Open access peer-reviewed chapter

In Vivo Biopsy of the Human Cornea

Written By

Akira Kobayashi, Hideaki Yokogawa and Kazuhisa Sugiyama

Submitted: July 6th, 2012 Reviewed: January 2nd, 2013 Published: March 20th, 2013

DOI: 10.5772/55657

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1. Introduction

The human cornea is the transparent, dome-shaped tissue that covers anterior segment of the eye. It consists of five thin layers: epithelium, Bowman’s layer, stroma, Descemet’s membrane and endothelium. Due to its transparency, real-time in vivoconfocal microscopic observation of the normal and diseased cornea was developed since the early 1990s.[1,2] Since histologic-like images are obtained by the device, it is called “painless biopsy” and/or “in vivobiopsy”. In this chapter, clinical application of in vivolaser confocal microscopy is demonstrated.


2. In vivolaser confocal microscopy

In 2005, cornea specific in vivolaser confocal microscopy (Heidelberg Retina Tomograph 2 Rostock Cornea Module, HRT2-RCM, Heidelberg Engineering GmbH, Dossenheim, Germany) has become available (Figure 1).[3,4] It has permitted detailed in vivolayer-by-layer observations of corneal microstructure with an axial resolution of nearly 1 μm. [4]

Figure 1.

Heidelberg Retina Tomograph 2 Rostock Cornea Module The device uses a 60× water-immersion objective lens (Olympus Europa GmbH, Hamburg, Germany) and utilizes a 670-nm diode laser as the light source with the area of observation 400μm square section.

Before examination, written informed consents are obtained from all patients; this includes possible consequences of this device such as superficial punctate keratopathy. A large drop of contact gel (Comfort Gel ophthalmic ointment®, Bosch & Lomb, GmbH, Berlin, German) is applied on the front surface of the microscope lens and ensuring no air bubbles had formed, a Tomo-cap® (Heidelberg Engineering GmbH, Dossenheim, Germany) is mounted on the holder to cover the microscope lens. Then, the center and peripheral cornea were examined layer by layer by in vivolaser confocal microscopy.


3. Normal human cornea and conjunctiva

In vivolaser confocal microscopy enables to visualize normal human cornea layer by layer: superficial epithelial cells, basal epithelial cells, Bowman’s layer with nerves, Bowman’s layer with K-structures (Kobayashi-structures), stroma and endothelial cells (Figure 2).[5,6] K-structures are fibrous structures with a diameter of 5 to 15 µm, and are considered to be anterior collagen fiber bundles running at the posterior surface of Bowman’s layer. [5] Mapping of the K-structure revealed that it showed mosaic pattern which is completely different from the whirl pattern of corneal nerves. [6]

In addition, conjuctival cells and meibomian glands are able to visualize in vivo(Figure 3).[7, 8]

Figure 2.

Normal human cornea. A. Superficial epithelial cells. B. Basal epithelial cells. C. Bowman’s layer with nerves. D. Bowman’s layer with K-structures (arrows). E. Stroma. F. Endothelial cells. (Bar=100µm)

Figure 3.

Normal human conjunctiva and meibomian glands. A. Conjuctival epithelium with Goblet cells (arrows). B. Sub-conjunctival fibrous tissue with conjunctival vessls (arrows). D. Palisade of Vogt of corneal limbus. D. Meibomian gland of the upper tarsus. (Bar=100µm)


4. Corneal infections

Acanthamoebais a ubiquitous, free-living amoeba found in water (swimming pool, hot tubs, tap water, contact lens solutions), air and soil, but Acanthamoebakeratitis is a relatively newly recognized entity: the first case was reported in 1974.[9] As the use of soft contact lenses increased in the early 1980s, the incidence of reported Acanthamoebakeratitis increased dramatically. Acanthamoebakeratitis is relatively uncommon but is a potentially blinding corneal infection. Clinical diagnosis is very difficult, especially in the early phase of the disease; it is often misdiagnosed and treated as a herpes simplex infection.[10] A definite diagnosis is made by confirmation of Acanthamoebain corneal lesions with direct examination, corneal biopsy or with culture; however, these methods are invasive, time-consuming, and are not always routinely available. The invasive methods are often postponed until there is a high index of suspicion for the disease and when there has been no response to treatments for bacterial, viral and/or fungal keratitis. [10] The usefulness of in vivowhite-light confocal microscopy in diagnosis and monitoring for improvement of Acanthamoebakeratitis has been reported. [11] In vivolaser confocal microscopy has also been shown to be useful in the early diagnosis of Acanthamoebakeratitis (Figure 4 A-C).[12-15] It is also reported that fungal hyphae can be well visualized by in vivolaser confocal microscopy.[16,17]

Figure 4.

