ANATOMY ANAD

IMMUNOLOGY OF OCULAR
SURFACE
Presented by : Dr.CH.Deepthi
Moderator : Dr.P.Viswamithra M.S
 DEFINITION

• The ocular surface includes the outer layer of the cornea, the tears,
the conjunctiva and the margin of the eyelids.

• This part of the eye has the most frequent injuries and disease manifestations due to
direct exposure to the environment
ANATOMY
 CORNEA
• The cornea is transparent, avascular tissue with a smooth, convex outer surface & concave
inner surface.
• Forms anterior 1/6th of outer fibrous coat of the eyeball
• Principal refractive surface accounting for some 40-45diopters of total refractive power.
• Dimensions:
1. Anterior surface is elliptical with horizontal diameter of 11.75mm and vertical diameter of
11mm
2. Posterior surface is circular with diameter of 11.5mm
3. Thickness in centre- 0.52mm while at periphery- 0.67mm
4. The anterior & posterior radii of curvature of central cornea are 7.8mm &6.5mm
respectively
5. Refractive index is 1.37
 HISTOLOGY OF CORNEA

Originally cornea was considered to consists of 5 layers from anterior to posterior, these are:
1. EPITHELIUM
2. BOWMAN’S MEMBRANE
3. STROMA
4. DESCEMET’S MEMBRANE
5. ENDOTHELIUM
Recently a new layer between the corneal stroma & descemet’s membrane named DUA’S
LAYER (pre-descemet’s membrane) has been discovered
 EPITHELIUM

• Epithelium is stratified squamous non keratinized

• Continues with bulbar conjunctiva at limbus but differs in possessing no goblet cells
• Thickness is about 50-90µm
• Consists of 5-6 layers of nucleated cells:
1. Basal layer- columnar cells
2. Mid 2-3 layers- wing/umbrella cells
3. Superficial 2 layers- flattened cells
Epithelium sheds at regular intervals & is replaced by growth from basal cells in a period of 6-8
days
BASAL LAYER:
• Tall columnar polygonal- shaped cells arranged in a palaside manner on a basement
membrane.
• Density is about 6000cells/sqmm
• Forms germinal layer & continuous with limbus
• Limbal stem cells: basal epithelial cells at limbus are called limbal stem cells
Undifferenciated pluripotent stem cells which amplify ,proliferate continuously
• Basal lamina: PAS positive structure made of hemidesmosomes & type 7 collagen fibrils
WING CELLS
• Form 2-3 layers of polyhedral cells which cap the basal cells and send processes between
them
FLATTENED CELLS
• 2 most superficial cell layers
• Represent the oldest epithelial cells
• Desmosomal attachment & maculae occludens are more
• Many microvilli 0.5mm in height contain glycocalyx associated with tear film stability
• Junctional complexes formed with adjacent cells maintain the barrier function of epithelium
FUNCTIONS :
1. Major refractive surface of the eye
2. Serves as a major surface to respond wound healing
3. Provides barrier to fluid loss & pathological organisms
CHEMICAL COMPOSITION:
• Water - 70% of wet weight
• Protein synthesis is higher than stroma, endothelium & descemet’s membrane
• Lipids – phospholipids & cholesterol
• ATP(2000mmol/kg wet wt), glycogen(10mg/g), glutathione(75-180mg/g) & ascorbic acid(47-
94mg/100g)
• Acetylcholine & cholinesterases
• Electrolytes – k⁺(142mEq/1H2O), Na⁺(75mEq/1H2O), CL⁻(30mEq/1H2O)
BLOOD SUPPLY
• An avascular structure
• Small loops derived from anterior ciliary vessels present in subconjunctival tissue invade the
periphery about 1mm & provide nourishment
NERVE SUPPLY
• Long ciliary & short ciliary nerves divide dichotomously after piercing the sclera & connect
with each other & conjunctival nerves forming PRECORNEAL PLEXUS
• Enter the cornea and loose myelin sheath & form STROMAL PLEXUS
• Some nerves pass anteriorly & form SUBEPITHELIAL PLEXUS
• Fibres from here extend between cells of all layers & form INTRAEPITHELIAL PLEXUS
 LIMBUS

