5 Performing LASIK in a Patient with an Iris-Fixated Lens Thomas Kohnen, Mehdi Shajari, Jose L. Güell,
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- new surgical videos in order to keep pace with the dramatic
gone significant transformation since the last edition of innovation in our field. The editors and authors have strived
Cornea. New diagnostic technology has vastly improved our to provide the most current material available for residents,
ability to detect disease. New medications and other thera- fellows, clinicians, and researchers to help in the manage-
peutic options have changed the treatment paradigm for ment of patients with cornea and external disease. We hope
many disorders. And new surgical techniques have had a this edition will benefit patients for years to come.
remarkable impact on surgical outcomes. Not only do these
new procedures provide better outcomes but, in addition, Mark J. Mannis
we can now offer surgical options earlier in the disease
process. Edward J. Holland
This edition of Cornea consists of numerous new chapters
and extensive revisions of existing chapters, as well as many
xiv
Acknowledgements
This fourth edition of Cornea is the result of an extraordinary, highest quality medical textbook possible both in print and
coordinated effort by many talented individuals. We cannot electronic format. Special thanks to Sharon Nash and Russell
thank our contributing authors and co-authors enough. We Gabbedy at Elsevier, who have motivated and guided us
appreciate their excellent contributions of the most current along this journey.
information on the diagnosis and management of cornea Finally, we would like to thank our families, who continue
and external disease. In addition, we thank these authors for to provide support and the considerable time needed to
adhering to the tight editorial requirements in order to keep produce what we hope is an outstanding textbook.
this textbook current and on time.
We have enjoyed our continued relationship with our
publisher, Elsevier, who shares our goal: to provide the
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 ebook, and video formats. We acknowledge the founding
market-leading comprehensive title covering fundamentals, editorial team who brought this project to fruition through
diagnosis, medical and surgical treatment of cornea and their tireless efforts, expertise, and devotion that started out
related external disorders. Continually used by practitioners over 20 years ago.
and trainees throughout the world, what started out as a
three volume book-set has now evolved into a complete Elsevier
multimedia resource delivering content in print, online,
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
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
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
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
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
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
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
xxii
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
xxiii
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
xxiv
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
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 Jacqueline Ng MD Karen W Oxford MD

Resident of Ophthalmology Department of Ophthalmology Director, Cornea and Refractive Surgery
Department of Ophthalmology Cornea Division Pacific Eye Associates
University of Chicago University of California, Irvine Clinical Professor of Ophthalmology
Chicago, IL, USA Gavin Herbert Eye Institute California Pacific Medical Center
Chapter 124 Irvine, CA, USA San Francisco, CA, USA
Parveen Nagra MD
Asssistant Surgeon Lisa M Nijm MD, JD David A Palay MD
Wills Eye Hospital Medical & Surgical Director Associate Clinical Professor
Assistant Professor Warrenville EyeCare and LASIK Department of Ophthalmology
Jefferson Medical College Warrenville, IL, USA Emory University School of Medicine
Philadelphia, PA, USA Assistant Clinical Professor of Atlanta, GA, USA
Chapter 18 Ophthalmology Chapter 22
University of Illinois Eye and Ear Infirmary
Afshan A Nanji MD, MPH Department of Ophthalmology and Sotiria Palioura MD, PhD
Assistant Professor Visual Sciences Instructor
Department of Ophthalmology Chicago, IL, USA Department of Ophthalmology
Casey Eye Institute Chapters 88; 108 Bascom Palmer Eye Institute
Oregon Health and Science University University of Miami
Portland, OR, USA Ken K Nischal MD, FRCOphth Miller School of Medicine
Chapter 17 Professor of Ophthalmology Miami, FL, USA
Director of Pediatric Ophthalmology Chapter 66
Leslie C Neems MD Strabismus and Adult Motility
Ophthalmology Resident Physician UPMC Eye Center Deval R Paranjpe MD, ScB
Northwestern University Children’s Hospital of Pittsburgh of UPMC Assistant Professor of Ophthalmology
Feinberg School of Medicine University of Pittsburgh Drexel University College of Medicine
Chicago, IL, USA Pittsburgh, PA, USA Pittsburgh, PA, USA
Kristiana D Neff MD Teruo Nishida MD, DSc Mansi Parikh MD

Partner Professor Emeritus Assistant Professor
Carolina Cataract & Laser Center Department of Ophthalmology Casey Eye Institute
Charleston, SC, USA Graduate School of Medicine Oregon Health and Sciences University
Chapter 53 Yamaguchi University Portland, OR, USA
Ube, Japan Chapter 56
Chapter 1
J Daniel Nelson MD, FACS
Professor of Ophthalmology Matthew R Parsons MD
University of Minnesota M Cristina Nishiwaki-Dantas MD Chief
Associate Medical Director Professor of Ophthalmology Corneal Service
HealthPartners Medical Group Department of Ophthalmology, Corneal Excel Eye Center
Minneapolis, MN, USA and External Disease Service Provo, UT, USA
Chapter 2 Santa Casa of São Paulo Chapter 88
São Paulo, Brazil
Chapter 84
Jeffrey A Nerad MD Sirichai Pasadhika MD
Partner, Cincinnati Eye Institute Director of Vitreoretinal Services
Professor of Ophthalmology Rudy MMA Nuijts MD, PhD Devers Eye Institute
University of Cincinnati Professor of Ophthalmology Legacy Health System
Cincinnati, OH, USA University Eye Clinic Maastricht Portland, OR, USA
Chapter 28 Medical University Center Maastricht Affiliate Instructor
Maastricht, The Netherlands Casey Eye Institute
Chapter 174
Marcelo V Netto MD, PhD Oregon Health & Science University
Department of Ophthalmology Portland, OR, USA
University of São Paulo Robert B Nussenblatt MD, MPH Chapter 102
São Paulo, Brazil Formerly Chief, Laboratory of Immunology
Medical Director National Eye Institute, NIH Dipika V Patel PhD, MRCOphth
Instituto Oftalmológico Paulista Bethesda, MD, USA Associate Professor
São Paulo, Brazil Chapter 101 Department of Ophthalmology
Chapter 168 New Zealand National Eye Centre
University of Auckland
Auckland, New Zealand
Chapter 94
xxvii
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
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
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
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
Alan E Sadowsky MD University of Siena
Adjunct Assistant Professor Siena, Italy
Boris Severinsky OD, MOptom
Contact Lens Service
University of Minnesota
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
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
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
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
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
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
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
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
one-third of the ocular tunic. Although most of both the

Key Concepts cornea and sclera consists of dense connective tissue, the
physiological roles of these two components of the eye shell
• The cornea and sclera form the outer shell of the eye. differ. The cornea serves as the transparent “window” of the
• The principal physiological role of the cornea is to allow eye that allows the entry of light, whereas the sclera provides
external light to enter the eye and to contribute to its a “dark box” that allows the formation of an image on the
focusing on the retina. Transparency and refractive retina. The cornea is exposed to the outer environment,
power are, thus, essential for this function. whereas the opaque sclera is covered with the semitranspar-
• The cornea consists of the epithelium, Bowman’s layer, ent conjunctiva and has no direct exposure to the outside.
