KORNEAKORNEABAGIAN I.P. MATA

FAKULTAS KEDOKTERANUNIVERSITAS WIJAYA KUSUMA

SURABAYA

KORNEAKORNEAANATOMI – HISTOLOGI : Kornea Adl Jaringan Transparan Dan Avaskuler,

Bersama Konjungtiva, Kornea Merupakan Batas Depan Bola Mata Berhubungan Dgn Dunia Luar.

Tebal Kornea Kurang Lebih 0,8 Mm – 1 Cm Dibagian Tepi & Makin Ketengah Makin Tipis, Sampai Mencapai 0,6 Mm Di Bagian Sentral.

Diameter Kornea Krg Lbh 11,5 Mm.

MIKRO KORNEA

MEGALOKORNEA

FUNGSI KORNEA Membran Protektif Media Refraksi :+43 Dioptri. Jendela Mata Sinar Masuk Mencapai

Retina.

SCR HISTOLOGI, KORNEA DIBAGI SCR HISTOLOGI, KORNEA DIBAGI 55 : :

1. EPITEL - 5-6 Lapisan Sel. Sel Epitel Kubus --Paling

Dasar, Poligonal & Berbentuk Pipih Di Permukaan.

- Elektron Mikroskop :Jonjot2 Menahan Air Mata Mencegah Kekeringan Kornea.

- Sel2 Epitel :Daya Regenerasi Yg Bsr

2. MEMBRANA BOWMANLapisan A Seluler Yg Jernih & Sebagian : Serabut2 Kolagen Modifikasi Bagian Stroma.

3. STROMATertebal Dari Kornea (90 % Tebal Kornea). Sabut2 Kolagen Bhn Dasar Mukopolisakarida. Tersusun Pararel Teratur Kornea Ttp Pransparan.

4. MEMBRANA DESCEMET Terkuat Tak Mdh Ditembus O/ Mikro Organisme

/Pun Trauma. Melapisi Stroma Dibagian Posterior tddSerat2

Kolagen Jernih & Dianggap Sbg Hasil Sekresi Endotel.5. ENDOTEL Lapis Sel2 Kubus. Tdk Punya Daya Regenerasi Kerusakan Pd Sel2

Endotel --Permanen & Lbh Berat Dibanding Epithel.

AANNAATTOOMMI I

KKOORRNNEEAA

NUTRISI Elemen2 Nutrisi Masuk Kedalam Rongga

Kornea Yg Avaskuler Dr Limbus Yg Kaya Pembuluh Darah.

Disamping Itu Kornea Jg Mendpt Nutrisi – Dr Aquous Humour Dlm Kamera Anterior – O2 Dr Udara Luar.

PERSYARAFANPERSYARAFAN( INERVASI )( INERVASI )

Dr Cabang2 N. Trigeminus (N.V)

Erosi Epitel

Rangsangan Nyeri

TRANSPARANCY TRANSPARANCY ( KEJERNIHAN KORNEA )( KEJERNIHAN KORNEA )

Karena :1. Uniform.2. Avaskularitas3. Deturgescence,

Dehidrasi Kornea : “Na-k PUMP” Sel2 Endotel & Epithel Integritas Anatomi.

Evaporasi Air Dari Tear Film Prekorneal Kerusakan Endothel Edema Kornea

KERATITIS Adalah : Radang Pada Kornea Apapun Sebabnya.

Penyebab : 1. Bakteri,. 2. Jamur 3. Virus 4. Defisiensi Vit A. 5. Exposure Keratitis: * Exophthalmus *Lagolpthalmus Akibat Paralyse N. 7.

Gejala klinis:– Rasa Nyeri // Bila Penderita Terkena

Rangsangan Chy.– (Photofobia) – Spasme Palpebra (Blepharospasme). – Air Mata Berlebihan (Epipora).– Kabur Infiltrat Berada Di Kornea Sentral.

Pada Pemeriksaan Dgn Lampu Senter / Opthalmoskop Tampak Adanya Infiltrasi.

PEMERIKSAAN LANJUTAN BILA DITEMUKAN INFILTRAT, ADL :

1. BENTUK INFILTRAT - Numuler, Mis: Keratitis Numularis. - Punctat, Mis : Keratitis Punctata Superficial. - Dendrit, Mis : Keratitis Herpes Simplex. - Filamen, Mis : Keratitis Herpes Simplex. - Disciform, Mis : Stromal Keratitis.