• Anatomically, limbus refers to a circumcorneal transitional zone of the conjunctivocorneal &

corneoscleral junction
• Substrantia propria of conjunctiva stops here but conjunctival epithelium continues with that of
cornea
• Limbal epithelium is similar to corneal epithelium but its basal cells are arranged in a peculiar pattern
as ‘palaside of Vogt’
SURGICAL LIMBUS:
• 2mm wide circumcorneal transitional zone between clear cornea on one side & opaque sclera on the
other side
• The surgical limbus is characterised by these external landmarks
1. Anterior limbal border
2. Mid limbal line
3. Posterior limbal border
ZONES:
• Surgical limbus can be divided into 2 zones by 3 borders
1. Blue limbal zone: bluish translucent zone seen posterior to the anterior limbal border which is
about 1mm in superior quadrant, 0.8mm in inferior quadrant, 0.4mm nasal &temporal
quadrant
2. White limbal zone: 1mm wide whitish area lies between the mid-limbal line & the posterior
limbal border. It overlies the trabecular meshwork
 PREOCULAR TEAR FILM
• The preocular tear film is the sheet of tears which covers the inter palpebral portion of globe
& cornea, thickness of about 7-8µm
• That portion overlying the cornea is called precorneal tear film
• The presence of precorneal layer is 1st demonstrated by Fischer
• Functions of tear film :
1. Forms an almost perfectly smooth optical surface on the cornea.
2. Serves as lubricant for preocular surface & lids.
3. Transfers O2 from ambient air to the cornea.
4. Prevents infection due to the presence of anti bacterial substances
5. Washes away debris & noxious irritants
6. Provides a pathway for WBCs in case of injury
 STRUCTURE OF TEAR FILM
• Wolf was the 1st to describe in detail about the structure of tear film
• He coined the term precorneal tear film and assumed it consists of 3 layers
 Outer oily layer
Intermediate aqueous layer
Inner mucoid layer
1. LIPID LAYER :
 Outermost superficial oily layer derived from secretions of Meibomian, Zeiss and Moll glands
 Marginal tear strip – this layer forms a strip which extends to posterior margin of openings of the
meibomian glands and limits the anterior end of the tear fluid reservoirs
 Thickness is about 0.1-0.2mm and depends on the palpebral fissure width i.e., it increases when the
lids are closed
 Consists of lipids having low polarity such as wax and cholesterol esters
 Control of lipid secretion is ‘neuroendocrinal’
 Functions:
Prevents the overflow of tears and retards their evaporation
Provides clear ocular medium and smooth surface
Barrier for preventing contamination
Acts as surfactant layer
Acts as lubricant
2. AQUEOUS LAYER:
 Secreted by the lacrimal gland and the accessory glands of Krause and wolfring
 It constitutes the main bulk of thickness of tear film
 Consists of ions of inorganic salts, glucose, urea and biopolymers such as enzymes, proteins
and glycoproteins
 Functions:
Provides atmospheric oxygen to the epithelium
Contains antibacterial substances like lysozyme and betalysin
Washes away debris & noxious irritants
3. MUCOUS LAYER:
 Said to be bounded to the glycocalyx of the surface epithelial cells
 Mainly secreted by conjunctival goblet cells, crypts of Henle, glands of
Manz
 MUC5AC is the main tear mucin produced along with protein TFF1&3
 Thickness is about 0.02-0.04µm
 Functions:
lubricates ocular & palpebral surface
Protects the cornea & conjunctiva against abrasive effects, foreign
bodies by providing a slippery coating
PHYSICAL PROPERTIES CHEMICAL COMPOSITION
 TEAR FLIM DYNAMICS

