Table Of ContentHISTOLOGY AND
HISTOPATHOLOGY OF
THE E YE AND ITS ADNEXA
By
I. G. SOMMERS, M.D.
Assistant Professor (Ophthalmology), College of
Medical Evangelists; Medical Officer (E.E.N.T.),
U.S. Public Health Service, Los Angeles, California
London
WILLIAM HEINEMANN · MEDICAL BOOKS · LTD,
1949
This book is copyright. It may not be reproduced in whole or in part,
nor may illustrations be copied for any purpose without permission.
Printed in the U. S. A.
PREFACE
For many years it has been my opportunity to examine eyes,
first clinically, and, if enucleation became necessary, also patho
logically in various clinics and laboratories. Both European
and American hospitals have made available to me for study
a vast amount of eye section material. During this time, too,
I have instructed a number of physicians specializing in oph
thalmology or doing postgraduate work toward specialization
in histology and histopathology of the eye, and for some years
I taught histology and histopathology in general to under
graduate medical students.
This book is an elaboration of the instruction courses I gave,
and has grown out of the desire expressed by my students to
have the lectures in more permanent form.
The material presented here is divided into three parts. As
introduction, the normal histology of the eye is outlined. Next
follows a section on general pathology, the emphasis being
placed on its application to pathology of the eye, with a brief
report on the bacteriology and parasitology of the eye included.
The main body of the book deals with the histopathology of
the eye, and in this third and very important part it has been
my attempt to describe the findings which lead to the pathologic
diagnosis of the sectioned eye.
For a subject so complex, clarity of presentation must be a
prime consideration. The text, then, has been arranged as
continuous and simple description, omitting as much as possible
cross references to other chapters or to previously noted data.
Rather, when necessary, I have repeated such facts in brief
form, this repetition, it is hoped, enabling the inexperienced
student to grasp the material more easily and fix it more firmly
in his mind. The book may serve not only the beginner but,
indeed, the practicing ophthalmologist as well; it may also
help the student who wishes to compare his findings in a section
of an eye with an authoritative text. Finally, I hope, too,
xi
Xll PREFACE
that the book in this form will offer a valuable guide to the
hospital and laboratory pathologist who is not already trained
in the specialty of eye pathology.
As a further aid to clarity of presentation, rather than inter
rupt the main current of discussion with constant references
to the names of the many hundreds of authors who have con
tributed to our knowledge and whose opinions are so often
contradictory, I have omitted these from the text and reserved
special sections for the literature. Following each of the first
two parts and each chapter of the third part, the reader will
find a separate discussion of published works arranged in the
same sequence as the chapter is subdivided in the text. This
rather complete outline of the current world literature on the
pertinent subjects covers the years 1920 to 1947, and is followed
in each instance by a detailed bibliography of the material
discussed. These annexes may be of value to those scientific
workers who possibly may not be able to orient themselves
quickly in the extensive material already published.
The literature of the years previous to 1920 may be found
in quite complete form in the volumes on the eye in Henke and
Lubarsch's comprehensive work listed below. The following
list of handbooks, textbooks and monographs contains material
of importance for more than one chapter of the present book.
Alt, A.: Kompendium der normalen und pathologischen Histologie des
Auges. Wiesbaden, Bergmann, 1880.
Army Medical Museum: Atlas of Ophthalmic Pathology. 1942.
Axenfeld, Th.: Bakteriologie des Auges. Jena, Fischer, 1907.
Bach, L., and Seefelder, K. : Atlas zur Entwicklungsgeschichte des
menschlichen Auges. Leipzig, Engelmann, 1912-1914.
Boyd, W.: A Textbook of Pathology, ed. 4. Philadelphia, Lea &
Febiger, 1943.
Clausen, W. : Vererbung in der Augenheilkunde. Ztbl. f. ges. Ophth.
11:81, 209, 417, 1924; 13:1, 161, 1925.
Collins, E. T., and Mayou, M. S.: Pathology and Bacteriology of the
Eye, ed. 2. Philadelphia, 1925.
