Cornea

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Cornea
Cornea.png
Schematic diagram of the human eye showing the cornea as separated from the sclera by the corneal limbus
Details
Part ofFront of eye
System Visual system
Identifiers
Latin cornea
MeSH D003315
TA A15.2.02.012
FMA 58238
Anatomical terminology

The cornea is the transparent front part of the eye that covers the iris, pupil, and anterior chamber. The cornea, with the anterior chamber and lens, refracts light, with the cornea accounting for approximately two-thirds of the eye's total optical power. [1] [2] In humans, the refractive power of the cornea is approximately 43 dioptres. [3] The cornea can be reshaped by surgical procedures such as LASIK. [4]

Human eye mammalian eye; part of the visual organ of the human body, and move using a system of six muscles

The human eye is an organ which reacts to light and pressure. As a sense organ, the mammalian eye allows vision. Human eyes help to provide a three dimensional, moving image, normally coloured in daylight. Rod and cone cells in the retina allow conscious light perception and vision including color differentiation and the perception of depth. The human eye can differentiate between about 10 million colors and is possibly capable of detecting a single photon.

Iris (anatomy) part of an eye

In humans and most mammals and birds, the iris is a thin, circular structure in the eye, responsible for controlling the diameter and size of the pupil and thus the amount of light reaching the retina. Eye color is defined by that of the iris. In optical terms, the pupil is the eye's aperture, while the iris is the diaphragm.

Pupil part of an eye

The pupil is a hole located in the center of the iris of the eye that allows light to strike the retina. It appears black because light rays entering the pupil are either absorbed by the tissues inside the eye directly, or absorbed after diffuse reflections within the eye that mostly miss exiting the narrow pupil.

Contents

While the cornea contributes most of the eye's focusing power, its focus is fixed. Accommodation (the refocusing of light to better view near objects) is accomplished by changing the geometry of the lens. Medical terms related to the cornea often start with the prefix " kerat- " from the Greek word κέρας, horn.

Accommodation (eye) focusing ability of eye

Accommodation is the process by which the vertebrate eye changes optical power to maintain a clear image or focus on an object as its distance varies. In this, distances vary for individuals from the far point—the maximum distance from the eye for which a clear image of an object can be seen, to the near point—the minimum distance for a clear image.

Ancient Greek Version of the Greek language used from roughly the 9th century BCE to the 6th century CE

The Ancient Greek language includes the forms of Greek used in Ancient Greece and the ancient world from around the 9th century BCE to the 6th century CE. It is often roughly divided into the Archaic period, Classical period, and Hellenistic period. It is antedated in the second millennium BCE by Mycenaean Greek and succeeded by medieval Greek.

Structure

The cornea has unmyelinated nerve endings sensitive to touch, temperature and chemicals; a touch of the cornea causes an involuntary reflex to close the eyelid. Because transparency is of prime importance, the healthy cornea does not have or need blood vessels within it. Instead, oxygen dissolves in tears and then diffuses throughout the cornea to keep it healthy. [5] Similarly, nutrients are transported via diffusion from the tear fluid through the outside surface and the aqueous humour through the inside surface, and also from neurotrophins supplied by nerve fibres that innervate it. In humans, the cornea has a diameter of about 11.5 mm and a thickness of 0.5–0.6 mm in the center and 0.6–0.8 mm at the periphery. Transparency, avascularity, the presence of immature resident immune cells, and immunologic privilege makes the cornea a very special tissue.

Nerve enclosed, cable-like bundle of axons in the peripheral nervous system

A nerve is an enclosed, cable-like bundle of nerve fibres called axons, in the peripheral nervous system. A nerve provides a common pathway for the electrochemical nerve impulses called action potentials that are transmitted along each of the axons to peripheral organs or, in the case of sensory nerves, from the periphery back to the central nervous system. Each axon within the nerve is an extension of an individual neuron, along with other supportive cells such as Schwann cells that coat the axons in myelin.

Eyelid thin fold of skin that covers and protects the human eye

An eyelid is a thin fold of skin that covers and protects the human eye. The levator palpebrae superioris muscle retracts the eyelid, exposing the cornea to the outside, giving vision. This can be either voluntarily or involuntarily. The human eyelid features a row of eyelashes along the eyelid margin, which serve to heighten the protection of the eye from dust and foreign debris, as well as from perspiration. "Palpebral" means relating to the eyelids. Its key function is to regularly spread the tears and other secretions on the eye surface to keep it moist, since the cornea must be continuously moist. They keep the eyes from drying out when asleep. Moreover, the blink reflex protects the eye from foreign bodies.