Tear film accomplishes its functions by the highly specialized and well organized dynamic
activities
• Secretion of tears
• Formation of tear film
• Retention and redistribution of tear film
• Displacement phenomenon
• Evaporation from the tear film
• Drying and break-up of tear film
• Dynamic events during blinking
• Elimination of tears
TEAR FILM BREAK-UP
DYNAMIC EVENTS DURING BLINKING
EVAPORATION OF TEARS THROUGH LACRIMAL PUMP MECHANISM
 LACRIMAL APARATUS
Lacrimal apparatus comprises the structures concerned with formation of tears and its
transport .

LACRIMAL GLANDS: This includes the formation of tears

MAIN LACRIMAL GLAND:
• The main lacrimal gland is situated in the fossa for lacrimal gland, formed by orbital plate
of frontal bone, in the anterolateral part of roof of orbit
• It is divided in the anterior aspect by lateral horn of levator aponeurosis into 2 parts
1. Superior orbital
2. Inferior palpebral
BLOOD SUPPLY:
• Arterial supply : Main lacrimal gland is supplied by lacrimal artery, branch of ophthalmic artery.
Sometimes a branch of transverse facial artery may also supply the gland.
• Venous supply : Lacrimal veins drain the gland & join the ophthalmic vein
LYMPHATIC DRAINAGE:
Drain into the preauricular lymph nodes
NERVE SUPPLY:
3 modes of innervation
1. Sensory nerve supply: lacrimal nerve, banch of ophthalmic nerve
2. Sympathetic nerve supply: From sympathetic plexus around internal carotid artery, some
fibres join the deep petrosal nerve, then the nerve of pterygoid canal & then ultimately reach
the lacrimal gland through lacrimal neve
3. Secretomotor fibres: Derived from the superior salivatory nucleus
 LACRIMAL PASSAGES

This includes the transport of tears

• Lacrimal puncta
• Lacrimal canaliculi
• Lacrimal sac
• Nasolacrimal duct
 CONJUNCTIVA
• Translucent mucous membrane which lines the posterior surface of eyelids and
anterior aspect of the eyeball
• (CONJOIN: to join) It joins the eyeball to the lids
• Stretches from the lid margin to the limbus and encloses a complex space –
“conjunctival sac” open in front at the palpebral fissure – normally contains about 7µl
of tear fluid can accommodate upto 30µl
Parts of conjunctiva:
• Palpebral conjunctiva – Marginal, Tarsal and Orbital
• Bulbar conjunctiva – scleral and limbal
• Conjunctival fornix – superior, inferior, lateral and medial
 PALPEBRAL CONJUNCTIVA

• Lines the lids

• Stratified squamous epithelium
1. Marginal conjuntiva – It is a transition zone between skin and conjunctiva proper. It is
continued on the back the lid for about 2mm to a shallow subtarsal fold (sulcs
subtarsalis) near which the perforating vessels pass through the tarsus to supply the
conjunctiva – a common site for lodgement of conjunctival foreign body. Puncta open
in the marginal zone, and thus conjunctival sac is continuous with nasal inferior meatus
via lacrimal passage
2. Tarsal conjunctiva – Thin, transparent and highly vascular. Firmly adherent to the
whole tarsal plate in the upper lid ,only to half width of the tarsus in lower lid. Tarsal
glands appear as yellow streaks through translucent tarsal conjunctiva
3. Orbital conjunctiva – Lies between tarsal plate and fornix. loosely attached and lies
over mullers muscle
 BULBAR CONJUNCTIVA