Craig, C. F., and Faust, E. C. : Clinical Parasitology, ed. 2. Philadelphia,
Lea & Febiger, 1940.
Duke-Elder, W. S.: Textbook of Ophthalmology, vols. I-III. St. Louis,
Mosby, 1945-1946.
Duyse, M. van: L'Hérédité en Ophthalmologie. Paris, Masson et Cie.,
1931.
PREFACE xiii
Elliot, R. H.: Tropical Ophthalmology. Oxford, 1920.
Ewing, J.: Neoplastic Diseases, ed. 4. Philadelphia, Saunders, 1940.
Friedenwald, J. S.: The Pathology of the Eye. New York, Macmillan,
1929.
Euchs, A.: Atlas der Histopathologie des Auges. Leipzig & Wien,
Deuticke. Part I, 1923; Part II, 1927.
Ginsberg, S.: Grundriss der patholog. Histologie des Auges. Berlin,
Karger, 1903.
Graef e-Saemisch : Handb. der ges. Augenh.; continued by v. Hess, Axen-
feld, Th., Elschnig, A., Springer, Berlin. Various chapters.
Greeff, E.: Die pathologische Anatomie des Auges. Lehrb. d. spez.
patholog. Anat. v. Orth. Ergaenzungsbd. 1, 2. Berlin, Hirschwald,
1902-1906.
Henke, F., and Lubarsch, O.: Handbuch der speziellen pathologischen
Anatomie und Histologie. XI. Bd. Auge. ed. by Wessely, K. Parts I-III.
Berlin, Springer, 1928-1937.
Herrenschwand, F. v.: Die pathogenen Mikroorganismen des Auges.
Berlin, Urban & Schwarzenberg, 1927.
Kaufmann, E.: Pathology. Transi, by Beimann, S. P. vol. I-III.
Philadelphia, Blakiston, 1929.
Lewin, L., and Guillery, H. : Die Wirkungen von Arzneimitteln und
Giften auf das Auge, ed. 2. Berlin, Hirschwald, 1913.
Lubarsch, O., and Ostertag, B. : Ergebnisse der allgemeinen Pathologie
und pathologischen Anatomie. Auge. Bergmann, Muenchen, various chap
ters of various years.
Mann, I.: The Development of the Human Eye. Cambridge, University
Press, 1928.
Mann, I.: Developmental Abnormalities of the Eye. Cambridge, Uni
versity Press, 1937.
Maximov, A. A., and Bloom, Wm. : A Textbook of Histology, ed. 4.
Philadelphia, Saunders, 1942.
Morax, V.: Pathologie oculaire. Histopathologie de l'oeil et des
annexes. Paris, Alcan, 1921.
Morax, V.: Cancer de l'Appareil Visuel. Paris, Doin & Co., 1926.
Park, W. H., and Williams, A. W. : Pathogenic Microorganisms, ed. 11.
Philadelphia, Lea & Febiger, 1939.
Parsons, J. H. : The Pathology of the Eye. London, Hodden & Stough-
ton, 1904-1908.
Polyak, S. L. : The Retina. Chicago, University of Chicago Press, 1941.
Salzmann, M.: The Anatomy and Histology of the Human Eye. Chi
cago, 1912.
Sattler, H.: Die boesartigen Geschwuelste des Auges. Leipzig, Hirzel,
1926.
Schieck, W., and Brueckner, A.: Kurzes Handbuch der gesamten
Ophthalmologie, 7 vol. (various chapters). Springer, Berlin, 1930-1932.
Siegrist, A. : Der graue Altersstar, seine Ursachen und seine nicht
operative Behandlung. Berlin u. Wien, Urban & Schwarzenberg, 1928.
Waardenburg, P. J. : Das menschliche Auge und seine Erbanlagen.
Haag, Nijhoff, 1932.
XIV PREFACE
Whitnall, S. E.: Anatomy of the Human Orbit and Accessory Organs
of Vision. New York, Oxford University Press, 1932.
Wolff, A.: A Pathology of the Eye. 2nd Ed. London, Lewis, 1944.
