A comparison of corneal stromal edema induced from the anterior or the posterior surface

BACKGROUND

Many differences between the anterior and posterior corneal stroma have been reported. The physiological and mechanical properties of the cornea are a summation of these properties across each of the corneal regions. This article investigates corneal stromal swelling that is experimentally induced through each surface.

METHODS

Corneal stromal swelling was induced in human and rabbit corneas through either the anterior or posterior surface. The rate of stromal swelling was analyzed with a linear regression model.

RESULTS

Swelling in the rabbit stroma was 3.65 x faster when induced through the posterior surface than through the anterior surface (p less than .0001), while the human stroma swelled 13.1 x faster through the posterior surface (p less than .0001). The hydration of the stroma increased during swelling through the posterior surface, but paradoxically decreased during swelling through the anterior surface.

CONCLUSIONS

These experiments showed that stromal swelling occurs more rapidly through the posterior corneal surface than through the anterior surface. These results may have implications for the refractive surgeon performing laser ablative procedures on the anterior surface of the cornea.

Comparison of corneal preservation media for corneal hydration and stromal proteoglycan loss

Changes in the composition of stromal proteoglycans (PGs) have been previously demonstrated in corneal edema, wound healing, and disease. To examine if PGs are lost during corneal preservation, rabbit corneal PGs were radiolabeled in situ with 35S-sulfate and 3H-glucosamine, excised and stored in either modified McCarey-Kaufman medium (MMK), K-Sol (Coopervision-Cilco, Bellevue, WA, U.S.A.), corneal storage medium (CSM), or Dexsol (Chiron Ophthalmics, Irvine, CA, U.S.A.) for up to 14 days. The percentage of total radio-label lost was significantly greater from de-epithelialized corneas (p less than 0.05) and from corneas stored in CSM (p less than 0.05) or K-Sol (p less than 0.05). Corneas stored in CSM for 4 and 7 days were significantly more hydrated than corneas stored in MMK, K-Sol, or Dexsol. After 14 days of storage, all corneas were hydrated above control values with the Dexsol-stored cornea showing the least hydration. Results suggest that loss of stromal PGs during corneal storage is reduced with epithelial integrity and with preservation media containing dextran.

Effect of gas-permeable contact lenses on the endothelium of corneal transplants

The effects of gas-permeable contact lens wear on the density and morphologic characteristics of corneal endothelial cells were prospectively studied by wide-field specular microscopy in 18 eyes that had undergone keratoplasty at least 14 months previously. Daily-wear rigid gas-permeable lenses were fitted to allow as much movement and tear exchange as possible. There was no evidence of morphologic instability of the endothelial cells during the course of the study, with a mean duration of lens wear of 9.8 months. Although there is concern over adverse effects associated with polymethylmethacrylate contact lens wear, this study suggests that the endothelium of a corneal transplant tolerates rigid gas-permeable lens wear without adverse effect during a limited period of follow-up.

Maturation of the corneal endothelial tight junction

Apical tight junctional formation of the rabbit corneal endothelium was examined by freeze-fracture analysis and measurement of paracellular permeability to 5(6)-carboxyfluorescein. Freeze-fracture analysis indicated that apical tight junction formation of the rabbit corneal endothelium is a dynamic process. At birth, there are few tight junctional strands present and a minimal barrier for paracellular diffusion. As the rabbit matures, a more complex network of anastomosing tight junctional strands begins to encircle the cell perimeter under the apical folds. However, even in the mature animal (3 months), there are discontinuities and free ends in the network, thus suggesting that the barrier is not complete even at this stage. Paracellular permeability measurements using 5(6)-carboxyfluorescein as a tracer corroborate these anatomic findings. Endothelial paracellular flux measurements steadily decrease as the rabbit matures from birth to young adult. This indicates that the tight junctional network is increasing in complexity and progressively limiting the flow of substances through the intercellular space.