• Stratified columnar epithelium

• Thin , transparent & lies loosely over the underlying structures & thus can be moved easily
• Separated from anterior sclera by episcleral tissue & tenons capsule
• A 3mm ridge of bulbar conjunctiva around the cornea is called “limbal conjunctiva”
• Subconjunctival vessels & anterior ciliary arteries can be seen in the loose tissue under the
bulbar conjunctiva
• In the area of limbus , conjunctiva , tenons capsule & episcleral tissue are fused into a
dense tissue which is strongly adherent to underlying corneoscleral tissue
 CONJUNCTIVAL FORNIX

• Continuous annular cul-de-sac, broken only on medial side by caruncle & plica semilunaris
conveniently divided into superior, inferior ,lateral and medial regions
1. Superior fornix : Reaches the orbital margin 8-10mm from the limbus. The extension of
fascial sheath of LPS & SR is attached in the upper part of superior fornix. In
subconjunctival tissue of superior fornix glands of Krause and mullers muscle are present .
2. Inferior fornix : Reaches the inferior orbital margin 8mm from the limbus. The extension
of fascial sheath of IO & IR is attached in the inferior fornix. In subconjunctival tissue,
glands of Krause are present.
3. Lateral fornix: It extends behind the equator of the eyeball & is about 14mm from the
lateral limbus
4. Medial fornix : Is the most shallow in which lie the caruncle & plica semilunaris dipped in a
pool of tears called ‘lacus lacrimalis or tear lake’
 MICROSCOPIC STRUCTURE OF CONJUNCTIVA

• It varies from region to region

• As the mucous membrane , conjunctiva has
1. An epithelium &
2. Submucosal lamina propria
 EPITHELIUM

CONJUNCTIVA NO. OF LAYERS CELLS IN THE LAYERS

MARGINAL 5 Layered non keratinised stratified 1. Superficial - squamous cells

squamous epithelium 2. Middle 3 layered - polyhedral cells
3. Deep - cylindrical cells
TARSAL & ORBITAL 2layered of stratified cuboidal 1. Superficial - cylindrical cells
epithelium 2. Deep – cuboidal cells

FORNIX & SCLERAL 3 layers of stratified squamous 1. Superficial – cylindrical cells

epithelium 2. Middle – polyhedral
3. Deep - cuboidal
LIMBAL 10 layers of stratified squamous 1. Superficial – squamous cells
epithelium 2. Middle – polygonal cells
3. Basal - cubical
4. Papillae – limbal palisades of vogt
 SUBMUCOSA

• The conjunctival submucosa has

1. Superficial- lymphoid / adenoid layer
2. Deep – fibrous layer
• LYMPHOID LAYER : Consists of fine connective tissue reticulum containing many
lymphocytes. It appears at fornices at 3-4 months of age & at tarsal at 5th month. This layer is
thickest in the fornices & ends at subtarsal fold. Lymphocytic nodules occur at canthi but
diminish in the conjunctival periphery.
• FIBROUS LAYER : This is a meshwork of collagenous & elastic fibers thicker than the
lymphoid layer except over the tarsal plate . Contains vessels & nerves & glands of Krause.
 CONJUNCTIVAL GLANDS

• 2 types
• Mucin secretory - goblet cells & crypts of henle & glands of manz
• Accessory lacrimal glands – glands of Krause & glands of wolfring
1. GOBLET CELLS:
Unicellular mucus glands-Present in between epithelial cells in all regions of
conjunctiva except marginal & limbal conjunctiva.
Destroyed after discharging mucin.
Density is high in children & young adults
Mucin lubricates & protects epithelial cells of conjunctiva & cornea & ensures tear
film stability by lowering surface tension
2. HENLE’S CRYPTS :
Not true gland but folds of mucous membrane – present in palpebral conjunctiva between
tarsal plates & fornices.
They have tubular structures with lumen of 15-30 µm which contain a few goblet cells
3. MELANOCYTES : Found in conjunctiva at limbus, fornix , caruncle,& at the site of entry of
anterior ciliary vessels
4. GLANDS OF KRAUSE:
 Lies in the deep subconjunctival tissue of upper fornix between palpebral part of lacrimal
gland & tarsal plate and lower fornix.
Ductules unite into a single duct which empties into a fornix .
5. GLAND OF WOLFRING :
Larger than Krause
Present along upper border of superior tarsus ( 2-5 ) & in lower border of inferior tarsus
 ACCESSORY CONJUNCTIVAL STRUCTURES