2. TES FLUORESCEIN.Cairan Fluorescein Infiltrat : Fl +

Fl -. 3. LOKASI. - Sub-Epithel, Epithel Dari Stroma. - Lokal - Merata

-Perifer - Sentral.

4. SENSIBILITAS KORNEAUjung Kapas

Hasil + (Sensabilitas Baik). Sensabilitas Menurun Herpes Simplex Keratitis.

EDEMA KORNEA

FLUORESCEIN POSITIFFLUORESCEIN POSITIF

INFILTRAT DENDRITIKA

KERATITIS MARGINALFLUORESCEIN POSITIF

KERATITISDENDRITIKA LUAS

ULKUS KORNEA

Fig. 5.2. Pathology of corneal ulcer : A, stage of progrB, stage of active ulceration; C, stage ofessiveinfiltration; regression; D, stage of cicatrization

PENGOBATANPENGOBATAN Salep Mata– Antibiotika– Anti Virus – Anti Jamur.

Simtomatis : Midriatikum Mengurangi Spasme Silier -- Rasa Nyeri Berkurang.

Bebat Mata :– Superinfeksi – Spasme Palpebra.

PERJALANAN PENYAKITPERJALANAN PENYAKIT

Sembuh Tanpa Bekas

Jaringan Parut Pd Kornea Infiltrat padaStroma Kornea.

LESI KORNEA

JARINGAN SIKATRIK PD KORNEAJARINGAN SIKATRIK PD KORNEADIBAGI MENURUT TEBALNYA :DIBAGI MENURUT TEBALNYA :

• NEBULA : Sikatrik Tipis, dgn Slit lamp.• MAKULA : Tebal, dgn Lampu Senter.• LEKOMA : Tebal , dgn Mata Biasa.

NEBULA, MAKULA, LEKOMA, LEKOMA ADHERENT

INFILTRAT SIKATRIKS

Radang

+ -

Batas Tidak jelas Tegas

Edema kornea

+ -

Permu kaan

Abu-abu Licin mengkilat

Tepi Tidak rata Rata

• PROGNOSIS• Tanpa Pengobatan Yg Baik • Ulkus Kornea• Descemetocele• Perforasi • Endopthalmitis • Phtisis Bulbi.• Pd Ulkus Kornea o.k Pneumococcus Sering Disertai

Hipopion & Tjd 24 – 48 Jam • Sangat Patogen U/ Kornea

ENDOFTALMITIS

ULKUS KORNEA KRN BAKTERI

• Disentral.• PenyebabTerbanyak :– Pneumococcus– Pseudomonas Aeroginosa – S. Aureus Dll.

• Kerusakan Epitel Ulkus .• Perifer Kornea, Kesentral Kornea.

KLINIS• Infiltrat Abu2 Di Perifer Ketengah

KorneaHipopyon.• Kornea sekitar Lesi Tetap Jernih.• Pd Pseudomonas: Infiltrat Abu2 & Cenderung

Menyebar Kepermukaan Kornea o.k Enzym Proteolitik.

TERAPI : - Antibiotika Lokal & Atau Sistemik. - Midriatikum Sikloplegikum - Bebat Mata.

ULKUS KORNEA& HIPOPION

ULKUS KORNEA\BAKTERIAL

PENGOBATAN MENURUTMERILL GRAYSON

Ukuran Ulkus LOKASI Cara Pengobatan

3 Mm Tdk Axial Poliklinik, Antibiotika Topikal Tiap Jam.

3 Mm Axial Tinggal Rawat

- Antibiotika Topikal Tiap Jam.

Antibiotika Sub Konjungtiva

3 Mm + HIPOPYON Di mana saja Idem Ad.2

Antibiotik Sistemik.

ULKUS KORNEA KRN JAMUR• Sering Pd Petani.

• Penyebabnya Adl : Candida, Fusarium, Aspergilus, Penicillium, Cephalosporium Dll

• Jenis : Ulkus Indolent – Infiltrat Berwarna Keabuan – Satu / Beberapa Lesi Satelit.

• Scraping : Hipopyon.• Scraping Ditemukan Hypha, Kecuali

Candida :Pseudohypa / Yeast.

• FAKTOR PREDISPOSISI :– Penggunaan Kortikosteroid Yg Lama.