Blood vessel a tubular structure which carries blood

The blood vessels are the part of the circulatory system, and microcirculation, that transports blood throughout the human body. These vessels are designed to transport nutrients and oxygen to the tissues of the body. They also take waste and carbon dioxide and carry them away from the tissues and back to the heart. Blood vessels are needed to sustain life as all of the body’s tissues rely on their functionality.There are three major types of blood vessels: the arteries, which carry the blood away from the heart; the capillaries, which enable the actual exchange of water and chemicals between the blood and the tissues; and the veins, which carry blood from the capillaries back toward the heart. The word vascular, meaning relating to the blood vessels, is derived from the Latin vas, meaning vessel. Some structures -- such as cartilage, the epithelium, and the lens and cornea of the eye -- do not contain blood vessels and are labeled avascular.

The most abundant soluble protein in mammalian cornea is albumin. [6]

Albumin family of globular proteins

The albumins are a family of globular proteins, the most common of which are the serum albumins. All the proteins of the albumin family are water-soluble, moderately soluble in concentrated salt solutions, and experience heat denaturation. Albumins are commonly found in blood plasma and differ from other blood proteins in that they are not glycosylated. Substances containing albumins, such as egg white, are called albuminoids.

The human cornea borders with the sclera via the corneal limbus. In lampreys, the cornea is solely an extension of the sclera, and is separate from the skin above it, but in more advanced vertebrates it is always fused with the skin to form a single structure, albeit one composed of multiple layers. In fish, and aquatic vertebrates in general, the cornea plays no role in focusing light, since it has virtually the same refractive index as water. [7]

Sclera

The sclera, also known as the white of the eye, is the opaque, fibrous, protective, outer layer of the human eye containing mainly collagen and some elastic fiber. In humans, the whole sclera is white, contrasting with the coloured iris, but in other mammals the visible part of the sclera matches the colour of the iris, so the white part does not normally show. In the development of the embryo, the sclera is derived from the neural crest. In children, it is thinner and shows some of the underlying pigment, appearing slightly blue. In the elderly, fatty deposits on the sclera can make it appear slightly yellow. Many people with dark skin have naturally darkened sclerae, the result of melanin pigmentation.

Corneal limbus

The corneal limbus is the border of the cornea and the sclera. The limbus is a common site for the occurrence of corneal epithelial neoplasm. The limbus contains radially-oriented fibrovascular ridges known as the palisades of Vogt that may harbour a stem cell population. The palisades of Vogt are more common in the superior and inferior quadrants around the eye. Aniridia, a developmental anomaly of the iris, disrupts the normal barrier of the cornea to the conjunctival epithelial cells at the limbus.

Lamprey order of vertebrates, the lampreys

Lampreys are an ancient, extant lineage of jawless fish of the order Petromyzontiformes, placed in the superclass Cyclostomata. The adult lamprey may be characterized by a toothed, funnel-like sucking mouth. The common name "lamprey" is probably derived from Latin lampetra, which may mean "stone licker", though the etymology is uncertain.

Microanatomy

Vertical section of human cornea from near the margin. (Waldeyer.) Magnified. #Epithelium. #Anterior elastic lamina. #substantia propria. #Posterior elastic lamina (Descemet's membrane). #Endothelium of the anterior chamber. #* a. Oblique fibers in the anterior layer of the substantia propria. #* b. Lamellae the fibers of which are cut across, producing a dotted appearance. #* c. Corneal corpuscles appearing fusiform in section. #* b. Lamellae the fibers of which are cut longitudinally. #* d. Transition to the sclera, with more distinct fibrillation, and surmounted by a thicker epithelium. #* e. Small bloodvessels cut across near the margin of the cornea. Vertical section human cornea-Gray871.png
Vertical section of human cornea from near the margin. (Waldeyer.) Magnified. #Epithelium. #Anterior elastic lamina. #substantia propria. #Posterior elastic lamina (Descemet's membrane). #Endothelium of the anterior chamber. #* a. Oblique fibers in the anterior layer of the substantia propria. #* b. Lamellæ the fibers of which are cut across, producing a dotted appearance. #* c. Corneal corpuscles appearing fusiform in section. #* b. Lamellæ the fibers of which are cut longitudinally. #* d. Transition to the sclera, with more distinct fibrillation, and surmounted by a thicker epithelium. #* e. Small bloodvessels cut across near the margin of the cornea.