The developing corneal endothelium: correlation of morphology, hydration and Na/K ATPase pump site density

The physiology and anatomy of the cornea of the New Zealand white rabbit were studied from birth to young adulthood (3 months). The main objective of the study was to follow the ontogeny of the corneal endothelium and correlate its maturation with the establishment of stromal transparency. With maturity, central corneal thickness increases as do corneal diameter and surface area. Endothelial morphology undergoes marked changes including an increase in cell hexagonality and cell surface area, along with a decrease in cell density and coefficient of variation of cell area. Corneal hydration decreases from a high value at birth to the adult level by 20 days after birth, the time of the onset of stromal transparency. By transmission electron microscopy, corneas of newborn rabbits exhibit an endothelium of irregular cell height with some overlap at the bases of adjacent cells. Apical junctions are incomplete in the neonates. With time the endothelium thins and cells becomes more regular in height, overlap of adjacent cells diminishes, and apical junctions develop. Descemet's membrane is thin in newborns and thickens and becomes more homogenous in appearance with maturation. The abundance of Na/K ATPase pump sites per endothelial cell, as determined by 3H-ouabain binding, increases progressively with age even after the establishment of corneal transparency at 20 days. Scatchard and LIGAND analyses of 3H-ouabain binding data indicate that there is a progressive increase in Bmax with no change in the KD from 7 days to 3 months.

Human corneal storage in modified McCarey-Kaufman and K-Sol media: effect on endothelial Na+/K+ ATPase pump site density and permeability

Endothelial permeability (Pac) to carboxyfluorescein and Na+/K+ ATPase pump site density were determined in human corneas following storage for 4 or 7 days at 4 degrees C in either modified McCarey-Kaufman (mMK) or K-Sol media. Following 4 days of storage, Pac values for mMK- and K-Sol-preserved corneas were not significantly different from those of their prestorage mates. After 7 days of storage, however, corneas stored in K-Sol media showed a significant increase in Pac compared to their prestorage mates, whereas the mMK-stored corneas showed no change in Pac. Na+/K+ ATPase pump site density determined using [3H]ouabain was similar to a control group in the K-Sol-stored tissue but higher in the mMK-stored tissue following 7 days of storage. These studies suggest that mMK medium maintains endothelial barrier function and Na+/K+ ATPase pump site density at least as well as K-Sol medium through 7 days of corneal storage.

A method for the in vitro determination of feline corneal endothelial permeability

A mounting block for in vitro perfusion of the cat cornea is described. Using this apparatus and the techniques of Araie, the permeability (Pac) of the normal cat corneal endothelium to carboxyfluorescein was determined to be 2.5 +/- 0.2 x 10(-4) cm/min. To assess the sensitivity of this technique in determining changes in Pac associated with alterations in endothelial, morphology, three cats underwent 2 successive unilateral, central, 10 mm diameter circular areas of endothelial debridement 6 weeks apart. Six weeks following the second wounding all 3 animals underwent morphometric analysis and Pac determination. A trend toward an elevation in Pac with extreme reductions in cell density was observed.

Loss of stromal glycosaminoglycans during corneal edema

This study tried to determine if glycosaminoglycans (GAGs) are released from the rabbit stroma during corneal edema. The GAGs of rabbit corneas were labeled in situ using anterior-chamber injections of 35S-sulfate and 3H-glucosamine. Labeled corneal pairs were excised and the endothelium perfused in vitro in the specular microscope. Edema was induced in one cornea by perfusion with a calcium-free balanced salt solution; the control cornea was perfused with glutathione bicarbonate Ringer's (GBR). Corneal thickness was measured every 15 minutes during the 3-hour perfusion period, and perfusate fractions were collected from each cornea and analyzed for the presence of GAGs. Edematous corneas swelled from 438 +/- 14.8 microns to 688 +/- 10.6 microns compared with control corneas (427 +/- 4.7 microns to 454 +/- 7.2 microns). Total 3H-glucosamine (4.00 +/- 0.68%) and 35S-sulfate (10.36 +/- 0.92%) released from the edematous corneas during perfusion exceeded that lost by control corneas (1.92 +/- 0.18% for 3H-glucosamine; 3.23 +/- 0.52% for 35S-sulfate). Enzymatic digestion studies showed the presence of keratan sulfate in the edematous perfusates. The results suggest that increased loss of radiolabeled components from edematous corneas represent a loss of stromal GAGs and possibly GAG fragments. Therefore, corneal edema involves loss of GAGs and water uptake.

