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NIKA BELLARINATASARI
* EYELIDS DAN EYELASHES
* TEAR FILM
* OCULAR SURFACE EPITHELIUM
* NORMAL FLORA
* TEAR PROTEIN

*
Table 1. Ocular Host Defense Mechanisms

Nonspecific Ocular Defenses Specific Ocular Defenses


Eyelids Eye-associated lymphoid tissue
Tears Antigen-presenting Langerhans' cells
Ocular epithelium
Normal ocular bacterial flora Immunoglobulins
Mucin Classical complement cascade
Antibacterial factors T lymphocytes
Alternative complement cascade B lymphocytes
Natural killer cells
Macrophages
* EYELIDS DAN EYELASHES
* Cilia acts as sensors and influence lid closure
* An effective barrier to foreign material
* The sweeping action of lids cleans the ocular
surface by blinking action and by increasing
lacrimal pump activity (renew tear film)
* Meibomian glands contribute to tear film
stability
* TEAR FILM
* responsible for providing a smooth refractive
surface for clear vision
* maintaining the health of corneal and
conjunctival epithelia
* acting as the first line of defense against
microbial infections
* composed of three separate and distinct layers :
mucin, aqueous, and lipid.
* serves multiple functions in the nonspecific
defense against ocular infection.
* It bathes the ocular surface and provides a
mechanical barrier to adhesion by pathogenic
organisms (are flushed nasally toward the two
puncta by this highly efficient washing
mechanism).
* Mucin layer
* composed of mucin, immunoglobulins, urea, salts, glucose,
leukocytes, cellular debris, and enzymes.
* are high molecular weight glycoproteins that are heavily
glycosylated
* Mucins are classified as either membrane-associated or
secretory.
* Secretory mucins are further divided into two groups: large
gel-forming mucins or small soluble mucins.
* Membrane-associated mucins form the glycocalyx, a dense
barrier to pathogen penetrance, at the epithelial celltear
film interface
* epidermal growth factor (EGF)-like domains on the
membrane associated mucins suggests a potential role in
the regulation of epithelial cell growth
* Ocular mucins are thought to serve a protective role; the
mucins trap pathogenic microorganisms until they are
swept to the inner canthus by the blinking action of the
eyelids.

* Mucins, by their nature, may also serve as a matrix within


which secretory IgA and other antibacterial factors are
concentrated

* The majority of ocular mucins are produced by


* the conjunctival goblet cells
* the stratified squamous epithelium of the cornea and
conjunctiva
* the lacrimal gland
* Aqueous Layer
* consists of water, electrolytes, proteins,
peptide growth factors, immunoglobulins,
cytokines, vitamins, antimicrobials, and
hormones secreted by the lacrimal glands
* Electrolytes present in the tear film include sodium,
potassium, magnesium, calcium, chloride, bicarbonate,
and phosphate ions.
* The electrolytes are responsible for the osmolarity of
tears, acting as a buffer to maintain a constant pH and
contribute to maintaining epithelial integrity of the
ocular surface.
* An increase in osmolarity of the aqueous layer is a global
feature of dry eye syndrome and damages the ocular
surface directly and indirectly by triggering
inflammation.
* The primary defense system of the ocular surface is
composed of the nonspecific immunity conferred by
lysozyme, lactoferrin, -lysin, complement, defensins,
and group II phospholipase A2 and the specific immunity
of antibodies, such as secretory immunoglobulin A (sIgA).
* Lipid layer
* The anterior layer of the tear film is composed of
meibomian oil secreted by the meibomian glands and is the
major barrier to evaporation from the ocular surface.
* The lipid layer is also responsible for
* providing stability to the tear film through interaction with the
aqueous-mucin phase,
* providing a smooth optical surface for the cornea, and
* acting as a barrier against foreign particles (to trap microbes
and efficiently flush them into the lacrimal excretory system)
* composed of two phases: a polar surfactant phase overlaid
by a nonpolar phase.
* The polar lipid phase, primarily composed of phospholipids
and glycolipids, is multifunctional.
* The nonpolar phase (mainly composed of wax, cholesterol
esters, and triglycerides) provides the air-tear film interface
and is responsible for retarding evaporation.
Table 2. The Tear Film