stroma, Descemet membrane, and endothelium. The differences in the functions of the cornea and sclera
• The functions of the corneal epithelium are regulated by reflect those in their microscopic structures and biochemical
various biologically active agents such as growth components (Fig. 1.1).
factors, cytokines, and chemokines in tear fluid, Interwoven fibrous collagen is responsible for the mechan-
whereas those of the endothelium are regulated by ical strength of both the cornea and sclera, protecting the
factors in aqueous humor. inner components of the eye from physical injury and main-
• Dynamic homeostasis of the corneal epithelium is taining the ocular contour.1 The corneal epithelium forms
maintained by the generation of new epithelial cells an effective mechanical barrier as a result of the interdigita-
from limbal stem cells, centripetal cell movement, tion of cell membranes and the formation of junctional
differentiation of basal cells into wing cells and then complexes such as tight junctions and desmosomes between
superficial cells, and cell desquamation via apoptosis. adjacent cells. Together with the cellular and chemical
• The corneal stroma is composed primarily of components of the conjunctiva and tear film, the corneal
extracellular matrix, predominantly type I collagen and surface protects against potential pathological agents and
proteoglycans. Collagen fibrils are homogeneous in microorganisms.
diameter and are aligned at a constant distance to The smooth surface of the cornea contributes to visual
maintain tissue transparency. Keratocytes are the clarity. The regular arrangement of collagen fibrils in the
resident cells of the stroma, and although relatively few
corneal stroma accounts for the transparency of this tissue.2,3
in number, they play important roles in the maintenance
of stromal structure through synthesis and secretion as Maintenance of corneal shape and transparency is critical
well as degradation of collagen and proteoglycans. for light refraction, with the cornea accounting for more
• The cornea is one of the most sensitive tissues in the than two-thirds of the total refractive power of the eye. A
body as a result of its abundant sensory nerve endings. functionally intact corneal endothelium is important for
Neural regulation is, thus, another important factor in maintenance of stromal transparency as a result of regula-
the maintenance of corneal structure and function. tion by the endothelium of corneal hydration. The cornea
• Morphogenesis of the eye is achieved by cell lineages thus plays a central role in vision as a result of its transpar-
of various origins including the surface and neural ency and refractive power, and it maintains the eye shell.
ectoderm during embryonic development. Each part of the cornea contributes to its transparency and
Characterization of the development of ocular tissues shape, and its anatomy is closely related to its physiology
during embryogenesis is important for understanding and function.
the pathogenesis of congenital anomalies of the cornea
and anterior eye segment.
Anatomy and Physiology
Structure of the cornea and sclera
Introduction
The ocular surface is composed of the cornea, conjunctiva,
The avascular cornea is not an isolated tissue. It forms, lacrimal glands, and other adnexa. The outermost portion
together with the sclera, the outer shell of the eye, occupying 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
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a water-closet; by some horrid drain; by proximity to a pig-sty; by an
overflowing privy, especially if vegetable matter be rotting at the
same time in it; by bad ventilation, or by contagion. Diphtheria may
generally be traced either to the one or to the other of the above
causes; therefore let me urgently entreat you to look well into all
these matters, and thus to stay the pestilence! Diphtheria might long
remain in a neighborhood if active measures be not used to
exterminate it.
210. Have the goodness to describe the symptoms of Measles?
Measles commences with symptoms of a common cold; the patient
is at first chilly, then hot and feverish; he has a running at the nose,
sneezing, watering and redness of the eyes, headache, drowsiness, a
hoarse and peculiar ringing cough, which nurses call “measle-
cough,” and difficulty of breathing. These symptoms usually last
three days before the eruption appears; on the fourth it (the
eruption) generally makes its appearance, and continues for four
days and then disappears, lasting altogether, from the
commencement of the symptoms of cold to the decline of the
eruption, seven days. It is important to bear in mind that the
eruption consists of crescent-shaped—half-moon-shaped—patches;
that they usually appear first about the face and the neck, in which
places they are the best marked; then on the body and on the arms;
and, lastly, on the legs, and that they are slightly raised above the
surface of the skin. The face is swollen, more especially the eyelids,
which are sometimes for a few days closed.
Well, then, remember, the running at the nose, the sneezing, the
peculiar hoarse cough, and the half-moon-shaped patches, are the
leading features of the disease, and point out for a certainty that it is
measles.
211. What constitutes the principal danger in Measles?
The affection of the chest. The mucous or lining membrane of the
bronchial tubes is always more or less inflamed, and the lungs
themselves are sometimes affected.
212. Do you recommend “surfeit water” and saffron tea to throw
out the eruption in Measles?
Certainly not. The only way to throw out the eruption, as it is
called, is to keep the body comfortably warm, and to give the
beverages ordered by the medical man, with the chill off. “Surfeit
water,” saffron tea, and remedies of that class, are hot and
stimulating. The only effect they can have, will be to increase the
fever and the inflammation—to add fuel to the fire.