Toxic endothelial cell destruction of the cornea after routine extracapsular cataract surgery

Eighteen patients developed an acute corneal decompensation following normal intraocular surgery (cataract extraction in 17 patients), characterized by star-shaped endothelial folds, a twofold increase in corneal thickness, and a visual acuity of counting fingers during several postoperative days. In some cases, there was an additional iritis and transient hypotony. There was no effect of topical and/or subconjunctival corticosteroids on the course of the decompensation. Endothelial morphometric analysis showed a mean endothelial cell loss of 72%. Endothelial wound healing, as determined by coefficient of variation and percentage hexagonals, stabilized 6 months postoperatively. We coined the term toxic endothelial cell destruction for this syndrome. Epidemiological evaluation revealed the toxic endothelial cell destruction syndrome to be linked with the 10-fold increase of a detergent solution in the ultrasonic bath for cleaning the surgical instruments.

Toxic effects of detergents on the corneal endothelium

Eighteen patients developed a toxic endothelial cell destruction syndrome following normal intraocular surgery, caused by a detergent residue originating from irrigating cannulas. The residue occurred after the concentration of a detergent solution has been increased from 0.4% to 4%, in combination with insufficient cleaning of the cannulas. Mass spectrometric analysis revealed the detergent to contain a nonionic ethoxylated fatty alcohol (6% vol/vol). Quantitative endothelial vital staining and in vitro corneal endothelial perfusion demonstrated endothelial toxic effects at the 1% and 0.06% level for the detergent and the pure ethoxylated fatty alcohol, respectively. Permeability studies showed that the toxic effects occurred as a result of endothelial barrier breakdown.

A bisulfite-free intraocular epinephrine solution

We evaluated a preservative-free, sulfite-free epinephrine solution for potential corneal toxicity, which has been described for sulfite-containing epinephrine solutions. The preservative-free, sulfite-free epinephrine solution did not exhibit endothelial toxicity in three-hour paired human corneal endothelial perfusion at two and four times the concentration of the 1:1,000,000 dilution currently recommended for anterior chamber intraocular irrigating solutions. When epinephrine at a dilution of 1:1,000 was injected directly into the anterior chamber of New Zealand white rabbits, there was markedly less corneal edema induced than there was in previous studies with sulfite-containing solutions of comparably low pH but higher buffer capacities. Although potential toxicity exists for any irrigating solution with a pH outside of the 6.5 to 8.5 pH range, the endothelial toxicity of this solution has been reduced by its low buffer capacity, lack of preservatives, and lack of sulfite, offering an extra margin of safety for intraocular use.

Corneal endothelial junctions and the effect of ouabain

Paired rabbit corneas were perfused in vitro for endothelial permeability (Pac) determination with glutathione bicarbonate Ringer's solution (GBR) and GBR plus ouabain (10(-4) M). Results indicated no difference in Pac between the two groups (3.39 vs 3.67, respectively) despite significantly greater stromal swelling in the group perfused with ouabain. Freeze-fracture microscopy of similarly perfused corneas revealed intact tight junctional complexes in both groups, although the tight junctional complex of perfused corneas appeared less organized than that of freshly enucleated, nonperfused controls. Gap junctions were abundant as observed in freeze-fracture replicas of GBR-perfused endothelium, and appeared to be decreased or absent in ouabain-perfused endothelium. These results indicate that corneal endothelial tight junctions are unaffected by perfusion with ouabain, whereas gap junctions appear to be lost. The permeability and freeze-fracture data reaffirms the importance of tight junctions as permeability barriers and indicates that gap junctions are not of primary importance for maintenance or control of the corneal endothelial barrier.