• Caruncle:
Small soft ovoid pinkish mass near inner canthus .
 Covered with stratified squamous epithelium & contain sweat glands, sebaceous glands
& hair follicles
• Plica semilunaris :
Pinkish crescentic fold of conjunctiva present in medial canthus.
 BLOOD SUPPLY OF CONJUNCTIVA
• ARTERIAL SUPPLY : Mainly derived from 3 sources
Marginal arcade of eyelid
Peripheral arterial arcade of eyelid
Anterior ciliary arteries
Deep ciliary system
• VENOUS SUPPLY :
Drain into venous plexus of eyelid which In turn drain in to
superior & inferior ophthalmic veins
Circum corneal zone of vein from limbus drain into anterior
ciliary veins
• LYMPHATIC SUPPLY :Arranged in 2 layers – superficial & deep
Lateral drain into preauricular LN
Medial drain into submandibular LN
• NERVE SUPPLY :
Bulbar conjunctiva anterior 2/3rd circumcorneal zone – long ciliary nerve of V1
Superior palpebral conjunctiva,
Superior fornix, Supratrochlear
supraorbital &
Superior 1/3rd of bulbar conjuncitiva frontal nerve

Lateral inferior palpebral conjunctiva ,

 lateral fornix , & Lacrimal
nerve
 lateral part of inferior peripheral 1/3rd part of bulbar conjunctiva
Nasal inferior palpebral conjunctiva, Infraorbital
 nasal fornix , nerve

 nasal half of peripheral 1/3rd of bulbar conjunctiva

PATTERN : Nerve branches supplying the conjunctiva form subepithelial plexus. From this plexus
fibre pass to form an intraepithelial plexus around the base of epithelial cells. These send free nerve
fibres between these epithelial cells which do not possess the myelin sheath
 EYELIDS
• The eyelids help to keep the cornea moist, protect against injury & excessive light
• Essential for distribution and drainage of tears
• Upper lid restores the preocular tear film at each blink
• Blinking has a pumping effect on lacrimal sac
• Upper eyelid extends over the orbital margin to the eyebrow above, the lower more into the
cheek
• Upper eyelid covers about 1/6th of the cornea , lower eyelid just touches the cornea – in 1°
position
• Opened eyelids enclose an elliptical space called Palpebral fissure which meet at medial &
lateral canthi- in adult it measures about 28-30mm horizontally & 9-11mm vertically
 CANTHI

• LATERAL CANTHI:
1. Acute about 30-40°
2. Continues as a inferolateral groove in the line of upper palpebral margin
3. 5-7mm medial to the orbital margin & 1cm from frontozygomatic suture

MEDIAL CANTHI:
1. More obtuse
2. Horizontal inferior rim & a superior rim sloping inferomedially
3. Continues medially into a visible ridge produced by medial palpebral ligament
 PALPEBRAL MARGIN

• Is about 2mm wide

• Vascularity increases with age
• From its rounded anterior border eyelashes are projected in 2 or 3 rows
• Superior cilia: longer, more numerous curled up
• Inferior cilia: curl down
• Unlike other hairs , cilia have no erector muscles
• GREY LINE: avascular palpebral plane between cilia & orifices of tarsal glands
 STRUCTURE OF EYELID

