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KORNEA

BAGIAN I.P. MATA


FAKULTAS KEDOKTERAN
UNIVERSITAS WIJAYA KUSUMA
SURABAYA

KORNEA
ANATOMI 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 5 :
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 BOWMAN
Lapisan A Seluler Yg Jernih & Sebagian :
Serabut2 Kolagen Modifikasi Bagian Stroma.
3. STROMA
Tertebal 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.

A
N
A
T
O
M
I
K
O
R
N
E
A

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.

PERSYARAFAN
( INERVASI )
Dr Cabang2 N. Trigeminus (N.V)
Erosi Epitel

Rangsangan Nyeri

TRANSPARANCY
( KEJERNIHAN KORNEA )

Karena :

1. Uniform.
2. Avaskularitas
3. 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.
3.
4.
5.

Jamur
Virus
Defisiensi Vit A.
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 KORNEA
Ujung Kapas
Hasil + (Sensabilitas Baik).
Sensabilitas Menurun
Simplex
Keratitis.

Herpes

EDEMA KORNEA

FLUORESCEIN POSITIF

INFILTRAT DENDRITIKA

KERATITIS MARGINAL
FLUORESCEIN POSITIF

KERATITIS
DENDRITIKA LUAS

ULKUS KORNEA

Fig. 5.2.
Pathology of
corneal ulcer :
A, stage of
progr
B, stage of
active
ulceration;
C, stage
ofessive
infiltration;
regression;
D, stage of
cicatrization

PENGOBATAN
Salep Mata
Antibiotika
Anti Virus
Anti Jamur.

Simtomatis : Midriatikum Mengurangi


Spasme Silier -- Rasa Nyeri Berkurang.
Bebat Mata :
Superinfeksi
Spasme Palpebra.

PERJALANAN PENYAKIT
Sembuh Tanpa Bekas
Jaringan Parut Pd Kornea Infiltrat padaStroma
Kornea.

LESI KORNEA

JARINGAN SIKATRIK PD KORNEA


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

Radan
g

Batas
Edema
kornea

Tidak jelas
+

Tegas
-

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 MENURUT
MERILL 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 FUNGAL
FILAMENTOSA

MYCOTIC KERATITIS

MYCOTIC KERATITIS

ULKUS KORNEA KRN VIRUS


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

AKIBAT VIRUS
HERPES 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 PENCETUS
KEKAMBUHAN

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 SIMPLEKS
DENDRITIKA

ULKUS GEOGRAPHIC

PENGOBATAN
1. 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
Dimmers 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

BANDAGE
LENSA KONTAK

KERATEKTASIA /
PENIPISAN KORNEA

NEOVASKULARISASI
STROMA

BANK MATA
BAGIAN 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 work
including promotional public relation activities and
enhancement of public awareness, tissue
harvesting,
tissue evaluation, tissue preservation, and tissue
distribution.

Operational Efficiency
Eye banking demands a very efficient round-theclock
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 bank


Mandatory 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 donors medical records
Check for the ocular and medical contraindications
Wash hands with alcohol or similar disinfectant
Put on protective clothingsurgical 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. Rabies
c. Active viral hepatitis
d. Creutzfeldt-Jakob disease.

2. Other contraindications:
a. Subacute sclerosing panencephalitis
b. Progressive multifocal leukoencephalopathy
c. Reyes syndrome
d. Death from unknown cause including unknown
encephalitis
e. Congenital rubella
f. Active septicemia including endocarditis
g. Acquired immunodeficiency high risk behavioral
features including homosexuals, intravenous drug
abusers, prostitutes and hemophilics
h. Leukemia (blast form)
i. Lymphoma and lymphosarcoma

II. Ocular
a. Intrinsic eye diseaseretinoblastoma, active
inflammatory disease (conjunctivitis, iritis,
uveitis,vitreitis, retinitis), congenital
abnormalities (keratoconus, keratoglobus),
central opacities and pterygium.
b. Prior refractive proceduresradial keratotomy
scars, lamellar inserts, laser photoablation.
c. Anterior segment surgical procedures
(cataract, glaucoma).

Preparation
Prepare the donor as per operating room standards.
Open the right eye with the help of a sterile cotton
tipped applicator or sterile hemostat and copiously
irrigate the conjunctiva sac with sterile saline. Repeat
the same procedure on the left eye using a new
cotton
tipped applicator or hemostat. After irrigation, clean
both sides of orbital area with alcohol swab/alcohol
gauze held in a sterile hemostat. Make sure alcohol
does not enter the eyes.

32.1A to F: Donor eye enucleation procedure. Following


360 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 Viability


Evaluation 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/mm2
2. Severe polymegathism or pleomorphism of the
endothelial cells
3. Presence of central cornea guttata
4. Abnormally shaped cells such as fused cells (these
cells are seen in stressed endothelium)
5. Abnormal single cell defects
6. Severe edema of endothelium
7. Presence of inflammatory cells or bacteria on
endothelium

Final cornea evaluation criteria


Excellent = rating 1
a. no epithelial defects
b. crystal clear stroma
c. no arcus senilis
d. no folds in Descemets membrane
e. excellent endotheliumno defects.

Very good = rating 2


a. slight epithelial haze or defects
b. clear stroma
c. very slight arcus
d. few light folds
e. very good to excellent endotheliumno
defects.

Good = rating 3
a. obvious moderate epithelial defects
b. light-to-moderate cloudiness
c. moderate arcus senilis < 2.5 mm
d. obvious folds (numerous but shallow)
e. few vacuolated cells.

Fair = rating 4
a. obvious epithelial defects (>60%)
b. moderate-to-heavy stromal cloudiness
c. heavy folds (numerous, deep, central)
d. heavy arcus senilis >2.5 mm
e. fair-to-good endotheliummoderate
endothelial defects, vacuolated cells,
low cell
density.

Poor
a. moderate vacuolated cells (some central)
b. severe stromal cloudiness
c. marked folds (heavy, numerous,central)
d. fair endotheliummarked defects, low cell
density, numerous central vacuolated cells
e. technical problems in removal.