213. What is the treatment of Measles?
What to do.—The child ought to be confined both to his room and
to his bed, the room being kept comfortably warm; therefore, if it be
winter time, there should be a small fire in the grate; in the summer
time, a fire would be improper. The child must not be exposed to
draughts; notwithstanding, from time to time, the door ought to be
left a little ajar in order to change the air of the apartment; for proper
ventilation, let the disease be what it may, is absolutely necessary.
Let the child, for the first few days, be kept on a low diet, such as
on milk and water, arrow-root, bread and butter, etc.
If the attack be mild, that is to say, if the breathing be not much
affected (for in measles it always is more or less affected), and if
there be not much wheezing, the acidulated infusion of roses’
mixture[228] will be all that is necessary.
But suppose that the breathing is short, and that there is a great
wheezing, then, instead of giving him the mixture just advised, give
him a teaspoonful of a mixture composed of ipecacuanha wine,
syrup, and water,[229] every four hours. And if, on the following day,
the breathing and the wheezing be not relieved, in addition to the
ipecacuanha mixture, apply a tela vesicatoria, as advised under the
head of inflammation of the lungs.
When the child is convalescing, batter puddings, rice, and sago
puddings, in addition to the milk, bread and butter, etc., should be
given; and, a few days later, chicken, mutton-chops, etc.
The child ought not, even in a mild case of measles, and in
favorable weather, to be allowed to leave the house under a fortnight,
or it might bring on an attack of bronchitis.
What NOT to do.—Do not give either “surfeit water” or wine. Do not
apply leeches to the chest. Do not expose the child to the cold air. Do
not keep the bedroom very hot, but comfortably warm. Do not let the
child leave the house, even under favorable circumstances, under a
fortnight. Do not, while the eruption is out, give aperients. Do not,
“to ease the cough,” administer either emetic tartar or paregoric—the
former drug is awfully depressing; the latter will stop the cough, and
will thus prevent the expulsion of the phlegm.
214. What is the difference between Scarlatina and Scarlet Fever?
They are, indeed, one and the same disease, scarlatina being the
Latin for scarlet fever. But, in a popular sense, when the disease is
mild, it is usually called scarlatina. The latter term does not sound so
formidable to the ears either of patients or of parents.
215. Will you describe the symptoms of Scarlet Fever?
The patient is generally chilly, languid, drowsy, feverish, and
poorly for two days before the eruption appears. At the end of the
second day, the characteristic, bright scarlet efflorescence, somewhat
similar to the color of a boiled lobster, usually first shows itself. The
scarlet appearance is not confined to the skin; but the tongue, the
throat, and the whites of the eyes put on the same appearance; with
this only difference, that on the tongue and on the throat the scarlet
is much darker; and, as Dr. Elliotson accurately describes it,—“the
tongue looks as if it had been slightly sprinkled with Cayenne
pepper.” The eruption usually declines on the fifth, and is generally
indistinct on the sixth day; on the seventh it has completely faded
away. There is usually, after the first few days, great itching on the
surface of the body. The skin, at the end of the week, begins to peel
and to dust off, making it look as though meal had been sprinkled
upon it.
There are three forms of scarlet fever,—the one where the throat is
little, if at all affected, and this is a mild form of the disease; the
second, which is generally, especially at night, attended with
delirium, where the throat is much affected, being often greatly
inflamed and ulcerated; and the third (which is, except in certain
unhealthy districts, comparatively rare, and which is VERY
dangerous), the malignant form.
216. Would it be well to give a little cooling, opening physic as
soon as a child begins to sicken for Scarlet Fever?
On no account whatever. Aperient medicines are, in my opinion,
highly improper and dangerous both before and during the period of
the eruption. It is my firm conviction that the administration of
opening medicine, at such times, is one of the principal causes of
scarlet fever being so frequently fatal. This is, of course, more
applicable to the poor, and to those who are unable to procure a
skillful medical man.
217. What constitutes the principal danger in Scarlet Fever?
The affection of the throat, the administration of opening medicine
during the first ten days, and a peculiar disease of the kidneys ending
in anasarca (dropsy), on which account, the medical man ought,
when practicable, to be sent for at the onset, that no time may be lost
in applying proper remedies.
218. How would you distinguish between Scarlet Fever and
Measles?
Measles commences with symptoms of a common cold; scarlet
fever does not. Measles has a peculiar hoarse cough; scarlet fever has
not. The eruption of measles is in patches of a half-moon shape, and
is slightly raised above the skin; the eruption of scarlet fever is not
raised above the skin at all, and is one continued mass. The color of
the eruption is much more vivid in scarlet fever than in measles. The
chest is the part principally affected in measles, and the throat in
scarlet fever.
There is an excellent method of determining, for a certainty,
whether the eruption be that of scarlatina or otherwise. I myself
have, in several instances, ascertained the truth of it: “For several
years M. Bouchut has remarked in the eruption of scarlatina a
curious phenomenon, which serves to distinguish this eruption from
that of measles, erythema, erysipelas, etc., a phenomenon essentially
vital, and which is connected with the excessive contractability of the
capillaries. The phenomenon in question is a white line, which can
be produced at pleasure by drawing the back of the nail along the
skin where the eruption is situated. On drawing the nail, or the
extremity of a hard body (such as a pen-holder), along the eruption,
the skin is observed to grow pale, and to present a white trace, which
remains for one or two minutes, or longer, and then disappears. In
this way the diagnosis of the disease may be very distinctly written
on the skin; the word ‘Scarlatina’ disappears as the eruption regains
its uniform tint.”[230]
219. Is it of so much importance, then, to distinguish between
Scarlet Fever and Measles?
It is of great importance, as in measles the patient ought to be kept
moderately warm, and the drinks should be given with the chill off;
while in scarlet fever the patient ought to be kept cool—indeed, for
the first few days, cold; and the beverages, such as spring water, toast
and water, etc., should be administered quite cold.
220. What is the treatment of Scarlet Fever?[231]
What to do.—Pray pay particular attention to my rules, and carry
out my directions to the very letter—as I can then promise you that if
the scarlet fever be not malignant, the plan I am about to
recommend will, with God’s blessing, be generally successful.