• Palpebral tissues, from front to back consists of

following layers:
1. Skin
2. Subcutaneous areolar tissue
3. Striated muscles
4. Submuscular areolar tissue
5. Tarsal plates & fibrous tissue
6. Non striated muscle
7. Conjunctiva
SKIN:
• Thin, elastic can fold & wrinkle easily
• Superior tarsal sulcus develops at superior tarsal border as the upper eyelid raises, inferior tarsal
sulcus is poorly developed
• It is attached to orbital margin & palpebral ligaments
• Nasal side of skin is smooth, shining & greasy in comparison to temporal part
• Epidermis made of 6-7 layers of stratified squamous epithelium- basal layer shows sebaceous
glands & sweat glands
• Dermis composed of network of elastic fibres, blood vessels, lymphatics, nerves & melanocytes
SUBCUTANEOUS AREOLAR TISSUE:
• Loose & contains no fat
• Easily distends by edema & haemorrhage
• Absent near ciliary margin, palpebral sulci & at canthi where skin adheres the ligaments
STRIATED MUSCLES:
• Consists of orbicularis muscle, in the upper lid also contains levator muscle
ORBICULARIS OCULI MUSCLE:
• Divided into 2 parts – the orbital part & the palpebral part
Orbital part:
1. Arise from anterior part of medial palpebral ligament & adjacent bones, meet at the lateral palpebral
raphe
2. Muscularis superciliaris: upper medial fibres of orbital part pass to the skin of medial part of eyebrow
3. Muscularis malaris: inferiorly, the medial & lateral fibres attached to skin of cheek
Palpebral part: subdivided into preseptal &pretarsal portions
1. Both portions arise from lacrimal fascia, posterior lacrimal crest(deep head) &anterior part of medial
palpebral ligament(superficial head)
2. Preseptal fibres unite at lateral palpebral raphe , pretarsal fibres join laterally to form lateral
canthal tendon
3. Pars lacrimalis: fibres of pretarsal portion help in drainage of tears by lacrimal sac
4. Pars ciliaris: fibres of pretarsal portion which keeps the lids in close apposition
LEVATOR PALPEBRAE SUPERIORIS:
• Origin – apex of the orbit from lesser wing of sphenoid
• Aponeurosis spreads out in a fan- shaped manner across the width of eyelid , inserting primarily
into the tarsal plate
• Aponeurosis from lateral & medial horns gets attached to respective canthal tendons
• Action is elevation of upper eyelid
• Nerve supply by superior division of oculomotor nerve
SUBMUSCULAR AREOLAR TISSUE:
• Loose connective tissue between orbicularis muscle & fibrous layer
• Communicates with subaponeurotic stratum of scalp, hence pus or blood can enter upper lid from
scalp – dangerous area of scalp
• Nerves & vessels of eyelids lie in this plane
• Pretarsal space:
Small area which appears fusiform in cross section
Peripheral arterial arcade is present in this space
• Preseptal space:
Triangular in cross section bounded by orbicularis in front, septum orbitale behind & preseptal
cushion of fat above
• Preseptal cushion of fat:
Crescent shaped pad of fat which lies in front of the septum & behind the orbicularis muscle
TARSAL PLATES AND FIBROUS TISSUE:
• Framework of lids consists of central thick part the tarsal plate & peripheral thin part the
septum orbitale
• Fibrous layer also includes medial & lateral palpebral ligaments
Tarsal plates:
• Firm plates of dense fibrous tissue & some elastic tissue , has no cartilage- form the skeleton of
eyelids