In vitro corneal endothelial permeability in rabbit and human: the effects of age, cataract surgery and diabetes

Endothelial permeability was examined in rabbit and human corneas using an in vitro perfusion system with 5(6)-carboxyfluorescein as the permeability tracer. Following endothelial removal, the permeability of de-epithelialized rabbit corneas increased from 3.19 x 10(-4) cm min-1 to 31.21 x 10(-4) cm min-1, and de-epithelialized human donor corneal permeability values increased from 2.26 to 12.85. In human corneas, no correlation was seen between endothelial permeability and donor age, moist chamber storage time, endothelial cell density, coefficient of variation of cell area, or percent hexagonal cells. A positive correlation was found between permeability and time between donor death and enucleation. Donor eyes from three separate populations, having undergone cataract surgery prior to death (aphakic, posterior and anterior chamber implants), all showed a significant increase in permeability. Neither Type I nor Type II diabetes had an effect on the endothelial permeability of human donor corneas.

Electrolyte composition of lacrimal gland fluid and tears of normal and vitamin A-deficient rabbits

Rabbit tears and lacrimal gland fluid were collected simultaneously during pilocarpine stimulation with the goal of comparing the ionic composition of these fluids at various flow rates. Ions measured were sodium, potassium, calcium, magnesium, zinc, chloride, and bicarbonate. Human tears were also analyzed for purposes of comparison. Generally, tears and lacrimal gland fluid do not differ in ionic composition except for zinc and bicarbonate, which are in higher concentration in tears than in lacrimal gland fluid. The ionic composition of tears and lacrimal gland fluid of vitamin A-deficient rabbits was also analyzed. The maximal flow rate of lacrimal gland fluid was decreased in vitamin A-deficient rabbits as were calcium levels in tears and lacrimal gland fluid, as compared with controls. Concentrations of other ions generally did not differ from normal levels, indicating that vitamin A deficiency has only moderate effects on lacrimal gland function in the rabbit.

Drug uptake and release by a hydrogel intraocular lens and the human crystalline lens

Implantation of a hydrogel (IOGEL) intraocular lens in humans has been reported. The polyhydroxyethyl methacrylate (poly HEMA) matrix of this hydrogel is permeable to water soluble drugs and may adsorb agents used intracamerally during cataract extraction or topically during the postoperative period. This study compared the in vitro uptake and release of chloramphenicol, dexamethasone, epinephrine, pilocarpine, and bovine serum albumin by polymethylmethacrylate and hydrogel intraocular lenses with that of the intact crystalline lens of humans and rabbits. An in vivo study compared the uptake and release of chloramphenicol and dexamethasone by hydrogel lenses implanted in the anterior chamber of rabbit eyes with that of the rabbit's crystalline lens. The in vitro uptake and washout of epinephrine and pilocarpine by the hydrogel lens was comparable to the human lens. Uptake of chloramphenicol and dexamethasone by the hydrogel lens exceeded that of the human lens and, following a two-hour washout period, the dexamethasone content of the hydrogel lens remained significantly greater than the human lens. The uptake and washout of bovine serum albumin by the hydrogel lens was half that of the human lens. In vivo, the hydrogel lens efficiently eluted both chloramphenicol and dexamethasone. These studies show that a hydrogel lens will not act as a significant depot for drugs in the eye.

Morphometric analysis of the corneal endothelium. Specular microscopy vs. alizarin red staining

Computer-assisted analysis of endothelial morphology provides useful indices of cell shape and size which appear to correlate to the monolayer's functional status. In this study morphometric data obtained by wide-field specular microscopy of in situ corneal endothelia are compared to data obtained by alizarin red S staining of excised corneas. Both human donor corneas and rabbit corneas were studied. The results of the study indicate that considerable (14%) cell shrinkage occurs in rabbit endothelia following staining. Associated with this cell shrinkage is a normalization of cell area which is manifest as a significant (P less than 0.001) decrease in the coefficient of variation of cell area. The percentage of hexagonal cells, however, remains unchanged. These changes were not mitigated by lowering the osmolality of the saline rinse following staining or by minimizing evaporation by placing a drop of silicone oil on the stained button. In human tissue no significant differences in cell area or cell shape were noted in comparing morphometric data obtained by staining to that obtained from specular microscopy. Useful morphometric data can be obtained by alizarin staining. This technique combined with cell morphometric analysis could provide valuable data in corneas whose lack of clarity limits or precludes specular microscopy. Caution, however, must be exercised in comparing morphometric data by this method to those obtained in situ for rabbit tissue.