Component Function
Flushing action Mechanical removal of pathogens
Mucin Prevents pathogen binding to ocular surface, traps microbes for
removal via lacrimal drainage
Lactoferrin Iron-binding protein, interferes with pathogen metabolism
Ceruloplasmin Copper-binding protein
-lysin Attacks bacterial membranes
Lysozyme Hydrolyzes bacterial cell wall peptidoglycan
Cytokines Regulation of immune responses, recruitment and activation of
phagocytic cells
Complement Opsonization of pathogens, attacks pathogen membranes, recruitment
of immune cells
Immunoglobulins Opsonization of pathogens, blocks pathogen binding to ocular surface,
neutralization of toxins
Phospholipase A2 Attacks pathogen membrane phospholipids
Defensins Inhibits pathogen growth
Component Function
Lysozyme Antibacterial, inh of C-convertase
Peroxidase Bactericidal, virucidal, fungicidal
Tear film specific prealbumin Enhances lyzozyme activity
Fibronectin Facilitates phagocytosis
Collagenase Collagen degradation
Sial Binds microorganisms
Plasminogen-activator Chemoattractant
Alpha 1-antitrypsin Modulation of tissue-degrading enzymes
Alpha 1-antichymotrypsin Modulation of tissue-degrading enzymes
Alpha 2-macroglobulin Protease inhibitor
Nitric oxide Antibacterial, antiviral
Defensins alpha and beta 1 Constitutively expressed & inducible
and 2 naturally occurring antimicrbial peptides
Antibodies (IgA, S-IgA, IgG, Opsonization, agglutination, histamin &
IgM, IgE) slow release components (MHC class I)
* OCULAR SURFACE EPITHELIUM
* prevents intraocular penetration by most
microorganisms.
* This nonkeratinized squamous epithelium, consisting of
five to six cell layers, is supported by a columnar basal
layer.
* The basement membrane, with its numerous junctional
complexes, presents a nearly impermeable anatomic
barrier.
* The outermost layer of the corneal epithelium is covered
by a layer of glycocalyx over which lies a layer of mucus.
* This glycocalyx serves as a scaffold that binds mucin,
antibodies, and other tear film components
* OCULAR MUCOSAL IMMUNITY
* Conjunctiva, lacrimal system, etc
* mucosa-associated lymphoid tissue (MALT) comprises an
important component
* MALT, by definition, consists of clusters (follicles) of
lymphatic cells situated within and beneath the epithelium
of a mucosal surface
* These follicles detect antigen and are capable of inducing
both cellular and humoral immune responses.
* MALT follicles possess professional antigen-presenting cells
(i.e., macrophages) and are the source of many secreted
antimicrobial compounds and cytokines.
* conjunctiva-associated lymphoid tissue (CALT)
revealed the presence of discreet follicles with
germinal centers, close interactions between
lymphocytes and surface lymphoepithelium,
layers of IgA+ plasma cells in the lamina propria,
and high endothelial venules
* lacrimal drainage-associated lymphoid tissue
(LDALT) and lacrimal gland-associated lymphoid
tissue (LGALT) have revealed the presence of
IgA+ plasma cells, T lymphocytes, major
histocompatibility complex (MHC) class II-
positive cells, and distinct lymphoid follicles
* eye-associated lymphoid tissue (EALT)
* NORMAL OCULAR MICROFLORA
* serve a protective role in inhibiting colonization by
more pathogenic species

* The normal flora described previously are ironically the


most frequent causes of many ocular infectious
diseases, which demonstrates the delicate balance of
host-parasite relationships in the external ocular
microenvironment