• Tarsi are about 29mm long & 1mm thick, the upper tarsus is about 10-11mm in height & lower
tarsus 4-5mm in height
• Anterior surface is convex separated by areolar tissue from orbicularis facilitating movement,
posterior surface is concave adherent to conjunctiva
Septum orbitale:
• Thin, floating membrane of connective tissue which takes part in all movements of eyelids
• Thick & strong on lateral side than medial side & in upper eyelid than lower eyelid
• Structures piercing it are:
1. Lacrimal vessels & nerves
2. Supraorbital vessels & nerves
3. Supratrochlear artery & nerve
4. Infratrochlear nerve
Medial palpebral ligament:
• Triangular band of connective tissue, attached to frontal process of maxilla from anterior lacrimal
crest to the suture line of frontal process with nasal bone
• MPL can be divided into 2 parts
Anterior part :
From its attachment fans out laterally
Angular artery & veins pass over the medial part
Splits into upper & lower bands, attached to upper & lower tarsal plates, resembles letter Y
Posterior part:
passes behind the lacrimal sac from anterior lacrimal crest to posterior lacrimal crest
Lateral palpebral ligament:
• Thin band of fibrous tissue about 7mm horizontally & 2.5mm in height
• Laterally attached Whitnall’s tubercle & medially upper & lower tarsal plates
NON STRIATED MUSCLE:
• Smooth muscle fibres of Muller lie just deep to septum orbitale in the upper & lower eyelids
• Arise from inferior terminal striated fibres of levator from upper eyelid & from expansion of
inferior rectus from lower eyelid
• Inserted in orbital margin of tarsal plate
• Nerve supply by sympathetic nerve fibres
CONJUNCTIVA:
• Posterior most layer of eyelid formed by palpebral conjunctiva extends from mucocutaneous
junction at the lid margin to the conjunctival fornix
 GLANDS OF EYELIDS
 TARSAL(MEIBOMIAN) GLANDS:
• Modified sweat glands present in the posterior part of stroma of tarsal plates
• Arranged in a single row vertically parallel to each other about 20-30 in each lid
• Openings are arranged in a single row, on the lid margin between grey-line and the posterior border of the
lid
• Secretions are oily(sebum) and form the oily layer of tear film
 GLANDS OF ZEISS:
• Modified sebaceous glands, attached directly to the eyelash follicle
• 2 glands are associated with each cilium
• Secretions are oily(sebum) prevents the eyelashes from becoming dry & brittle
GLANDS OF MOLL:
• Modified sweat glands lie between cilia
• More numerous in lower eyelid than upper
ARTERIAL SUPPLY:
• The medial and lateral palpebral arteries are branches of ophthalmic & lacrimal arteries
• The divisions of these arteries anastomose each other to form the tarsal arcades in the
submuscular areolar tissue
• In the upper lid a second arterial arcade is formed
VEINS:
• Palpebral veins form dense plexus near conjunctival fornices .
• Some drain into frontal & temporal veins, others become tributaries of ophthalmic veins
LYMPHATICS:
• Form pre and posttarsal plexus
• Lateral side drain into preauricular & parotid nodes, medial side drain into submandibular LN
NERVE SUPPLY:
• Motor : orbicularis by facial nerve, levator by oculomotor nerve & muller’s by sympathetic nerves
• Sensory: branches of 1st & 2nd division of 5th nerve
upper eyelid- supraorbital, supratrochlear, infratrochlear, lacrimal
lower eyelid- infraorbital, infratrochlear, lacrimal
IMMUNOLOGY
 DEFINITION