Drug binding of ophthalmic viscoelastic agents

When viscoelastic agents that contain hyaluronate sodium are used during anterior segment surgical procedures, it is common for some of the material to remain intraocularly after the surgery is completed. A variety of drugs, used intracamerally or topically following surgery, are also present. These drugs may be bound to the polyanionic hyaluronate molecule. This occurrence may cause drug alterations in therapeutic effectiveness, pharmacokinetics, and toxicity. To investigate the possibility for drug-viscoelastic agent adsorption, in vitro drug-binding studies were performed on three commercial viscoelastic agents; undiluted aliquots of Amvisc, Healon, or Viscoat were mixed with radiolabeled D-threo-chloramphenicol, dexamethasone, L-epinephrine, or pilocarpine hydrochloride, placed in dialysis membranes, and dialyzed for 24 hours against an isotonic phosphate buffer. The calculated drug binding by a viscoelastic agent ranged from 0% to 1.5%. These extremely low values for in vitro drug uptake by viscoelastic agents made it unlikely that any significant drug-viscoelastic agent interaction would occur in the postoperative eye.

Intracameral thrombin and the corneal endothelium

We perfused the endothelia of isolated human corneas mounted in the specular microscope with BSS Plus containing 1,000-U/ml or 100-U/ml dilutions of two commercially available topical thrombin preparations. Corneas perfused with thrombin at 1,000 U/ml showed intracellular and intercellular vacuole formation and altered junctional complexes. As listed on the package inserts, the thrombin preparations contained preservatives and other additives that present a significant osmotic load in 1,000-U/ml preparations. Corneas perfused with 100-U/ml thrombin solutions showed a significant attenuation in their deswelling rate but no ultrastructural alterations. One available thrombin preparation when diluted to 100 U/ml had a glycine concentration associated with previous retinal electroretinography changes. Polyacrylamide gel electrophoresis of one manufacturer's thrombin solution showed multiple high and low molecular weight constituents. Analysis of particulate contamination showed one 100-U/ml thrombin preparation to have a large quantity of particulates. Although thrombin may be useful when applied topically as an aid in surgical hemostasis, its use intraocularly presents substantial concern regarding the preparation's purity, additives, contaminants, and adverse effects on ocular tissues.

Ophthalmic irrigants: a current review and update

The search for an ideal intraocular irrigating solution is of paramount importance to te ophthalmic surgeon. An intraocular irrigating solution, as well as surgical technique, can have deleterious effects on ocular tissues. Since an intraocular irrigating solution comes in contact with the cornea, lens, trabecular meshwork, uvea, vitreous, and retina, and ideal irrigant would be ome that ensures biological function for all of these tissues. In a practical sense, the best irrigant is one that causes the least possible damage to the structural integrity and function of the intraocular environment. This paper summarizes the development, uses, and efficacy of intraocular irrigating solutions as currently used during intraocular surgery.

Permeability of human cornea and sclera to sulfonamide carbonic anhydrase inhibitors

Corneal penetration of sulfonamide carbonic anhydrase inhibitors for topical treatment of glaucoma has been tested in human eye bank and rabbit tissue. Paired corneas, with the epithelia intact or removed, and excised sclera were perfused in vitro. Corneal permeability (Kp) to methazolamide and ethoxzolamide was similar in both species, but for benzolamide and bromacetazolamide the Kp was greater in humans. Human corneas without epithelium had Kp the same as scleral Kp. Topical methazolamide (6 mmol/L) was studied in vivo in rabbits and in ten humans before cataract surgery. The mean (+/- SE) concentration in the rabbit aqueous was 3.2 +/- 1.4 mumol/L at eight minutes and 1.2 +/- 0.16 mumol/L at one hour. In humans, less than 0.2 mumol/L was detected at eight minutes; at one hour none was detected in three cases, and 0.4 +/- 0.08 mumol/L was detected in four cases. Lower permeability in humans than rabbits may result from a fourfold greater blinking rate, a twofold greater tear turnover, and a twofold lower corneal/conjunctival area.