• TERAPI ANTI FUNGI : – Ampotericin B Flucytocin

Nystatin Symtomatis

KERATITIS FUNGALFILAMENTOSA

MYCOTIC KERATITIS

MYCOTIC KERATITIS

ULKUS KORNEA KRN VIRUS

• Virus Yg Sering Menyebabkan Infeksi Kornea : - Herpes Simplex - Herpes Zoster - Varicella - Variolla, Dll.

AKIBAT VIRUSHERPES SIMPLEX ( HSV )

• Ada 2 Type Virus :

1. Hsv Type 1 (H. Labialis).2. Hsv Type 2 (H. Genitalis).

• Hsv Tipe 1 Keratitis.

• Gejala :Sangat Ringan Tdk Terdiagnosis, Berupa : Konjungtivitis Folikularis, Blepharoconjungtivitis.

• Yg Berat Dijumpai : - Pseudomembran - Kelopak Mata Bengkak & Dijumpai Vesikel2.

• Dlm 2 Mgg Pd 50% Di Epitel Berbentuk : Punctat, Stellata / Filamen

• Disertai Gejala Epiphora, fotofobia & Perasaan Adanya Benda Asing.

KERATITIS HERPES SIMPLEK

CARA TJDNYA INFEKSI & PERJALANAN PENYAKIT

• Infeksi Primer Terutama Didapati Pd Anak 1-5 Thn Setelah Kontak Langsung Dgn Penderita.

• Kontak Langsung Dpt Tjd Scr Oral, Tetapi Dpt Ditularkan Melalui Tangan / Sexual.

• Setelah Masa Inkubasi ( 3-12 Hari ) Timbul Gejala : Demam, Malaise, Gejala Git, Dll.

Dgn Tes Fluorescein Lesi Kornea Memberikan Hasil +.

Gejala Lain Yg Khas Adalah Hilangnya Kepekaan Kornea (Hipo Annestesi).

Lesi Primer Ini Bersifat Subklinik & Akan Sembuh Sendiri,tetapi Krg Lbh 25% Penderita Dgn Infeksi Primer Akan Mengalami Kekambuhan.

FAKTOR PENCETUSKEKAMBUHAN

• Demam• Stress Psikis • Trauma Kornea • Irradiasi• Ultra Violet• Imunosuppresi Lokal / Sistemik• Menstruasi, Dll.

GAMBARAN KLINIS• Hsv Bersifat Epiteliotrof & Neurotrof.

• Punctat, : Filamen / Stelata.

• Dendrit Tanda Khas U/ Keratitis Herpetika.

• Geograpis / Amuboid.

• Keratitis Disciformis

VESIKEL & BULA KORNEA

HERPES SIMPLEKSDENDRITIKA

ULKUS GEOGRAPHIC

PENGOBATAN1. Anti Virus. # Vidorabine, Ara.A : Inhibitor Dna Polimerase Idu

(5 Iodo Deoxy Uridine). - Mengganggu Sintesa Dna - Tetes Mata / Salep Mata - Efek Samping Banyak : A. Penyembuhan Epitel Lambat. B. Punctat Keratopati. C. Kemosis. D. Edema Perilimbal, Dll.

# Tft ( Tri Fluoro Tymidine ).• Mempengaruhi Enzym U/ Sintesa Dna.• Lebih Efektif Dibanding Idu & Ara. A.• Tetes Mata 1 Tetes / Jam• Salep Mata• Toksisitas Lebih Kecil Dibanding Idu & Ara.A

# Acycloguanosine (Acyclovir Zovirax).• Mengganggu Sintesa Dna• Salep Mata 3% 5-6 Kali Sehari• Dpt Secara Sistemik

# INTERFERON • Dihasilkan Akibat Rx Antigen-antibodi.• Mencegah Perbanyakan Virus. • Mempercepat Penyembuhan Akibat Infeksi

Virus.• Tetes Mata.• Sebaiknya Dikombinasi Dengan Obat2

Antivirus Yg Lain.

2. Scraping / Pengerokan Dikerjakan Dgn Menggunakan Kapas Lidi /

Spatula U/ Epithel Yg Nekrotik.

3. Krio Aplikasi Terhadap Epithel Kornea Yg Sakit.

4. Keratoplasti Indikasi : - Ulkus Yg Akan / Mengalami Perforasi. - Ulkus Besar Ditengah Kornea. - Ulkus Yg Sering & Berulang2 Kambuh.