What is the first thing to be done? Send the child to bed; throw
open the windows, be it winter or summer, and have a thorough
ventilation; for the bedroom must be kept cool, I may say cold. Do
not be afraid of fresh air, for fresh air, for the first few days, is
essential to recovery. Fresh air, and plenty of it, in scarlet fever, is
the best doctor a child can have: let these words be written legibly on
your mind.[232]
Take down the curtains of the bed; remove the valances. If it be
summer time, let the child be only covered with a sheet: if it be
winter time, in addition to the sheet, he should have one blanket over
him.
Now for the throat.—The best external application is a barm and
oatmeal poultice. How ought it to be made, and how applied? Put
half a teacupful of barm into a saucepan, put it on the fire to boil; as
soon as it boils take it off the fire, and stir oatmeal into it, until it is of
the consistence of a nice soft poultice; then place it on a rag, and
apply it to the throat; carefully fasten it on with bandage, two or
three turns of the bandage going round the throat, and two or three
over the crown of the head, so as nicely to apply the poultice where it
is wanted—that is to say, to cover the tonsils. Tack the bandage: do
not pin it. Let the poultice be changed three times a day. The best
medicine is the acidulated infusion of roses, sweetened with syrup.
[233]
It is grateful and refreshing, it is pleasant to take, it abates fever
and thirst, it cleans the throat and tongue of mucus, and is peculiarly
efficacious in scarlet fever; as soon as the fever is abated it gives an
appetite. My belief is that the sulphuric acid in the mixture is a
specific in scarlet fever, as much as quinine is in ague, and sulphur in
itch. I have reason to say so, for, in numerous cases, I have seen its
immense value.
Now, with regard to food.—If the child be at the breast, keep him
entirely to it. If he be weaned, and under two years old, give him milk
and water, and cold water to drink. If he be older, give him toast and
water, and plain water from the pump, as much as he chooses; let it
be quite cold—the colder the better. Weak black tea, or thin gruel,
may be given, but not caring, unless he be an infant at the breast, if
he take nothing but cold water. If the child be two years old and
upwards, roasted apples with sugar, and grapes will be very
refreshing, and will tend to cleanse both the mouth and the throat.
Avoid broths and stimulants of every kind.
When the appetite returns, you may consider the patient to be
safe. The diet ought now to be gradually improved. Bread and butter,
milk and water, and arrow-root made with equal parts of new milk
and water, should for the first two or three days be given. Then a
light batter or rice pudding may be added, and in a few days
afterward, either a little chicken or a mutton-chop.
The essential remedies, then, in scarlet fever, are, for the first few
days—(1) plenty of fresh air and ventilation, (2) plenty of cold water
to drink, (3) barm poultices to the throat, and (4) the acidulated
infusion of roses’ mixture as a medicine.
Now, then, comes very important advice. After the first few days,
probably five or six, sometimes as early as the fourth day, watch
carefully and warily, and note the time, the skin will suddenly
become cool, the child will say that he feels chilly; then is the time
you must now change your tactics—instantly close the windows, and
put extra clothing, a blanket or two, on his bed. A flannel night-gown
should, until the dead skin has peeled off, be now worn next to the
skin, when the flannel night-gown should be discontinued. The
patient ought ever after to wear, in the daytime, a flannel waistcoat.
[234]
His drinks must now be given with the chill off; he ought to have
a warm cup of tea, and gradually his diet should, as I have previously
recommended be improved.
There is one important caution I wish to impress upon you,—do
not give opening medicine during the time the eruption is out. In all
probability the bowels will be opened: if so, all well and good; but do
not, on any account, for the first ten days, use artificial means to
open them. It is my firm conviction that the administration of
purgatives in scarlet fever is a fruitful source of dropsy, of disease,
and death. When we take into consideration the sympathy there is
between the skin and the mucous membrane, I think that we should
pause before giving irritating medicines, such as purgatives. The
irritation of aperients on the mucous membrane may cause the
poison of the skin disease (for scarlet fever is a blood poison) to be
driven internally to the kidneys, to the throat, to the pericardium
(bag of the heart), or to the brain. You may say, Do you not purge if
the bowels be not open for a week? I say emphatically, No!
I consider my great success in the treatment of scarlet fever to be
partly owing to my avoidance of aperients during the first ten days of
the child’s illness.
If the bowels, after the ten days, are not properly opened, a dose or
two of the following mixture should be given:
Take of—Simple Syrup, three drachms;
Essence of Senna, nine drachms:
To make a Mixture. Two teaspoonfuls to be given early in the morning

occasionally, and to be repeated in four hours, if the first dose should not
operate.
In a subsequent Conversation, I shall strongly urge you not to
allow your child, when convalescent, to leave the house under at least
a month from the commencement of the illness; I therefore beg to
refer you to that Conversation, and hope that you will give it your
best and earnest consideration! During the last seventeen years I
have never had dropsy from scarlet fever, and I attribute it entirely to
the plan I have just recommended, and in not allowing my patients
to leave the house under the month—until, in fact, the skin that has
peeled off has been renewed.
Let us now sum up the plan I adopt:
1. Thorough ventilation, a cool room, and scant clothes on the bed,
for the first five or six days.
2. A change of temperature of the skin to be carefully regarded. As
soon as the skin is cool, closing the windows, and putting additional
clothing on the bed.
3. The acidulated infusion of roses with syrup is the medicine for
scarlet fever.
4. Purgatives to be religiously avoided for the first ten days at least,
and even afterward, unless there be absolute necessity.
5. Leeches, blisters, emetics, cold and tepid spongings, and
painting the tonsils with caustic, inadmissible in scarlet fever.
6. A strict antiphlogistic (low) diet for the first few days, during
which time cold water to be given ad libitum.
7. The patient not to leave the house in the summer under the
month; in the winter, under six weeks.
What NOT to do.—Do not, then, apply either leeches or blisters to
the throat; do not paint the tonsils with caustic; do not give
aperients; do not, on any account, give either calomel or emetic
tartar; do not, for the first few days of the illness, be afraid of cold air
to the skin, and of cold water as a beverage; do not, emphatically let
me say, do not let the child leave the house for at least a month from
the commencement of the illness.
