Corneal innervation

We need corneal innervation for:

- Sensory nerves are needed for physical protection, e.g. corneal blink reflex, tearing
(feedback action is induced)
- Tear production, we need neural feedback to lacrimal gland (“lacrimal Functional Unit”)
o To wash things out
o Parasympathetic = more tears produced
o Sympathetic = less tears produced
- Tropic functions; Corneal nerves promote epithelial growth, damage repair and wound
healing (e.g. NGF growth factor)

White lines are the nerve fibres from the Wound (neural tropic ulcer) not healing
anterior cornea because someone has lost their corneal
nerves (nerves can’t help healing process)
Corneal ( & scleral) nerves:
- Long posterior ciliary nerves to cornea & equatorial + anterior sclera.
- Short posterior ciliary nerves to posterior sclera
- Mixed innervation = motor, sensory, autonomic

LPCN branches of Nasociliary nerve (from CN V1) and go to the cornea in the subbasal layer,
penetrate bowman’s layer and into the epithelium cells (
 Very dense nerve fibres at the epithelium
layer (lots of branches)! This it the view
of the branched nerve fibres from the
front of the cornea.
Dense innervations!
= hence any abrasion of cornea, even a
superficial one, is quite painful due to
high sensory inneration.

The nerves branching INCREASES from stroma

to epithelium layer of cornea.

- The cornea is densely innervated with sensory fibres. 70-80 large nerves.
o Branches of long and short ciliary nerves enter the peripheral stroma
o Approx. 203mm after they pass into the cornea, the nerves lose their myelin sheath,
but the covering from the Schwann cell remains
Considerable branching occurs and 3 nerve networks are formed:
1. Mid-stromal
2. Sub-epithelial
3. Intra-epithelial

Cornea: neural supply:

- Sub-basal plexus single beaded fibres
anteriorly into the epithelium
- Sparse nerves in posterior stroma, none in
Descemet’s layer or endothelium!
- Sensory nerves comes in thorugh the
bowman’s layer!
Nerves:
- Trigeminal nerve (CNV) (primarily sensory fibres)
 ophthalmic n.  Nasociliary n. long posterior
ciliary nerves (also supply b=ciliary body + iris)
- Primary sensory fibres (+sympathetic supply)
- Enter radially from sclera in anterior & mid-stroma
(70-80 bundles); Lose myelin within 2 to 3mm
- Form a SPARSE plexus beneath bowman’s layer
- Form a DENSE plexus between bowman’s layer and
basal epithelial cells; lose schwann cells
- As epithelial cells divide, nerves ‘shift & re-pattern”

3 Types of Nerve Fibre terminals in cornea:

1. Mechanosensory (20%)
- Low and high pressure
- Respond purely to mechanical/touch stimulation
2. Polymodal (70%)
- Respond to Mechanical, chemical stimulation
- Respond to heat (noxious)
3. Cold sensitive units (10%)
- Respond to low temperature and maybe chemical

The intra-epithelial corneal nerve fibres = neural receptors

- Cornea: most densely innervated tissue in human body (400x density of skin)
- Human corneal epithelium: 7000 nociceptors/mm
- Corneal nerves bifurcate and project towards corneal surface through basal and more
superficial layers of the corneal epithelium
- Endings are like ‘nerve fingertips’, transduce mechanical chemical and thermal inputs into
integrated neural output tearing and blink response.
- Nocireceptors = specialised peripheral sensory neurons that alert us to potentially damaging
physical stimuli; (detect extremes in temperature, pressure and injury-related chemicals)
Human cornea nerve
architecture.
Altered nerve fibres (diabetic
cornea) = problems with wound
healing
Sensation
- Sensation = result of activation of nociceptive and non-nociceptive nerve endings in the
cornea (and conjunctiva)
- Sensory terminals transduce various modalities of stimulus energy (e.g. physical pressure,
temperature, chemical)
- Afferent process:
o Stimuli produce Action Potentials (AP)
o APs propagate centrally along nerve
o Cause neurotransmitter release at synapses
How we measure corneal sensitivity:
- We use Cochet-Bonnet Aesthesiometer to measure corneal sensivity
- Short and blunt = more pressure to cornea
- Longer = less pressure to cornea
- They use during post-surgery to test areas of corneal sensitivity.
Problems
- Disrupts epithelium: not appropriate
post-surgery
- Patient apprehension
- Restricted stimulus intensity range,
adaptation
- Application/perpendicularly
- Filament susceptible to
environmental conditions e.g.
humidity
Changes in sensitivity
- Changes in corneal sensitivity, corneal nerve density & organisation
- Increased nerve visibility in diseases e.g. keratoconus, diabetes
o Keratoconus patients have a thin, bulging cornea (degenerative condition)
o There is swelling in the NASAL INFERIOR area of cornea
Normal nerve patterns: vortex or
whorl-like pattern of the sub-basal
nasal nerve plexus in the inferio-
central cornea of subject 2. This
montage was constructed using 32
confocal images.