KORTIKOSTEROID LOKAL

. Kortikosteroid Lokal Sebaiknya Tdk Digunakan Sebab Akan :

1. Menambah Aktivitas Destruksi Kolagenase Kornea.2. Menambah Aktivitas Virus.3. Mengurangi Kerentanan Terhadap Mikroorganisme

Lain. Pada Pemakaian Yg Lama Kortikosteroid Akan :

- Memudahkan Infeksi Jamur. - Menimbulkan Katarak. - Tekanan Bola Mata Yg Meningkat (Glaukoma).

KERATITIS NUMULARIS

• Dimmer’s Keratitis• Padi Keratitis• Keratitis Sawahica

Banyak Dijumpai Pd Petani, Virus (Diduga). Virus Mengadakan Replikasi Di Epitel,

Kemudian Mati, Tetap Timbul Rx. Ag-ab. Dibawah Epitel.

KLINIS• Infiltrat Bulat2 / Coin Shaped & Cenderung

Bergabung Mjd Satu.• Hasil Test Fluoroscein (-).• Sensasi Benda Asing Kadang Disertai Epifora,

Fotofobia Ringan & Kabur Bila Infiltrat Ditengah Kornea.

Terapi : Kortikosteroid Lokal, Sembuh Krg Lbh 10 Hari -2

Minggu.

KERATOPLASTI ( PENCANGKOKAN KORNEA ).

• Istilah - Donor = Kornea Diambil Dari Orang Yg Telah

Meninggal Kemudian Digunakan Langsung / Dipindahkan Pd Resipien / Diawetkan Dulu Dgn Es / Medium Tertentu.

- Resipien = Penderita2 Dengan Kelainan Kornea Tertentu.

INDIKASI

• OPTIK : - Makula Kornea / Lekoma –

Kornea Ditengah2 Kornea. - Therapeutik : Herpes Simplex Keratitis. - Kosmetik : Lekoma Kornea.

CARA / METODE

• Keratoplasti Tembus : Terhadap Seluruh Tebal Kornea.

• Keratoplasti Lameller : Endotel Kornea Ditinggalkan.

KERATOPLASTI

KERATOPLASTI TEMBUS

KERATOPROSTHESIS

ARCUS SENILIS

KERATOGLOBUS

KERATOCONUS

BANDAGELENSA KONTAK

KERATEKTASIA /PENIPISAN KORNEA

NEOVASKULARISASISTROMA

BANK MATABAGIAN I.P. MATA

FAKULTAS KEDOKTERAN UNIVERSITAS WIJAYA KUSUMA

SURABAYA

Eye banks are conceived to provide for: procurement, processing, and distribution of safe quality donor eyes therapeutic use and research.1

Eye banks undertake comprehensive workincluding promotional public relation activities andenhancement of public awareness, tissue harvesting,tissue evaluation, tissue preservation, and tissuedistribution.

• Operational Efficiency• Eye banking demands a very efficient round-the-

clock• operational system in receiving a donor call and executing a response for eye collection to that call preferably within 20-30 minutes

• Equipment for an eye bankMandatory Desirable• Refrigerator with temperature• Recording device• Biological safety cabinet or• Slit lamp• Sterilization facilities• Enucleation and corneal• Excision instruments

• TISSUE RETRIEVAL• Tissue can be retrieved for transplantation either by• an enucleation,• an in situ corneoscleral excision

• Preliminary Procedures :• Legal permission • The donor’s medical records • Check for the ocular and medical contraindications• Wash hands with alcohol or similar disinfectant• Put on protective clothing—surgical gown,cap, mask,

eye protection and non sterile or prep gloves.• Identify the donor either by a toe tag or some other

form of identification label on the body of the donor

• I. Systemic• 1. Conditions potentially hazardous to eye bank personnel and fatal, if transmitted:

a. Acquired immunodeficiency syndrome or HIV seropositivity

b. Rabiesc. Active viral hepatitisd. Creutzfeldt-Jakob disease.