My firm conviction is, that purgatives, emetics, and blisters, by
depressing the patient, sometimes cause ordinary scarlet fever to
degenerate into malignant scarlet fever.
I am aware that some of our first authorities advocate a different
plan to mine. They recommend purgatives, which I may say, in
scarlet fever, are my dread and abhorrence. They advise cold and
tepid spongings—a plan which I think dangerous, as it will probably
drive the disease internally. Blisters, too, have been prescribed; these
I consider weakening, injurious, and barbarous, and likely still more
to inflame the already inflamed skin. They recommend leeches to the
throat, which I am convinced, by depressing the patient, will lessen
the chance of his battling against the disease, and will increase the
ulceration of the tonsils. Again, the patient has not too much blood;
the blood is only poisoned. I look upon scarlet fever as a specific
poison of the blood, and one which will be eliminated from the
system, not by bleeding, not by purgatives, not by emetics, but by a
constant supply of fresh and cool air, by the acid treatment, by cold
water as a beverage, and for the first few days by a strict
antiphlogistic (low) diet.
Sydenham says that scarlet fever is oftentimes “fatal through the
officiousness of the doctor.” I conscientiously believe that a truer
remark was never made; and that under a different system to the
usual one adopted, scarlet fever would not be so much dreaded.[235]
221. How soon ought a child to be allowed to leave the house after
an attack of Scarlet Fever?
He must not be allowed to go out for at least a month from the
commencement of the attack, in the summer, and six weeks in the
winter; and not even then with out the express permission of a
medical man. It might be said that this is an unreasonable
recommendation but when it is considered that the whole of the skin
generally desquamates, or peels off, and consequently leaves the
surface of the body exposed to cold, which cold flies to the kidneys,
producing a peculiar and serious disease in them, ending in dropsy,
this warning will not be deemed unreasonable.
Scarlet fever dropsy, which is really a formidable disease,
generally arises from the carelessness, the ignorance, and the
thoughtlessness of parents in allowing a child to leave the house
before the new skin is properly formed and hardened. Prevention is
always better than cure.
Thus far with regard to the danger to the child himself. Now, if you
please, let me show you the risk of contagion that you inflict upon
families, in allowing your child to mix with others before a month at
least has elapsed. Bear in mind, a case is quite as contagious, if not
more so, while the skin is peeling off, as it was before. Thus, in ten
days or a fortnight, there is as much risk of contagion as at the
beginning of the disease, and when the fever is at its height. At the
conclusion of the month the old skin has generally all peeled off, and
the new skin has taken its place; consequently there will then be less
fear of contagion to others. But the contagion of scarlet fever is so
subtle and so uncertain in its duration, that it is impossible to fix the
exact time when it ceases.
Let me most earnestly implore you to ponder well on the above
important facts. If these remarks should be the means of saving only
one child from death, or from broken health, my labor will not have
been in vain.
222. What means do you advise to purify a house from the
contagion of Scarlet Fever?
Let every room be lime-washed and then be white washed;[236] if
the contagion has been virulent, let every bedroom be freshly
papered (the walls having been previously stripped of the old paper
and then lime-washed); let the bed, the bolsters, the pillows, and the
mattresses be cleansed and purified; let the blankets and coverlids be
thoroughly washed, and then let them be exposed to the open air—if
taken into a field so much the better; let the rooms be well scoured;
let the windows, top and bottom, be thrown wide open; let the drains
be carefully examined; let the pump-water be scrutinized, to see that
it be not contaminated by fecal matter, either from the water-closet
or from the privy; let privies be emptied of their contents—
remember this is most important advice—then put into the empty
places lime and powdered charcoal, for it is a well-ascertained fact
that it is frequently impossible to rid a house of the infection of
scarlet fever without adopting such a course. “In St. George’s,
Southwark, the medical officer reports that scarlatina ‘has raged
fatally, almost exclusively where privy or drain smells are to be
perceived in the houses.’”[237] Let the children who have not had, or
who do not appear to be sickening for scarlet fever, be sent away
from home—if to a farm-house so much the better. Indeed, leave no
stone unturned, no means untried, to exterminate the disease from
the house and from the neighborhood.
223. Will you describe the symptoms of Chicken-pox?
It is occasionally, but not always, ushered in with a slight shivering
fit; the eruption shows itself in about twenty-four hours from the
child first appearing poorly. It is a vesicular[238] disease. The eruption
comes out in the form of small pimples, and principally attacks the
scalp, the neck, the back, the chest, and the shoulders, but rarely the
face; while in small-pox the face is generally the part most affected.
The next day these pimples fill with water, and thus become vesicles;
on the third day they are at maturity. The vesicles are quite separate
and distinct from each other. There is a slight redness around each of
them. Fresh ones, while the others are dying away, make their
appearance. Chicken-pox is usually attended with a slight itching of
the skin; when the vesicles are scratched the fluid escapes, and leaves
hard pearl-like substances, which, in a few days, disappear. Chicken-
pox never leaves pit-marks behind. It is a child’s complaint; adults
scarcely, if ever, have it.
224. Is there any danger in Chicken-pox; and what treatment do
you advise?
It is not at all a dangerous, but, on the contrary, a trivial
complaint. It lasts only a few days, and requires but little medicine.
The patient ought, for three or four days, to keep the house, and
should abstain from animal food. On the sixth day, but not until
then, a dose or two of a mild aperient is all that will be required.
225. Is Chicken-pox infectious?
There is a diversity of opinion on this head, but one thing is certain
—it cannot be communicated by inoculation.
