Leading causes of endothelial failure include inadvertent endothelial trauma from intraocular surgery (such as cataract surgery) and Fuchs' dystrophy. Both stromal light scatter and surface epithelial irregularity contribute to degraded optical performance of the cornea and can compromise visual acuity. In addition, excessive corneal hydration can result in edema of the corneal epithelial layer, which creates irregularity at the optically critical tear film-air interface. Excess hydration of the corneal stroma disrupts the normally uniform periodic spacing of Type I collagen fibrils, creating light scatter. Corneal edema can also occur as the result of compromised endothelial function due to intraocular inflammation or other causes. Typically, loss of endothelial cell density is accompanied by increases in cell size variability (polymegathism) and cell shape variation (polymorphism). This threshold of endothelial cell density varies considerably amongst individuals, but is typically in the range of 500 - 1000 cells/mm². Endothelial cell loss, if sufficiently severe, can cause endothelial cell density to fall below the threshold level needed to maintain corneal deturgescence. Wounding of the corneal endothelium, as from trauma or other insults, prompts healing of the endothelial monolayer by sliding and enlargement of adjacent endothelial cells, rather than mitosis. Mechanisms of corneal edema Ĭorneal endothelial cells are post-mitotic and divide rarely, if at all, in the post-natal human cornea. Bicarbonate ions formed by the action of carbonic anhydrase are translocated across the cell membrane, allowing water to passively follow. Critical to this energy-driven process is the role of Na +/K +ATPase and carbonic anhydrase. The corneal endothelium then transports water from the stromal-facing surface to the aqueous-facing surface by an interrelated series of active and passive ion exchangers. This dual function of the corneal endothelium is described by the "pump-leak hypothesis." Since the cornea is avascular, which renders it optimally transparent, the nutrition of the corneal epithelium, stromal keratocytes, and corneal endothelium must occur via diffusion of glucose and other solutes from the aqueous humor, across the corneal endothelium. The principal physiological function of the corneal endothelium is to allow leakage of solutes and nutrients from the aqueous humor to the more superficial layers of the cornea while at the same time pumping water in the opposite direction, from the stroma to the aqueous. Hexagonal cells of corneal endothelium visualized by specular microscopy. The corneal endothelium is attached to the rest of the cornea through Descemet's membrane, which is an acellular layer composed mostly of collagen IV. This honeycomb tiling scheme yields the greatest efficiency, in terms of total perimeter, of packing the posterior corneal surface with cells of a given area. The normal corneal endothelium is a single layer of uniformly sized cells with a predominantly hexagonal shape. The number of endothelial cells in the fully developed cornea decreases with age up until early adulthood, stabilizing around 50 years of age. Thereafter the endothelial cell density (but not the absolute number of cells) rapidly declines, as the fetal cornea grows in surface area, achieving a final adult density of approximately 2400 - 3200 cells/mm². The postnatal total endothelial cellularity of the cornea (approximately 300,000 cells per cornea) is achieved as early as the second trimester of gestation. The corneal endothelium is embryologically derived from the neural crest. The corneal endothelium governs fluid and solute transport across the posterior surface of the cornea and maintains the cornea in the slightly dehydrated state that is required for optical transparency. The corneal endothelium are specialized, flattened, mitochondria-rich cells that line the posterior surface of the cornea and face the anterior chamber of the eye. It faces the chamber formed between the cornea and the iris. The corneal endothelium is a single layer of endothelial cells on the inner surface of the cornea.
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