IMMUNE RESPONSE:
• An immune response is a sequence of molecular and cellular events intended to rid the
host of a threat ; pathogenic organisms, toxic substances, cellular debris or neoplastic
cells.
• There are 2 broad categories of immune responses – Adaptive
Innate
IMMUNE RESPONSE ARC
 OCULAR IMMUNE RESPONSE
• Many organs & tissue sites possess modifications to the classic immune response arc, this
concept is called regional immunity.
• Regional immunity can effect all 3 phases of the response arc- afferent, processing & effector
• These regional differences can occur down to the level of specific locations within & around
eye such as
1. Conjunctiva
2. Anterior chamber, anterior uvea & vitreous
3. Cornea & sclera
4. Retina, retinal pigment epitheium & choriocapillaris
5. choroid
 IMMUNE RESPONSES OF THE CORNEA

• It is unique in that the peripheral & central portions represent differently in different
immunologic microenvironments
• In normal eyes only limbus is vascularised & richly invested with Langerhans cells.
• Various stimuli like mild trauma, interleukins(IL-1), infection can recruit APC’s to the central
cornea
• Plasma derived proteins such as complement
IgM
IgG are present
• Only low levels of IgM are present centrally
• Corneal cells also synthesize various antimicrobial & immunoregulatory proteins
• Corneal epithelium secrete IL-1, IL-6, IL-8, TNF-alpha, INF-gamma, TGF-alpha, C5a & LTB4
Afferent & efferent pathway of immune regulation in cornea:
• Vascular limbus is an important efferent & afferent regulatory structure
• Plays a critical role in peripheral corneal disease & angiogenesis
• Corneal neovascularisation alters the microenvironment of the ocular surface & cornea –
provides a conduit for progress of antigen specific & nonspecific cellular elements
 IMMUNE RESPONSES OF TEAR FILM AND
LACRIMAL APPARATUS
• Tear film & lacrimal gland play an important role in ocular immune response
• Tear film contains proteins, lipids, mucopolysacharides
PROTEINS:
These proteins are subdivided into 2 groups A & B
Group A:- immunoglobulin-G, albumin, transferrin, alpha-1 antitrypsin, alpha-1
antichymotrypsin & beta-2- microglobulins
Group B:- specific proteins, synthesized by tear glands also known as ‘rapid migrating proteins’.
These are lysozyme, lactoferrin, immunoglobulin-A
IMMUNOGLOBULINS:
Tear IgA :-
• Is a secretory immunoglobulin produced locally by plasma cells of adenoid layer of
conjunctiva
• More effective defense against externally invasive viral/bacterial antigens
Tear IgM & IgE:-
• Also produced locally in the conjunctiva
• In general tear immunoglobulins are found in higher concentration in reflex tears than
continuous tears
LYSOZYME:
• Also termed as muramidase
• Proteolytic enzyme produced by the acinar cells of the lacrimal gland
• It causes lysis of bacterial cell wall by hydrolysis of N-glucosamine-N-acetyl muramic acid
present in bacterial cell wall
• It also facilitates secretory IgA mediated bacteriolysis in the presence of complement
• Lysozyme is active only against certain gram positive orgnisms
LACTOFERIN:
• Inhibits the formation of C3 convertase
• Prevents complement activation thereby decreases inflammation
BETALYSIN:
• Antibacterial agent ruptures bacterial cell membranes
GLYCOPROTEINS:
• Found in the mucoid layer as well as in the tear fluid
LACRIMAL GLAND:
• IgA & IgD produces adaptive immune response
• Autoantibdies play an important role in mediating lacrimal gland inflammation
SJOGREN’S SYNDROME:
• In this lacrimal & salivary glands are infilterated with Th, Tc, B cells
• Dry eye & dry mouth are seen
 IMMUNE RESPONSE OF CONJUNCTIVA

• Conjunctiva shares many features typical of mucosal sites

• The tissue contains numerous APC’s like
1. Langerhans cells
2. Other dendritic cells
3. Macrophages
• Conjunctival follicles represent collections of T lymphocytes, B lymphocytes and APC’s
• These follicles are sites for localised immune processing of antigens
• Substantia propria is richly populated with potential effector cells predominately mast cells
• Conjunctiva supports most adaptive & innate immune effector responses especially antibody
mediated & lymphocyte mediated
• IgE - mediated & mast cell degranulation is common
IMMUNOREGULATORY SYSTEMS:
• The conjunctiva contains MALT(mucsa associated lymphoid tissue) – a network of mucosal
sites that share certain immunologic features:
1. Rich investment of APC’s
2. Specialized for localised antigen processing(peyer patches)
3. Unique effector cells(intraepithelial T lymphocytes & mast cells)
• MALT immune response arc favour T helper-2(Th2) resulting in production of IgA & IgE
antibodies
• Ocular malt is also present in lacrimal gland, tear film, cornea