226. What are the symptoms of Modified Small-pox?
The modified small-pox—that is to say, small-pox that has been
robbed of its virulence by the patient having been either already
vaccinated, or by his having had a previous attack of small-pox—is
ushered in with severe symptoms, with symptoms almost as severe
as though the patient had not been already somewhat protected
either by vaccination or by the previous attack of small-pox—that is
to say, he has a shivering fit, great depression of spirits and debility,
malaise, sickness, headache, and occasionally delirium. After the
above symptoms have lasted about three days, the eruption shows
itself. The immense value of the previous vaccination, or the previous
attack of small-pox, now comes into play. In a case of unprotected
small-pox, the appearance of the eruption aggravates all the above
symptoms, and the danger begins; while in the modified small-pox,
the moment the eruption shows itself, the patient feels better, and, as
a rule, rapidly recovers. The eruption of modified small-pox varies
materially from the eruption of the unprotected small-pox. The
former eruption assumes a varied character, and is composed, first of
vesicles (containing water), and secondly of pustules (containing
matter), each of which pustules has a depression in the center, and
thirdly of several red pimples without either water or matter in them,
and which sometimes assume a livid appearance. These “breakings-
out” generally show themselves more upon the wrist, and sometimes
up one or both of the nostrils. While in the latter disease—the
unprotected small-pox—the “breaking-out” is composed entirely of
pustules containing matter, and which pustules are more on the face
than on any other part of the body. There is generally a peculiar
smell in both diseases—an odor once smelt never to be forgotten.
Now, there is one most important remark I have to make,—the
modified small-pox is contagious. This ought to be borne in mind, as
a person laboring under the disease must, if there be children in the
house, either be sent away himself, or else the children ought to be
banished both the house and the neighborhood. Another important
piece of advice is, let all in the house—children and adults, one and
all—be vaccinated, even if any or all have been previously vaccinated.
Treatment.—Let the patient keep his room, and if he be very ill, his
bed. Let the chamber be well ventilated. If it be winter time, a small
fire in the grate will encourage ventilation. If it be summer, a fire is
out of the question; indeed, in such a case, the window-sash ought to
be opened, as thorough ventilation is an important requisite of cure,
both in small-pox and in modified small-pox. While the eruption is
out, do not on any account give aperient medicine. In ten days from
the commencement of the illness a mild aperient may be given. The
best medicine in these cases is, the sweetened acidulated infusion of
roses,[239] which ought to be given from the commencement of the
disease, and should be continued until the fever be abated. For the
first few days, as long as the fever lasts, the patient ought not to be
allowed either meat or broth, but should be kept on a low diet, such
as on gruel, arrow-root, milk puddings, etc. As soon as the fever is
abated he ought gradually to resume his usual diet. When he is
convalescent, it is well, where practicable, that he should have
change of air for a month.
227. How would you distinguish between Modified Small-pox and
Chicken-pox?
Modified small-pox may readily be distinguished from chicken-
pox, by the former disease being, notwithstanding its modification,
much more severe and the fever much more intense before the
eruption shows itself than chicken-pox; indeed, in chicken-pox there
is little or no fever either before or after the eruption; by the former
disease, the modified small-pox, consisting partly of pustules
(containing matter), each pustule having a depression in the center,
and the favorite localities of the pustules being the wrists and the
inside of the nostrils: while, in the chicken-pox, the eruption consists
of vesicles (containing water), and not pustules (containing matter),
and the vesicles having neither a depression in the center, nor having
any particular partiality to attack either the wrists or the wings of the
nose. In modified small-pox each pustule is, as in unprotected small-
pox, inflamed at the base; while in chicken-pox there is only very
slight redness around each vesicle. The vesicles, too, in chicken-pox
are small—much smaller than the pustules are in modified small-
pox.
228. Is Hooping-cough an inflammatory disease?
Hooping-cough in itself is not inflammatory, it is purely
spasmodic; but it is generally accompanied with more or less of
bronchitis—inflammation of the mucous membrane of the bronchial
tubes—on which account it is necessary, in all cases of hooping-
cough, to consult a medical man, that he may watch the progress of
the disease and nip inflammation in the bud.
229. Will you have the goodness to give the symptoms, and a brief
history, of Hooping-cough?
Hooping-cough is emphatically a disease of the young; it is rare for
adults to have it; if they do, they usually suffer more severely than
children. A child seldom has it but once in his life. It is highly
contagious, and therefore frequently runs through a whole family of
children, giving much annoyance, anxiety, and trouble to the mother
and the nurses; hence hooping-cough is much dreaded by them. It is
amenable to treatment. Spring and summer are the best seasons of
the year for the disease to occur. This complaint usually lasts from
six to twelve weeks—sometimes for a much longer period, more
especially if proper means are not employed to relieve it.
Hooping-cough commences as a common cold and cough. The
cough, for ten days or a fortnight, increases in intensity; at about
which time it puts on the characteristic “hoop.” The attack of cough
comes on in paroxysms.
In a paroxysm the child coughs so long and so violently, and
expires so much air from the lungs without inspiring any, that at
times he appears nearly suffocated and exhausted; the veins of his
neck swell; his face is nearly purple; his eyes, with the tremendous
exertion, seem almost to start from their sockets; at length there is a
sudden inspiration of air through the contracted chink of the upper
part of the windpipe—the glottis—causing the peculiar “hoop; and,
after a little more coughing, he brings up some glairy mucus from the
chest; and sometimes, by vomiting, food from the stomach; he is at
once relieved until the next paroxysm occurs, when the same process
is repeated, the child during the intervals, in a favorable case,
appearing quite well, and after the cough is over, instantly returning
either to his play or to his food. Generally, after a paroxysm he is
hungry, unless, indeed, there be severe inflammation either of the
chest or of the lungs. Sickness, as I before remarked, frequently
accompanies hooping-cough; when it does, it might be looked upon
as a good sign. The child usually knows when an attack is coming on;
he dreads it, and therefore tries to prevent it; he sometimes partially
succeeds; but if he does, it only makes the attack, when it does come,
more severe. All causes of irritation and excitement ought, as much
as possible, to be avoided, as passion is apt to bring on a severe
paroxysm.
A new-born babe, an infant of one or two months old, commonly
escapes the infection; but if at that tender age he unfortunately catch
hooping-cough, it is likely to fare harder with him than if he were
older—the younger the child the greater the risk. But still, in such a
case, do not despair, as I have known numerous instances of new-
born infants, with judicious care, recover perfectly from the attack,
and thrive after it as though nothing of the kind had ever happened.