The human cornea has five layers (possibly six, if the Dua's layer is included). [8] Corneas of other primates have five known layers. The corneas of cats, dogs, wolves, and other carnivores only have four. [9] From the anterior to posterior the layers of the human cornea are:

Dua's layer, according to a 2013 paper by Harminder Singh Dua's group at the University of Nottingham, is a layer of the cornea that had not been detected previously. It is hypothetically 15 micrometres thick, the fourth caudal layer, and located between the corneal stroma and Descemet's membrane. Despite its thinness, the layer is very strong and impervious to air. It is strong enough to withstand up to 2 bars of pressure. While some scientists welcomed the announcement, other scientists cautioned that time was needed for other researchers to confirm the discovery and its significance. Others have met the claim "with incredulity". The choice of the name Dua's Layer has also been criticized.

Primate An order of mammals

A primate is a eutherian mammal constituting the taxonomic order Primates. Primates arose 85–55 million years ago from small terrestrial mammals (Primatomorpha), which adapted to living in the trees of tropical forests: many primate characteristics represent adaptations to life in this challenging environment, including large brains, visual acuity, color vision, altered shoulder girdle, and dexterous hands. Primates range in size from Madame Berthe's mouse lemur, which weighs 30 g (1 oz), to the eastern gorilla, weighing over 200 kg (440 lb). There are 190–448 species of living primates, depending on which classification is used. New primate species continue to be discovered: over 25 species were described in the first decade of the 2000s, and eleven since 2010.

  1. Corneal epithelium : an exceedingly thin multicellular epithelial tissue layer (non-keratinized stratified squamous epithelium) of fast-growing and easily regenerated cells, kept moist with tears. Irregularity or edema of the corneal epithelium disrupts the smoothness of the air/tear-film interface, the most significant component of the total refractive power of the eye, thereby reducing visual acuity. It is continuous with the conjunctival epithelium, and is composed of about 6 layers of cells which are shed constantly on the exposed layer and are regenerated by multiplication in the basal layer.
  2. Bowman's layer (also known as the anterior limiting membrane): when discussed in lieu of a subepithelial basement membrane, Bowman's Layer is a tough layer composed of collagen (mainly type I collagen fibrils), laminin, nidogen, perlecan and other HSPGs that protects the corneal stroma. When discussed as a separate entity from the subepithelial basement membrane, Bowman's Layer can be described as an acellular, condensed region of the apical stroma, composed primarily of randomly organized yet tightly woven collagen fibrils. These fibrils interact with and attach onto each other. This layer is eight to 14 micrometres (μm) thick [10] and is absent or very thin in non-primates. [9] [11]
  3. Corneal stroma (also substantia propria): a thick, transparent middle layer, consisting of regularly arranged collagen fibers along with sparsely distributed interconnected keratocytes, which are the cells for general repair and maintenance. [10] They are parallel and are superimposed like book pages. The corneal stroma consists of approximately 200 layers of mainly type I collagen fibrils. Each layer is 1.5-2.5 μm. Up to 90% of the corneal thickness is composed of stroma. [10] There are 2 theories of how transparency in the cornea comes about:
    1. The lattice arrangements of the collagen fibrils in the stroma. The light scatter by individual fibrils is cancelled by destructive interference from the scattered light from other individual fibrils. [12]
    2. The spacing of the neighboring collagen fibrils in the stroma must be < 200 nm for there to be transparency. (Goldman and Benedek)
  4. Descemet's membrane (also posterior limiting membrane): a thin acellular layer that serves as the modified basement membrane of the corneal endothelium, from which the cells are derived. This layer is composed mainly of collagen type IV fibrils, less rigid than collagen type I fibrils, and is around 5-20 μm thick, depending on the subject's age. Just anterior to Descemet's membrane, a very thin and strong layer, Dua's layer, 15 microns thick and able to withstand 1.5 to 2 bars of pressure. [13]
  5. Corneal endothelium : a simple squamous or low cuboidal monolayer, approx 5 μm thick, of mitochondria-rich cells. These cells are responsible for regulating fluid and solute transport between the aqueous and corneal stromal compartments. [14] (The term endothelium is a misnomer here. The corneal endothelium is bathed by aqueous humor, not by blood or lymph, and has a very different origin, function, and appearance from vascular endothelia.) Unlike the corneal epithelium, the cells of the endothelium do not regenerate. Instead, they stretch to compensate for dead cells which reduces the overall cell density of the endothelium, which affects fluid regulation. If the endothelium can no longer maintain a proper fluid balance, stromal swelling due to excess fluids and subsequent loss of transparency will occur and this may cause corneal edema and interference with the transparency of the cornea and thus impairing the image formed. [14] Iris pigment cells deposited on the corneal endothelium can sometimes be washed into a distinct vertical pattern by the aqueous currents - this is known as Krukenberg's Spindle.