* The spectrum of normal ocular flora varies with the age


and even the geographic locale of the host
* TEAR PROTEINS
* Lysozyme
* bacteriostatic and bactericidal activity against a wide range of
primarily gram-positive bacteria
* facilitates the breakdown of bacterial cell wall peptidoglycan
* approximately 30% to 40% of total tear protein
* Is synthesized by acinar cells of the lacrimal gland
* may potentiate the antibacterial activity of complement in
conjunction with secretory IgA
* Phospholipase A2
* the most active component
* attacks the phospholipids of bacterial membranes.
* is found in mucous secretions at other body sites and is known
to be produced by leukocytes
* Betalysin
* The target of -lysin is generally considered to be
the bacterial lipid membrane
* -lysin is known to act synergistically with
lysozyme.
* Synthesized primarily by platelets, its presence in
the ocular tear film is thought to be due to leakage
from serum
* Dll (lactoferrin, complement, Ig, cytokines)
* CORNEA
* EYE ASSOCIATED LYMPHOID TISSUE

*
* CORNEA
* The central cornea is considered to be relatively devoid
of immune cells because of the absence of lymphatic
vessels
* The peripheral limbal cornea is primarily populated by
Langerhans' cells, a type of dendritic cells that plays a
role in antigen processing
* Following corneal injury, surgery, or infection, migration
of immune cells into the central cornea can occur; this is
presumably the result of production of chemotactic
substances at the site of infection or injury, including
pathogen-derived components as well as proinflammatory
mediators secreted from corneal epithelial cells and
fibroblasts
* CONJUNCTIVA
* contains immunoglobulins and a few
polymorphonuclear leukocytes (neutrophils),
lymphocytes, macrophages, plasma cells, and mast
cells within the subepithelial tissue.
* In addition, the conjunctival stroma has its own
endowment of dendritic antigen-presenting cells
(APCs).
* The epithelium contains a special subpopulation of
dendritic APCs known as Langerhans cells, which
are capable of both antigen uptake and priming
(sensitizing) of naive antigen-inexperienced T
lymphocytes.
* the conjunctiva has a plentiful supply of lymphatic
vessels, which facilitate the trafficking of immune
cells and antigens to the draining lymph nodes,
where the adaptive immune response is generated.
* EYE-ASSOCIATED LYMPHOID TISSUE
* the conjunctiva and lacrimal drainage system
may constitute an important arm of the common
mucosal immune system and are capable of
participating in both afferent and efferent
immunologic responses.
* Macrophages is the major nonspecific cellular
constituent of ocular mucosal lymphoid tissue
* The role of ocular mucosal macrophages in
protection against viral infection of the cornea
* Conjunctival and lacrimal tissues are rich in T
and B lymphocytes
* HUMORAL INTRAOCULAR DEFENSES
* CELLULAR INTRAOCULAR DEFENSES

*
* HUMORAL INTRAOCULAR DEFENSES
* The blood-ocular barrier prevents the free passage of
most large molecules from the bloodstream into the
aqueous and vitreous humor. As a result, levels of soluble
immunologic components within the fluid-filled spaces of
the eye are relatively low
* The humoral factors, leak into the inferior of the eye
following inflammatory perturbation of the blood-ocular
barrier and perform their natural antimicrobial function
* Unfortunately, unchecked intraocular complement
activation has the potential to damage sensitive
intraocular tissues such as the retina.
* CELLULAR INTRAOCULAR DEFENSES
* The aqueous and vitreous humor are not
normally populated by immune cells
* the roles of intraocular macrophages and
dendritic cells (distributed in the stroma of the
iris, stroma of the ciliary body, and
perivascularly within the choroid) in typical
innate immunity and/or presentation of
microbial antigens remain poorly defined.
* Mast cells, eosinophils, lymphocytes (T cells &
NK cells) intraocular tissue unclear
*