A new-born babe laboring under hooping-cough is liable to
convulsions, which is, in this disease, one, indeed the great, source of
danger. A child, too, who is teething, and laboring under the disease,
is also liable to convulsions. When the patient is convalescing, care
ought to be taken that he does not catch cold, or the “hoop” might
return. Hooping-cough may either precede, attend, or follow an
attack of measles.
230. What is the treatment of Hooping-cough?
We will divide the hooping-cough into three stages, and treat each
stage separately.
What to do.—In the first stage, the commencement of hooping-
cough: For the first ten days give the ipecacuanha wine mixture,[240] a
teaspoonful three times a day. If the child be not weaned, keep him
entirely to the breast; if he be weaned, to a milk and farinaceous diet.
Confine him for the first ten days to the house, more especially if the
hooping-cough be attended, as it usually is, with more or less of
bronchitis. But take care that the rooms be well ventilated, for good
air is essential to the cure. If the bronchitis attending the hooping-
cough be severe, confine him to his bed, and treat him as though it
were simply a case of bronchitis.[241]
In the second stage, discontinue the ipecacuanha mixture, and
give Dr. Gibb’s remedy—namely, nitric acid—which I have found to
be an efficacious and valuable one in hooping-cough:
Take of—Diluted Nitric Acid, two drachms;
Compound Tincture of Cardamoms, half a drachm;
Simple Syrup, three ounces;
Water, two ounces and a half:
Make a Mixture. One or two teaspoonfuls, or a tablespoonful, according to the

age of the child—one teaspoonful for an infant of six months, and two
teaspoonfuls for a child of twelve months, and one tablespoonful for a child of
two years, every four hours, first shaking the bottle.
Let the spine and the chest be well rubbed every night and
morning either with Roche’s Embrocation, or with the following
stimulating liniment (first shaking the bottle):
Take of—Oil of Cloves, one drachm;
Oil of Amber, two drachms;
Camphorated Oil, nine drachms:
Make a Liniment.
Let him wear a broad band of new flannel, which should extend
round from his chest to his back, and which ought to be changed
every night and morning, in order that it may be dried before putting
on again. To keep it in its place it should be fastened by means of
tapes and with shoulder-straps.
The diet ought now to be improved—he should gradually return to
his usual food; and, weather permitting, should almost live in the
open air—fresh air being, in such a case, one of the finest medicines.
In the third stage, that is to say, when the complaint has lasted a
month, if by that time the child is not well, there is nothing like
change of air to a high, dry, healthy, country place. Continue the
nitric acid mixture, and either the embrocation or the liniment to the
back and the chest, and let him continue to almost live in the open
air, and be sure that he does not discontinue wearing the flannel
until he be quite cured, and then let it be left off by degrees.
If the hooping-cough have caused debility, give him cod-liver oil, a
teaspoonful twice or three times a day, giving it him on a full
stomach after his meals.
But, remember, after the first three or four weeks, change of air,
and plenty of it, is for hooping-cough the grand remedy.
What NOT to do.—Do not apply leeches to the chest, for I would
rather put blood into a child laboring under hooping-cough than take
it out of him—hooping-cough is quite weakening enough to the
system of itself without robbing him of his life’s blood; do not, on any
account whatever, administer either emetic tartar or antimonial
wine; do not give either paregoric or syrup of white poppies; do not
drug him either with calomel or with gray powder; do not dose him
with quack medicine; do not give him stimulants, but rather give him
plenty of nourishment, such as milk and farinaceous food, but no
stimulants; do not be afraid, after the first week or two, of his having
fresh air, and plenty of it—for fresh, pure air is the grand remedy,
after all that can be said and done, in hooping-cough. Although
occasionally we find that if the child be laboring under hooping-
cough and is breathing a pure country air, and is not getting well so
rapidly as we could wish, change of air to a smoky, gas-laden town
will sometimes quickly effect a cure; indeed, some persons go so far
as to say that the best remedy for an obstinate case of hooping-cough
is for the child to live the great part of every day in gas-works!
231. What is to be done during a paroxysm of Hooping-cough?
If the child be old enough, let him stand up; but if he be either too
young or too feeble, raise his head, and bend his body a little
forward; then support his back with one hand, and the forehead with
the other. Let the mucus, the moment it is within reach, be wiped
with a soft handkerchief out of his mouth.
232. In an obstinate case of Hooping-cough, what is the best
remedy?
Change of air, provided there be no active inflammation, to any
healthy spot. A farm-house, in a high, dry, and salubrious
neighborhood, is as good a place as can be chosen. If, in a short time,
he be not quite well, take him to the sea-side: the sea breezes will
often, as if by magic, drive away the disease.
233. Suppose my child should have a shivering fit, is it to be
looked upon as an important symptom?
Certainly. Nearly all serious illnesses commence with a shivering
fit: severe colds, influenza, inflammations of different organs, scarlet
fever, measles, small-pox, and very many other diseases, begin in
this way. If, therefore, your child should ever have a shivering fit,
instantly send for a medical man, as delay might be dangerous. A few
hours of judicious treatment, at the commencement of an illness, is
frequently of more avail than days and weeks, nay months, of
treatment, when disease has gained a firm footing. A serious disease
often steals on insidiously, and we have, perhaps, only the shivering
fit, which might be but a slight one, to tell us of its approach.
A trifling ailment, too, by neglecting the premonitory symptom,
which, at first, might only be indicated by a slight shivering fit, will
sometimes become a mortal disorder:
“The little rift within the lute,
That by-and-by will make the music mute,
And ever widening slowly silence all.”[242]
234. In case of a shivering fit, perhaps you will tell me what to

do?
Instantly have the bed warmed, and put the child to bed. Apply
either a hot bottle or a hot brick, wrapped in flannel, to the soles of
his feet. Put an extra blanket on his bed, and give him a hot cup of
tea.
As soon as the shivering fit is over, and he has become hot,
gradually lessen the extra quantity of clothes on his bed, and take
away the hot bottle or the hot brick from his feet.
What NOT to do.—Do not give either brandy or wine, as
inflammation of some organ might be about taking place. Do not
administer opening medicine, as there might be some “breaking-out”
coming out on the skin, and an aperient might check it.