Nerve supply

The cornea is one of the most sensitive tissues of the body, as it is densely innervated with sensory nerve fibres via the ophthalmic division of the trigeminal nerve by way of 70–80 long ciliary nerves. Research suggests the density of pain receptors in the cornea is 300-600 times greater than skin and 20-40 times greater than dental pulp, [15] making any injury to the structure excruciatingly painful. [16]

The ciliary nerves run under the endothelium and exit the eye through holes in the sclera apart from the optic nerve (which transmits only optic signals). [10] The nerves enter the cornea via three levels; scleral, episcleral and conjunctival. Most of the bundles give rise by subdivision to a network in the stroma, from which fibres supply the different regions. The three networks are, midstromal, subepithelial/sub-basal, and epithelial. The receptive fields of each nerve ending are very large, and may overlap.

Corneal nerves of the subepithelial layer terminate near the superficial epithelial layer of the cornea in a logarithmic spiral pattern. [17] The density of epithelial nerves decreases with age, especially after the seventh decade. [18]

Function

Refraction

The optical component is concerned with producing a reduced inverted image on the retina. The eye's optical system consists of not only two but four surfaces—two on the cornea, two on the lens. Rays are refracted toward the midline. Distant rays, due to their parallel nature, converge to a point on the retina. The cornea admits light at the greatest angle. The aqueous and vitreous humors both have a refractive index of 1.336-1.339, whereas the cornea has a refractive index of 1.376. Because the change in refractive index between cornea and aqueous humor is relatively small compared to the change at the air–cornea interface, it has a negligible refractive effect, typically -6 dioptres. [10] The cornea is considered to be a positive meniscus lens. [19] In some animals, such as species of birds, chameleons and a species of fish, the cornea can also focus. [20]

Transparency

Upon death or removal of an eye the cornea absorbs the aqueous humor, thickens, and becomes hazy. Transparency can be restored by putting it in a warm, well-ventilated chamber at 31 °C (88 °F, the normal temperature), allowing the fluid to leave the cornea and become transparent. The cornea takes in fluid from the aqueous humor and the small blood vessels of the limbus, but a pump ejects the fluid immediately upon entry. When energy is deficient the pump may fail, or works too slowly to compensate, causing swelling. This could arise at death, but a dead eye can be placed in a warm chamber and the reservoirs of sugar and glycogen can keep the cornea transparent for at least 24 hours. [10]

The endothelium controls this pumping action, and as discussed above, damage thereof is more serious, and is a cause of opaqueness and swelling. When damage to the cornea occurs, such as in a viral infection, the collagen used to repair the process is not regularly arranged, leading to an opaque patch (leukoma). When a cornea is needed for transplant, as from an eye bank, the best procedure is to remove the cornea from the eyeball, preventing the cornea from absorbing the aqueous humor. [10]

Clinical significance

The most common corneal disorders are the following:

Management

Slit lamp image of the cornea, iris and lens (showing mild cataract) Cornea.jpg
Slit lamp image of the cornea, iris and lens (showing mild cataract)

Surgical procedures

Various refractive eye surgery techniques change the shape of the cornea in order to reduce the need for corrective lenses or otherwise improve the refractive state of the eye. In many of the techniques used today, reshaping of the cornea is performed by photoablation using the excimer laser.

If the corneal stroma develops visually significant opacity, irregularity, or edema, a cornea of a deceased donor can be transplanted. Because there are no blood vessels in the cornea, there are also few problems with rejection of the new cornea.

There are also synthetic corneas (keratoprostheses) in development. Most are merely plastic inserts, but there are also those composed of biocompatible synthetic materials that encourage tissue ingrowth into the synthetic cornea, thereby promoting biointegration. Other methods, such as magnetic deformable membranes [21] and optically coherent transcranial magnetic stimulation of the human retina [22] are still in very early stages of research.