Corneal sensitivity is affected by

1. Normal physiology: age, time of day, sleep , lid closure, gender, pregnancy, menstrual cycle
2. Disease (e.g. diabetes, keratocons, herpes, simplex virus, dry eyes/Sjogren’s syndrome,
corneal dystrophies, neautopathies..)
3. Post-surgery: cataract surgery, dependent on incision size; keratoplasty (partial recovery
over 5 years); refractive surgery (e.g. LASIK)
4. Therapeutic Agents
5. Contact lens (CL) wear: lens type &material, duration of wear.
- increase duration of small hard CL = adaptation to foreign body corneal response
Epithelial wound healing
Wound healing depends on:
- Initial wound size
- If epithelial basement membrane is affected
- Corneal nerve disruption
- Limbal niche involvement
-
CORNEAL INJURY
Phase 1 (latent phase)
- MITOSIS STOPSO WE CAN USE THE ENERGY TO ALLOW CELLS TO COVER.
o Growth factors, cytokines, matrix metalloproteinases etc. released from damaged
epithelial and stromal cells to INITIATE AND CONTINUE the processes necessary for
corneal repair
o Junctions (hemidesmosomes) in basal membrane are DISASSEMBLED along the
leading edge of the wound
Phase 2 (Migration and adhesion)
- monolayer of epithelium cells move across to COVERS the wounded area
o Changes in the cytoskeleton allows for cells to change shape TO DEVELOP
MEMBRANE EXTENSIONS (filopodia) to enable cells to migrate and COVER WOUND
- Adhesion molecules allow the leading edge of the epithelial sheets/cells to adhere to the
basement membrane, in the absence of hemidesmosomes.
- cell-to-cell junctions are constructed between neighbouring cells.
Phase 3 (proliferation)
- Once covered, CENTRAL MITOSIS RESUMES = to cell density of re-stratification tissue (to
reconnect)
- Hemisdesmosomes are RE-ESTABLISHED for basal epithelium
o Epithelium cells may be lost before hemidesmosomes are established
X,Y, Z  hypothesis for epithelial cell hypothesis

Wounds severity:
- When the wounds are in the centre, you get resurfacing and rgood recovery.
- When the wound is at the limbus area, where the stem cells are, the you will get chronic
wound-healing ; takes longer to recover. No new cells
- The bigger the wound, the longer it takes to recover the cells at the surface, and longer to
re-cover
- Reduced corneal innervation = slower wound-healing
Scratch in corneal epithelial  can recover overnight!

Stromal Wound Healing

- E.g. cut in the stroma
- Initial wound is covered by overlying epithelium
o Epithelium covers to keep out the invaders. Good protection; prevent invaders e.g.
bacteria, fundus from coming in.
- Keratocytes become activated, they transform to myofibroblasts
- Myofibroblasts help wound contraction (express smooth muscle actin – contractile protein)
1. Epithelium covers wound to keep out the invaders e.g. bacteria, fungus etc. from coming in
– gives good protection
2. No. of Keratocytes INCREASES & stimulated to become MYOFIBROBLASTS
a. Myofibroblasts help wound bed to CONTRACT (express smooth muscle actin) and
hence allows for more rapid wound coverage by epithelium
3. New stromal connective tissues forms, including new collagen fibrils, ECM to heal
 a. The newly formed collagen fibrils of the regenerated cornea differ slightly from
those of original tissue:
i. Larger diameter = the alignment and organisation of the replacement fibrils
are NOT as precise = disorganised stroma = increases chance of scaring =
haze in vision
ii. Less tensile strength  my take MONTHS to approach the typical strength
4. Myofilbroblasts die or change phenotypes to keratocytes