• 2. Other contraindications:a. Subacute sclerosing panencephalitisb. Progressive multifocal leukoencephalopathyc. Reye’s syndromed. Death from unknown cause including unknown encephalitise. Congenital rubellaf. Active septicemia including endocarditisg. Acquired immunodeficiency high risk behavioral features including

homosexuals, intravenous drug abusers, prostitutes and hemophilics

h. Leukemia (blast form)i. Lymphoma and lymphosarcoma

• II. Oculara. Intrinsic eye disease—retinoblastoma, active

inflammatory disease (conjunctivitis, iritis, uveitis,vitreitis, retinitis), congenital abnormalities (keratoconus, keratoglobus), central opacities and pterygium.

b. Prior refractive procedures—radial keratotomy scars, lamellar inserts, laser photoablation.

c. Anterior segment surgical procedures (cataract, glaucoma).

• PreparationPrepare the donor as per operating room standards.Open the right eye with the help of a sterile cottontipped applicator or sterile hemostat and copiouslyirrigate the conjunctiva sac with sterile saline. Repeatthe same procedure on the left eye using a new cottontipped applicator or hemostat. After irrigation, cleanboth sides of orbital area with alcohol swab/alcoholgauze held in a sterile hemostat. Make sure alcoholdoes not enter the eyes.

32.1A to F: Donor eye enucleation procedure. Following360 degree peritomy (A), ocular muscles are cut (B), eyeball is then lifted (C), and optic nerve (D), as well as oblique muscles are cut (E). Finally, harvested eyeball is placed in a glass vial (F)

Corneoscleral button excision procedure. Scleral incision 4-5 mm in length at 2-3 mm behind limbus (A) is made, scleral incision is extended for 360 degrees (B), iris is pulled away from the cornea (C, D)

Donor Cornea ViabilityEvaluation Methods

• Gross Ex • A. Adnexa Dacryocystitis, styes, pustules, discharge

(conjunctivitis)• B. Cornea Epithelium edema, exposure, trauma and foreign

bodies. Stroma Arcus senilis, corneal scars—central/limbal (evidence of prior surgery), corneal infiltrates, abnormal corneal shape/size, e.g. keratoconus, edema.

• Endothelium Keratic precipitates, central guttata• C. Anterior chamber Shallow/flat, blood in anterior chamber,

abnormal anatomy• congenital and acquired due to prior intraocular surgery.

amination

• Cornea viability rating scale2,4,5• Parameter Not present 1 2 3 4• Clarity crystal clear slight haze moderate haze heavy haze• Epithelial defects none not in center 50-90% of center > 90%• Epithelial edema none slight overall moderate marked• Scars 0 none peripheral peripheral central• Foreign bodies none none peripheral central• Stromal edema nonapparent slight peripheral mild entire thick• Opaque infiltrate 0 none none none none• Keratic none peripheral few central dense• precipitates• Arcus senilis none light, >8 mm >6 mm clear < 6 mm clear• clear cornea• Folds none peripheral central central• Guttata none 3-4 spots >4, central > 4, central• Jaundice 0 none light yellow moderate yellow orange• Endothelial count 2500/mm2 2000/mm2

• Cornea with specular endothelial patterns unfit for transplantation

1. An endothelial cell density less than 1500 cells/mm22. Severe polymegathism or pleomorphism of the

endothelial cells3. Presence of central cornea guttata4. Abnormally shaped cells such as fused cells (these cells are

seen in stressed endothelium)5. Abnormal single cell defects6. Severe edema of endothelium7. Presence of inflammatory cells or bacteria on endothelium

• Final cornea evaluation criteria• Excellent = rating 1 a. no epithelial defectsb. crystal clear stromac. no arcus senilisd. no folds in Descemet’s membranee. excellent endothelium—no defects.

• Very good = rating 2a. slight epithelial haze or defectsb. clear stromac. very slight arcusd. few light foldse. very good to excellent endothelium—no defects.

• Good = rating 3 a. obvious moderate epithelial defectsb. light-to-moderate cloudinessc. moderate arcus senilis < 2.5 mmd. obvious folds (numerous but shallow)e. few vacuolated cells.

• Fair = rating 4a. obvious epithelial defects (>60%)b. moderate-to-heavy stromal cloudinessc. heavy folds (numerous, deep, central)d. heavy arcus senilis >2.5 mme. fair-to-good endothelium—moderate

endothelial defects, vacuolated cells, low cell density.

• Poor a. moderate vacuolated cells (some central)b. severe stromal cloudinessc. marked folds (heavy, numerous,central)d. fair endothelium—marked defects, low cell

density, numerous central vacuolated cellse. technical problems in removal.