Other procedures

Orthokeratology is a method using specialized hard or rigid gas-permeable contact lenses to transiently reshape the cornea in order to improve the refractive state of the eye or reduce the need for eyeglasses and contact lenses.

In 2009, researchers at the University of Pittsburgh Medical center demonstrated that stem cell collected from human corneas can restore transparency without provoking a rejection response in mice with corneal damage. [23] For corneal epithelial diseases such as Stevens Johnson Syndrome, persistent corneal ulcer etc., the autologous contralateral (normal) suprabasal limbus derived in vitro expanded corneal limbal stem cells are found to be effective [24] as amniotic membrane based expansion is controversial. [25] For endothelial diseases, such as bullous keratopathy, cadaver corneal endothelial precursor cells have been proven to be efficient. Recently emerging tissue engineering technologies are expected to be capable of making one cadaver-donor's corneal cells be expanded and be usable in more than one patient's eye. [26] [27]

See also

Related Research Articles

Keratoconus corneal disease characterized by structural changes within the cornea causing it to thin and change, leading to a protruding conical shape

Keratoconus (KC) is a disorder of the eye which results in progressive thinning of the cornea. This may result in blurry vision, double vision, nearsightedness, astigmatism, and light sensitivity. Usually both eyes are affected. In more severe cases a scarring or a circle may be seen within the cornea.

Lens (anatomy) transparent structure of eye

The lens is a transparent, biconvex structure in the eye that, along with the cornea, helps to refract light to be focused on the retina. The lens, by changing shape, functions to change the focal distance of the eye so that it can focus on objects at various distances, thus allowing a sharp real image of the object of interest to be formed on the retina. This adjustment of the lens is known as accommodation. Accommodation is similar to the focusing of a photographic camera via movement of its lenses. The lens is more flat on its anterior side than on its posterior side.

Radial keratotomy

Radial keratotomy (RK) is a refractive surgical procedure to correct myopia (nearsightedness) that was developed in 1974, by Svyatoslav Fyodorov, a Russian ophthalmologist. It has been largely supplanted by newer operations, such as photorefractive keratectomy, LASIK, Epi-LASIK and the phakic intraocular lens.

Refractive surgery

Refractive eye surgery is an eye surgery used to improve the refractive state of the eye and decrease or eliminate dependency on glasses or contact lenses. This can include various methods of surgical remodeling of the cornea (keratomileusis), lens implantation or lens replacement. The most common methods today use excimer lasers to reshape the curvature of the cornea. Successful refractive eye surgery can reduce or cure common vision disorders such as myopia, hyperopia and astigmatism, as well as degenerative disorders like keratoconus.

Bowmans membrane

The Bowman's membrane is a smooth, acellular, nonregenerating layer, located between the superficial epithelium and the stroma in the cornea of the eye. It is composed of strong, randomly oriented collagen fibrils in which the smooth anterior surface faces the epithelial basement membrane and the posterior surface merges with the collagen lamellae of the corneal stroma proper.

Corneal endothelium

The corneal endothelium is a single layer of cells on the inner surface of the cornea. It faces the chamber formed between the cornea and the iris.

Corneal transplantation surgical procedure

Corneal transplantation, also known as corneal grafting, is a surgical procedure where a damaged or diseased cornea is replaced by donated corneal tissue. When the entire cornea is replaced it is known as penetrating keratoplasty and when only part of the cornea is replaced it is known as lamellar keratoplasty. Keratoplasty simply means surgery to the cornea. The graft is taken from a recently dead individual with no known diseases or other factors that may affect the chance of survival of the donated tissue or the health of the recipient.

Fuchs dystrophy corneal dystrophy characterized by accumulation of focal outgrowths (guttae) and thickening of Descemets membrane, leading to corneal edema and loss of vision

Fuchs' dystrophy, also referred to as Fuchs' corneal endothelial dystrophy (FCED) and Fuchs' endothelial dystrophy (FED), is a slowly progressing corneal dystrophy that usually affects both eyes and is slightly more common in women than in men. Although early signs of Fuchs' dystrophy are sometimes seen in people in their 30s and 40s, the disease rarely affects vision until people reach their 50s and 60s.

Corneal collagen cross-linking surgical treatment for corneal ectasia

Corneal collagen cross-linking with riboflavin (vitamin B2) and UV-A light is a surgical treatment for corneal ectasia such as keratoconus, PMD, and post-LASIK ectasia.