Wound severity:
- Active phase: first 6months stromal scar
- Remodelling phase: improved corneal strength & transparency (over years..)
The type of wound is important for outcome; for example, different type of refractive surgery

Corneal wound healing

- Very little mitosis occurs in the endothelium
- Cell loss = neighbouring cells enlarge and flatten to cover the area of loss = decrease cell
density
- The cells remodel into the hexagonal shape
- Pump and barrier functions are re-established
- In certain conditions, the number of ion pumps in an endothelium cell can INCREASE
DRAMATICALLY to compensate for the loss of pumps that occur when cells are lost.
- Endothelium DOESN’T DIVIDE IN HUMANS

Bowman’s layer & Descemet’s layer

- Bowman’s layer: does NOT regenerate if damaged but is replaced either by stroma-like
fibrous tissue (made by fibroblasts) or epithelial cells
- Descemet’s layer: is a strong and resistant membrane, but if damaged, can be secreted and
re-formed by strong keratocytes and endothelium. Can form Folds when you cut it;

Immune cells in cornea

- Local corneal immune cell populations are important for understanding initiation of immune
response at the ocular surface in response to trauma, infection, transplantation
 - Human cornea = populations of corneal antigen presenting cells (APCs) or Langerhan’s cells
(dendritic cells – DCs) from foetal to adult
- Peripheral to central gradient; with age?
- Unique stratification of APCs within normal human cornea; DCs and LCs mostly basal
epithelium; anterior stroma = macrophages.
- Cells come in from vessels around the cornea, from aqueous humor
- Circulating immune cells vs resident immune cells (= for surveillance)
- Myeloid DCs throughout stroma. More towards central cornea = DECEASES DC density

Overall summary
1. Corneal
DRAFT

Epithelial wound healing

- High rate of cell turnover = mitosis is constantly occurring in basal epithelial layer
- When corneal injury mitosis stops, and growth factors and cytokines are RELEASED from
damaged epithelial and stromal cells to INITIATE AND CONTINUE the processes necessary for
corneal repair
- Hemi desmosomes in basal layer are dissembled along the leading edge of the wound
- Changes in the cytoskeleton allows for cells to change shape TO DEVELOP MEMBRANE
EXTENSIONS (filopodia) to enable cells to migrate and COVER WOUND
- CELL MIGRATION requires precise control of hemidesmosomes, the cytoskeleton structure,
and cell-to-matrix adhesion, which preserves the structural integrity of the epithelial sheet.
- Adhesion molecules allow the leading edge of the epithelial sheets to adhere to the
basement membrane, in the absence of hemidesmosomes.
- Growth factors stimulate the production of matrix components that enhance this cell-to-
substrate adhesion
- Once defect is covered by a single layer of cells, cell-to-cell junctions are constructed
between neighbouring cells. Mitosis resumes and glycogen utilisation and protein synthesis
increases.
When corneal injury extends into the stroma, keratocytes INCREASES & stimulated to become
MYOFIBROBLASTS. These cells cause wound bed to CONTRACT  allowing for more rapid wound
coverage by epithelium.
- The newly formed connective tissue components of stroma differ slightly from those of the
original tissue
o The diameter of the regenerated cornel stromal collagen is LARGER than the original
fibrils, and the alignment and organisation of the replacement fibrils are NOT as
precise! These factors INCREASES THE CHANCE OF RESULTING IN A SCAR.
o The tensile strength of the corneal collagen fibrils is diminished and may take
MONTHS to approach the typical strength.
- Once the healing is complete, the myofibroblasts undergo apoptosis or revert back to
keratocytes.