NIKA BELLARINATASARI
* The organism has to penetrate into the eye
* It can be facilitated by an epithelial defect or
be due to a contaminated contact lens or
direct corneal trauma.
* For invasion of the corneal stroma to occur, the
organism must first adhere to the epithelium
* The organism must proliferate to establish
sufficient numbers of cells to overcome host
defenses
* The virulence of the organism also dictates the
outcome for the patient.
* This usually relates to the production of lethal
toxins, by the bacterium, which are quickly
effective at causing tissue necrosis
* The initiation, severity, and characteristics of
subsequent infection are influenced by the interplay
between the virulence of the pathogen, the size of the
inoculum, and the competence and nature of host
defense mechanisms.
* Successful infection of ocular tissues requires
microorganisms to adhere, evade, invade, replicate,
and persist, inoculum.
* The epithelium of the ocular surface forms a
mechanical barrier against microbial invasion.
* Phagocytosis and subsequent digestion of bacteria,
combined with rapid cycling of epithelial cells, aid
in the removal of microbes.
* Antigen-presenting cells such as Langerhans cells in
the conjunctiva carry antigen to regional lymphatic
tissue and facilitate an acquired immune response.
* In response to microbial invasion, ocular surface
epithelial cells secrete interleukin-I (IL-I) and other
cytokines that boost the local immune response
through the enhancement of immune-cell
migration, adhesion, and activation.
* Human conjunctiva contains a complete spectrum of
immunologically competent cell types.
* Uninfected conjunctival epithelium possesses CD8+
cytotoxic/suppressor T lymphocytes and Langerhans
cells.
* Conjunctival substantia propria contains CD4+ helper T
cells and CD8+ T cells in roughly equal numbers, along
with natural killer T cells, mast cells, B lymphocytes,
plasma cells, macrophages, and occasional
polymorphonuclear leukocytes.
* Hyperplasia of conjunctival lymphoid follicles and
painful swelling of draining preauricular lymph nodes
accompany conjunctival infection by viruses,
Chlamydia, and Neisseria species.
* The vascular and lymphatic channels of the
conjunctiva transport humoral and cellular immune
components to and from the eye.
* During an infection, inflammatory mediators promote
vascular dilation, permeability, and diapedesis from
conjunctival blood vessels.
* The healthy cornea has classically been
considered devoid of leukocytes, but activated
Langerhans cells and other dendritic cells
normally present in the peripheral corneal
epithelium can migrate rapidly to the central
cornea.
* Upon infection, the constitutive cells of the
cornea, the keratocytes in particular, augment
the inflammatory cascade by the secretion of
proinflammatory cytokines.
* Lymphocytes and neutrophils are recruited into
the cornea from the tear film , the limbal
vascular arcades, and the anterior chamber.
*
* VISION
* PAIN
* FOREIGN BODY SENSATION
* PHOTOPHOBIA
* TEARING
* RED EYE
* SWELLING
* ITCHY
* DISCHARGE

*
* VISION
* Visual impairment occurs when corneal inflammatory
disease results in infiltration/edema affecting the
clarity of cornea and obstructing the visual axis
* PAIN
* The origin of pain is either from exposed,
irritatrd, or inflamed corneal nerves or from a
spasm of the sphincter muscles of the iris or
ciliary body
* PHOTOPHOBIA
* More often due to irritable corneal nerve endings
* Is a reflex reaction mediated by N.V (afferent)
and N. VII (efferent) to lids
* TEARING
* Is a reflex reaction of lacrimal and accessory
glands
* To dilute and wash away any foreign matter
* RED EYE
* SWELLING
* HYPEREMIA CONJUNCTIVA
* CHEMOSIS
* EDEMA
* PAPILLA CONJUNCTIVA
* FOLLICLE CONJUNCTIVA
* DISCHARGE
* FIBROVASCULAR FIBER
* DLL

*
CONJUNCTIVAL PAPILLA
MILD PAPILLA

MODERATE PAPILLA

SEVERE PAPILLA/
COBBLESTONE
INFILTRATE CORNEA

CORNEAL ULCER WITH


HYPOPION

CORNEAL ULCER
PERFORATED
NEBULA

MAKULA

LEKOMA
CONJUCTIVAL FOLLICLE
CONJUCTIVAL INJECTION

CILIAR INJECTION
FOAMY DISCHARGE

CHEMOSIS
OEDEMA PALPEBRAE

FIBROVASCULAR FIBER
POSTERIOR SYNECHIAE

KERATIC PERCIPITATE
MATURE CATARACT

IMMATURE CATARACT