Comparison of conjunctival and corneal surface areas in rabbit and human

This comparative study shows the surface area ratio of conjunctiva to cornea to be two times larger in humans than in rabbits. This large heretofore unrecognized interspecies difference may affect the applicability of drug pharmacokinetic data obtained using rabbit models and should be taken into consideration in topical drug development and future comparative drug penetration studies between rabbit and man.

Effect of inflammation on the corneal endothelial pump and barrier

Corneal thickness is a reflection of endothelial barrier and pump functions. The corneal edema that occurs during intraocular inflammation is a consequence of the breakdown of one or both of these parameters. Results of this study demonstrate that, during intraocular inflammation induced by an intravitreal injection of bovine serum albumin (BSA), the permeability of rabbit corneal endothelia to inulin was increased. By comparison, treatment with oral aspirin and/or subconjunctival triamcinolone acetonide prevented the endothelial barrier breakdown induced by the BSA. Concomitant with the loss of the barrier function, endothelial ouabain binding decreased in the BSA injected eye, indicating a reduction in endothelial Na/K ATPase pump site density. A subconjunctival injection of triamcinolone prevented this decrease in pump sites. The increase in endothelial permeability and the decrease in pump site density correlated with an increase in corneal thickness. It can be concluded that the intraocular inflammation induced by BSA effects corneal edema by both an increase in endothelial permeability and a decrease in Na/K ATPase pump site density. Subconjunctival triamcinolone is effective in preventing this response.

Specular microscopy of vertebrate corneal endothelium: a comparative study

Central corneal endothelia in a variety of lower- and higher vertebrate animals were photographed with a widefield specular microscope and analysed with either fixed-frame or computer-assisted morphometric analysis. The endothelium of the dogfish shark, an elasmobranch, contained 2300 cells mm-2 and demonstrated a very delicate irregular 'reversal pattern'. The goldfish, a teleost, had 432 cells mm-2 and displayed a jigsaw-puzzle-like pattern. The bullfrog, an amphibian, and the gecko, a reptile, had 550- and 481 cells mm-2, respectively, and a relatively uniform polygonal endothelial pattern similar to that observed in mammals. The goose, a bird, had a cell density of 2410 cells mm-2 with a uniform hexagonal pattern (79%) which was similar to mammalian (rat, 58-76%; rabbit, 71%; dog, 78%; human, 61-75%) hexagonal patterns. The findings on the endothelial appearance in these vertebrate animals suggest that a correlation exists between endothelial morphology, vertebrate phylogeny and their respective functional and structural capacity.

Treatment of corneal xerophthalmia in rabbits with micromolar doses of topical retinoic acid

Several reports have appeared on the efficacy of topically applied 0.01% or 0.1% all-trans retinoic acid (0.04-0.4 millimolar) for treatment of xerophthalmia, conjunctival squamous metaplasia, and corneal epithelial erosions in humans and animals. An observation common to many of these studies is the occurrence of an adverse reaction to retinoic acid in the form of lid margin hyperemia and blepharoconjunctivitis. Since retinoic acid is biologically active at micromolar to nanomolar concentrations, it may be possible to reduce side effects while maintaining therapeutic effectiveness by reducing the retinoic acid concentration in ophthalmic formulations. In the present study, topical 0.005% retinoic acid in petrolatum ointment reversed corneal keratinization in xerophthalmic, vitamin A-deficient rabbits in 3-4 days while 0.0005% (2 micromolar) retinoic acid ointment was effective in 4-6 days. Further clinical trials of topical retinoic acid for treatment of ocular surface disease should be conducted using micromolar concentrations of retinoic acid which are expected to maintain a therapeutic effect while reducing adverse reactions.