Zinsser, H., and Bayne-Jones, S. : Textbook of Bacteriology, ed. 8.
New York, Appleton, 1939.
I am indebted and very grateful to Dr. Edgar 0. Breakstone
of Chicago, Illinois, and Dr. Victor Marshall of Los Angeles,
California, who have studied with the greatest care the text
of the manuscript, corrected it thoroughly and improved it by
their valuable advice. They helped also in reading the proofs
to make the book as free of errors as possible.
I should like to express my thanks, too, to my publisher,
Mr. Henry M. Stratton, who has shown the greatest interest
in the progress of this extensive work, and who has done all
possible to give the book its attractive form.
Finally, I would not have been able to begin this great task,
continue and carry it to completion if my good wife Vita had
not helped and advised me continuously during the many hours
I spent with the work. I want to express my deep gratitude
to her.
I. G. SOMMERS, M.D.
Los Angeles, California
December, 1948
CHAPTER I
NORMAL HISTOLOGY OF THE EYE
THE EYE has three tunics: (1) An external tunic consisting
of cornea and sclera; this is the fibrous tunic. (2) A middle
tunic consisting of the uvea; this is the vascular tunic. (3) An
inner tunic consisting of the retina and the optic nerve; this is
the nervous tunic.
1. THE CORNEA
The cornea consists of five layers, from without inward:
(1) the epithelium, (2) Bowman's membrane, (3) substantia
propria, (4) Descemet's membrane, and (5) endothelium.
The epithelium is a stratified squamous cell epithelium and is
very regular. The basal layer consists of cylindrical cells with
oval nuclei, covered by two layers of prickle cells, on top of
which are two layers of flat cells. The epithelial cells are
connected with one another by tonofìbrils. A few migratory
cells are found in the epithelium.
Bowman's membrane is a homogeneous lamella with a smooth
anterior surface. Fibers extend from its posterior surface to
the corneal lamella. Bowman's membrane is therefore easily
separated from the epithelium, but only with difficulty from the
propria. The membrane contains many pores for the passage
of corneal nerves which end in the epithelium. It ends abruptly
at the limbus. The membrane does not regenerate when injured.
The substantia propria is composed of lamellae which are very
regular and arranged parallel to the surface. The lamellae
consist of collagenous fibers connected by cement. Pine spaces
between the lamellae serve as lymph spaces. They contain flat
fixed cells (corneal corpuscles), which form a syncytium, and
a few compressed migratory cells. The substantia propria
constitutes about 90 per cent of the thickness of the cornea.
Descemet's membrane is a thin, homogeneous elastic mem
brane. When injured, it curls up and readily regenerates.
3
4 HISTOLOGY AND HISTOPATHOLOGY OF THE EYE
The endothelium is attached to Descemet's membrane, con
sisting of a single layer of flat epithelium-like cells lining the
anterior chamber. Their oval nuclei bulge the cells somewhat
toward the anterior chamber.
2. THE SCLERA
The sclera consists of the episclera, the substantia propria,
and the lamina fusca.
The episclera is composed of loose connective tissue mixed
with elastic fibers surrounding many blood vessels. Its deeper
FIG. 1.—CORNEA. B, Bowman's membrane; cc, corneal corpuscles; D,
Descemet's membrane; e, epithelium; en, endothelium; 1, lamellae. 105χ.
layers contain heavier connective tissue bundles which fuse into
the propria.
The substantia propria has coarse connective tissue bundles
which show lamellar structure. The lamellae are composed of
fibers. Near the limbus, the bundles are arranged for the most
part in circular fashion; otherwise they lie meridionally, inter
woven with bundles which run in an equatorial direction. A few
flat fix cells lie between the bundles. The sclera has only a few of
its own blood vessels and nerves but is penetrated by many chan
nels for arteries, veins, and nerves near the limbus, on the equa
tor, and around the optic nerve. The channels penetrate obliquely
and are lined by tissue of the suprachoroid. The anterior ciliary
NORMAL HISTOLOGY OF THE EYE 5
veins leave the eye, carrying the fluid from Schlemm's canal,
and the anterior ciliary arteries enter the eye and proceed to
the large iris circle. At the equator, the vortex veins leave the
eye, carrying the blood from the uvea. The short and long
posterior ciliary arteries enter posteriorly, carrying blood to the
uvea. Only a few small branches of the short posterior ciliary
arteries enter the sclera, but a few branches go off which
anastomose with one another and form a ring around the optic
nerve.