235. My child, apparently otherwise healthy, screams out in the
night violently in his sleep, and nothing for a time will pacify him:
what is likely to be the cause, and what is the treatment?
The causes of these violent screamings in the night are various. At
one time, they proceed from teething; at another, from worms;
sometimes, from night-mare; occasionally, from either disordered
stomach or bowels.
Each of the above causes will, of course, require a different plan of
procedure; it will, therefore, be necessary to consult a medical man
on the subject, who will soon, with appropriate treatment, be able to
relieve him.
236. Have the goodness to describe the complaint of children
called Mumps.
The mumps, inflammation of the “parotid” gland, is commonly
ushered in with a slight feverish attack. After a short time, a swelling,
of stony hardness, is noticed before and under the ear, which
swelling extends along the neck toward the chin. This lump is
exceedingly painful, and continues painful and swollen for four or
five days. At the end of which time it gradually disappears, leaving
not a trace behind. The swelling of mumps never gathers. It may
affect one or both sides of the face. It seldom occurs but once in a
lifetime. It is contagious, and has been known to run through a whole
family or school; but it is not dangerous, unless, which is rarely the
case, it leaves the “parotid” gland, and migrates either to the head, to
the breast, or to the testicle.
237. What is the treatment of Mumps?
Foment the swelling, four or five times a day, with a flannel wrung
out of hot chamomile and poppy-head decoction;[243] and apply,
every night, a barm and oatmeal poultice to the swollen gland or
glands. Debar, for a few days, the little patient from taking meat and
broth, and let him live on bread and milk, light puddings, and arrow-
root. Keep him in a well-ventilated room, and shut him out from the
company of his brothers, his sisters, and young companions. Give
him a little mild, aperient medicine. Of course, if there be the
slightest symptom of migration to any other part or parts, instantly
call in a medical man.
238. What is the treatment of a Boil?
One of the best applications is a Burgundy pitch plaster spread on
a soft piece of wash-leather. Let a chemist spread a plaster, about the
size of the hand; and, from this piece, cut small plasters, the size of a
shilling or a florin (according to the dimensions of the boil), which
snip around and apply to the part. Put a fresh one on daily. This
plaster will soon cause the boil to break; when it does break, squeeze
out the contents, the core, and the matter, and then apply one of the
plasters as before, which, until the boil be well, renew every day.
The old-fashioned remedy for a boil—namely, common yellow
soap and brown sugar, is a capital one for the purposes; it should be
made into a paste, and spread on a piece of coarse linen, the size
either of a shilling or of a florin (according to the size of the boil); it
eases the pain and causes the boil soon to break, and draws it when it
is broken; it should be renewed daily.
If the boils should arise from the child being in a delicate state of
health, give him cod-liver oil, meat once a day, and an abundance of
milk and farinaceous food. Let him have plenty of fresh air, exercise,
and play.
If the boils should arise from gross and improper feeding, then
keep him for a time from meat, and let him live principally on a milk
and farinaceous diet.
If the child be fat and gross, cod-liver oil would be improper; a
mild aperient, such as rhubarb and magnesia, would then be the best
medicine.
239. What are the symptoms of Earache?
A young child screaming shrilly, violently, and continuously, is
oftentimes owing to earache; carefully, therefore, examine each ear,
and ascertain if there be any discharge; if there be, the mystery is
explained.
Screaming from earache may be distinguished from the screaming
from bowelache by the former (earache) being more continuous—
indeed, being one continued scream, and from the child putting his
hand to his head; while, in the latter (bowelache), the pain is more of
a coming and of a going character, and he draws up his legs to his
bowels. Again, in the former (earache), the secretions from the
bowels are natural; while, in the latter (bowelache), the secretions
from the bowels are usually depraved, and probably offensive. But a
careful examination of the ear will generally at once decide the
nature of the case.
240. What is the best remedy for Earache?
Apply to the ear a small flannel bag, filled with hot salt—as hot as
can be comfortably borne, or foment the ear with a flannel wrung out
of hot chamomile and poppy-head decoction. A roasted onion,
inclosed in muslin, applied to the ear, is an old-fashioned and
favorite remedy, and may, if the bag of hot salt, or if the hot
fomentation do not relieve, be tried. Put into the ear, but not very far,
a small piece of cotton wool, moistened with warm olive oil. Taking
care that the wool is always removed before a fresh piece be
substituted, as if it be allowed to remain in any length of time, it may
produce a discharge from the ear. Avoid all cold applications. If the
earache be severe, keep the little fellow at home, in a room of equal
temperature, but well ventilated, and give him, for a day or two, no
meat.
If a discharge from the ear should either accompany or follow the
earache, more especially if the discharge be offensive, instantly call
in a medical man, or deafness for life may be the result.
A knitted or crocheted hat, with woolen rosettes over the ears, is,
in the winter time, an excellent hat for a child subject to earache. The
hat may be procured at any baby-linen warehouse.
241. What are the causes and the treatment of discharges from
the Ear?
Cold, measles, scarlet fever, healing up of “breakings-out” behind
the ear; pellets of cotton wool, which had been put in the ear, and
had been forgotten to be removed, are the usual causes of discharges
from the ear. It generally commences with earache.
The treatment consists in keeping the parts clean, by syringing the
ear every morning with warm water, by attention to food, keeping
the child principally upon a milk and a farinaceous diet, and by
change of air, more especially to the coast. If change of air be not
practicable, great attention ought to be paid to ventilation. As I have
before advised, in all cases of discharge from the ear, call in a
medical man, as a little judicious medicine is advisable—indeed,
essential; and it may be necessary to syringe the ear with lotions,
instead of with warm water; and, of course, it is only a doctor who
has actually seen the patient who can decide these matters, and what
is best to be done in each individual case.
242. What is the treatment of a “sty” in the eyelid?

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one-third of the ocular tunic. Although most of both the

Fig. 1.1 Anatomy of the human

faces the environment. The anterior corneal surface is

To make a Mixture. Two teaspoonfuls to be given early in the morning

Make a Mixture. One or two teaspoonfuls, or a tablespoonful, according to the

234. In case of a shivering fit, perhaps you will tell me what to

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