Descemets membrane

Descemet's membrane is the basement membrane that lies between the corneal proper substance, also called stroma, and the endothelial layer of the cornea. It is composed of different kinds of collagen than the stroma. The endothelial layer is located at the posterior of the cornea. Descemet's membrane, as the basement membrane for the endothelial layer, is secreted by the single layer of squamous epithelial cells that compose the endothelial layer of the cornea.

Corneal ulcers in animals

A corneal ulcer, or ulcerative keratitis, is an inflammatory condition of the cornea involving loss of its outer layer. It is very common in dogs and is sometimes seen in cats. In veterinary medicine, the term corneal ulcer is a generic name for any condition involving the loss of the outer layer of the cornea, and as such is used to describe conditions with both inflammatory and traumatic causes.

Corneal dystrophy human disease

Corneal dystrophy is a group of rare hereditary disorders characterised by bilateral abnormal deposition of substances in the transparent front part of the eye called the cornea.

Stroma of cornea The lamellated connective tissue of the cornea between the Bowman and Descemet membranes

The substantia propria is fibrous, tough, unyielding, and perfectly transparent.

Corneal ulcer is an inflammatory or more seriously, infective condition of the cornea involving disruption of its epithelial layer with involvement of the corneal stroma. It is a common condition in humans particularly in the tropics and the agrarian societies. In developing countries, children afflicted by Vitamin A deficiency are at high risk for corneal ulcer and may become blind in both eyes, which may persist lifelong. In ophthalmology, a corneal ulcer usually refers to having an infectious cause while the term corneal abrasion refers more to physical abrasions.

Bullous keratopathy Human disease

Bullous keratopathy is a pathological condition in which small vesicles, or bullae, are formed in the cornea due to endothelial dysfunction.

Ocular immune system

The ocular immune system protects the eye from infection and regulates healing processes following injuries. The interior of the eye lacks lymph vessels but is highly vascularized, and many immune cells reside in the uvea, including mostly macrophages, dendritic cells, and mast cells. These cells fight off intraocular infections, and intraocular inflammation can manifest as uveitis or retinitis. The cornea of the eye is immunologically a very special tissue. Its constant exposure to the exterior world means that it is vulnerable to a wide range of microorganisms while its moist mucosal surface makes the cornea particularly susceptible to attack. At the same time, its lack of vasculature and relative immune separation from the rest of the body makes immune defense difficult. Lastly, the cornea is a multifunctional tissue. It provides a large part of the eye’s refractive power, meaning it has to maintain remarkable transparency, but must also serve as a barrier to keep pathogens from reaching the rest of the eye, similar to function of the dermis and epidermis in keeping underlying tissues protected. Immune reactions within the cornea come from surrounding vascularized tissues as well as innate immune responsive cells that reside within the cornea.

Corneal keratocytes are specialized fibroblasts residing in the stroma. This corneal layer, representing about 85-90% of corneal thickness, is built up from highly regular collagenous lamellae and extracellular matrix components. Keratocytes play the major role in keeping it transparent, healing its wounds, and synthesizing its components. In the unperturbed cornea keratocytes stay dormant, coming into action after any kind of injury or inflammation. Some keratocytes underlying the site of injury, even a light one, undergo apoptosis immediately after the injury. Any glitch in the precisely orchestrated process of healing may cloud the cornea, while excessive keratocyte apoptosis may be a part of the pathological process in the degenerative corneal disorders such as keratoconus, and these considerations prompt the ongoing research into the function of these cells.

Herpes simplex keratitis keratitis that has material basis in herpes simplex type infection

Herpetic simplex keratitis is a form of keratitis caused by recurrent herpes simplex virus (HSV) infection in the cornea.

Pre Descemet’s endothelial keratoplasty (PDEK) is a kind of endothelial keratoplasty, where the pre descemet’s layer (PDL) along with descemet's membrane (DM) and endothelium is transplanted. Conventionally in a corneal transplantation, doctors use a whole cornea or parts of the five layers of the cornea to perform correction surgeries. In May 2013, Dr Harminder Dua discovered a sixth layer between the stroma and the descemet membrane which was named after him as the Dua's layer. In the PDEK technique, doctors take the innermost two layers of the cornea, along with the Dua's layer and graft it in the patient's eye.

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General references