The lamina fusca is the innermost layer of the sclera next
to the choroid. Its bundles are smaller than those of the propria,
and contain more elastic fibers and chromatophores.
The sclera is connected with the cornea at the limbus; it has
posteriorly a large canal through which the optic nerve leaves
the eye.
3. THE LIMBUS
At the limbus cornea, conjunctiva, episclera, and sclera meet.
The anterior layers of the limbus consist of epithelium and loose
connective tissue with blood vessels and nerves.
The epithelium is a stratified squamous cell epithelium of the
type of the conjunctival epithelium; it shows flat papillae and
is higher and more irregular than the corneal epithelium. The
basement cells are narrower and more closely packed, while
the prickle cells and the flat cells are more numerous than
in the corneal epithelium.
The loose connective tissue of the limbus flows together from
the mucosa of the conjunctiva, Tenon's capsule, and episclera.
The tissue converges at the end of Bowman's membrane. The
blood vessels have thin walls and are surrounded by lymph
spaces. Branches of the ciliary nerves enter the sclera from
the suprachoroid and reach the cornea from the limbus. After
losing their medullary, sheaths, they enter into the anterior cornea
and go vertically up to Bowman's membrane, which they pass
to enter the epithelium. Nerves of the conjunctiva and epi
sclera form a pericorneal plexus which anastomoses with the
corneal nerves. ·
The irregularly arranged lamellae of the sclera continue at
the limbus into the regularly arranged lamellae of the cornea.
6 HISTOLOGY AND HISTOPATHOLOGY OF THE EYE
4. THE UVEA
The uvea is the pigmented vascular tunic of the eye, composed
of the iris, the ciliary body, and the choroid.
In the iris, several layers can be distinguished histologically.
They are, anterio-posteriorly : (1) endothelium, (2) anterior
border layer, (3) stroma with blood vessels and sphincter muscle,
(4) dilator muscle, and (5) pigment epithelium.
Some assert and some deny that the iris has an endothelium.
On the anterior surface of the iris may be found flat cells with
oval nuclei which project over the surface. These cells are
considered by some as a continuation of the corneal endothelium.
The anterior border layer consists of several layers of cells
lying very close to each other with only a little collagenous
fibrous tissue between. Their nuclei are oval and are arranged
parallel to the surface. These cells are considered as densely
arranged chromatophores which are loaded with pigment gran
ules in brown eyes, but have no pigment in blue eyes. The
endothelium and anterior border layer are missing in the iris
crypts, and are more developed in the ciliary zone of the iris
than in the pupillary zone. In the depth of the crypt, the
iris stroma is open to the aqueous humor of the anterior chamber.
The stroma consists of a meshwork of fine collagenous fibers
mixed with a few elastic fibers and has large spaces filled with
fluid. The stroma cells are represented by nonpigmented cells
with fusiform nuclei, fine processes, and starlike chromatophores
containing pigment granules. The chromatophores appear as
spider-shaped formations in sections parallel to the surface of
the membrane. The processes are few; they are connected with
processes of adjacent chromatophores to form a syncytium.
The cell body around the oval nucleus is also oval. The pigment
(melanin) appears as fine granules and is dark brown to black
in color. The normal stroma has few migratory cells, occasional
plasma cells with acidophil granules, and so-called clump cells
found mostly around the sphincter. They are round, heavily
pigmented cells without processes and are apparently pushed
out of the pigment epithelium into the stroma. The stroma
contains a plexus of nerves and ganglion cells.
The blood vessels of the stroma originate in the greater circle
of the iris. Arteries branch off, course radially between the