Corneal infections. A. Slit-lamp photograph of the cornea withAcanthamoebakeratitis. Subepithelial opacities and numerous radial keratoneuritis lesions were observed. B. In the epithelial basal cell layer, numerous highly reflective, high-contrast round-shaped particles 10-20μm in diameter suggestive ofAcanthamoebacysts were detected byin vivolaser confocal microscopy. (Bar=50μm) C. Direct examination of the epithelial scraping with Parker ink-potassium hydroxide revealed Acanthamoeba cysts. Note that the cysts have double walls with characteristic wrinkled outer wall. (Bar=10μm) D. Slit-lamp photograph of the cornea withAspergilluskeratitis. Severe corneal ulcer was observed. E. In the stormal layer, numerous highly reflective, high-contrast branching filaments suggestive ofAspergillushyphae were detected byin vivolaser confocal microscopy. (Bar=50μm) F. Direct examination of the epithelial scraping revealedAspergillushyphae


5. Corneal dystrophies

In vivolaser confocal microscopy are proven useful to visualize pathological changes of corneal dystrophies in vivo(Figure 5) [18-20]. It is also useful to differentially diagnose confusing corneal dystrophies. Previously, considerable confusion exists clinically in distinguishing between Thiel-Behnke and Reis-Bücklers corneal dystrophy (Figure 5A, 5C). However, using in vivolaser confocal microscopy, unique and characteristic confocal images are readily obtained at the levels of Bowman’s layer; relatively highly reflective deposits in Thiel-Behnke dystrophy but extremely highly reflective deposits in Reis-Bücklers corneal dystrophy. The deposits in Thiel-Behnke corneal dystrophy had round-shaped edges with dark shadows, whereas the deposits in Reis-Bücklers corneal dystrophy did not have round-shaped edges but consisted of highly reflective small granular materials without any shadows (Figure 5B, 5D)[18]. It is also possible to differentially diagnose with corneal stromal dystrophies including Avellino (Figure 5E, 5F), lattice (Figure 5G, 5H), macular (Figure 5I, 5J) and Schnyder dystrophy (Figure 5K, 5L).[19, 20]

Figure 5.

Corneal dystrophies. A. Slit-lamp biomicroscopic photograph of Thiel-Behnke corneal dystrophy (TGFBIR555Q). Honeycomb-shaped gray opacities were observed at the level of Bowman’s layer. B.In vivolaser confocal microscopy showed focal deposition of homogeneous reflective materials with round-shaped edges in the basal epithelial layer. All deposits accompanied dark shadows. C. Slit-lamp biomicroscopic photograph of Reis-Bücklers corneal dystrophy (TGFBIR124L). Bilateral gray-white, amorphous opacities of various sizes at the level of Bowman’s layer were observed. D.In vivolaser confocal microscopy showed focal deposition of highly reflective irregular and granular materials in the basal epithelial layer. No deposits accompanied dark shadows. E. Slit-lamp biomicroscopic photograph of Avellino corneal dystrophy (TGFBIR124H) showed round gray-white deposits and scattered stellate opacities in the superficial and mid-stroma. F.In vivolaser confocal microscopy showed focal deposits of extremely highly reflective material with irregular edges in the stromal layer. G. Slit-lamp biomicroscopic photograph of lattice corneal dystrophy (TGFBIR124C) showed radially oriented thick lattice lines in the stroma. H.In vivolaser confocal microscopy showed highly reflective lattice-shaped materials in the stromal layer. I. Slit-lamp biomicroscopic photograph of macular corneal dystrophy (CHST6A217T) showed anterior and deep stromal opacities with indistinct borders that extend out to the corneal periphery. Some gray-white discrete deposits could be seen in the stroma. J.In vivolaser confocal microscopy showed homogeneous reflective materials with dark striae-like images. Normal keratocytes were not seen. K. Slit-lamp biomicroscopic photograph of Schnyder corenal dystrophy (UBIAD1N233H) showed dense anterior stromal disciform opacity with lipoid arcus. L.In vivolaser confocal microscopy showed numerous crystals with varying sizes were observed in the sub-epithelial stromal layer.


6. Cytomegalovirus corneal endotheliits/uveitis

Corneal endotheliitis, characterized by corneal edema associated with linear keratic precipitates and endothelial dysfunction, may be caused by herpes simplex virus, varicella zoster virus, or other viruses such as mumps. It often leads to irreversible corneal endothelial cell damage and severe visual disturbance. Most recently, cytomegalovirus (CMV) was recognized as a new etiologic factor for corneal endotheliitis [21-24]. Clinical manifestations of CMV endotheliitis are characterized by linear keratic precipitates associated with multiple coin-shaped lesions and local corneal stromal edema with minimal anterior chamber reactions. In vivolaser confocal microscopy is able to demonstrate the characteristic owl’s eye cells in the corneal endothelial cell layer (Figure 6). Owl’s eye cells are typically seen at autopsy or in biopsy specimens from the kidneys, lungs and other organs in cases of congenital or acquired CMV infection. By in vivolaser confocal microscopy, owl’s eye cells are readily seen in vivoas large corneal endothelial cells with an area of high reflection in the nucleus surrounded by a halo of low reflection. Therefore, owl’s eye cells may be a useful adjunct for the non-invasive diagnosis of CMV corneal endotheliitis [25].

Figure 6.

Owl’s eye cells in cytomegalovirus corneal endotheliitis. In vivolaser confocal microscopic photo showed numerous owl’s eye cells (arrows) in the corneal endothelial cell layer. (bar=100µm)


7. Post surgical anatomies

In vivolaser confocal microscopy is useful for visualization of post keratoplasty anatomies (Figure 7). Descemet’s stripping automated endothelial keratoplasty (DSAEK) is a new type of keratoplasty technique in which only posterior portion of the donor cornea is transplanted inside the eye. Since the donor is attached with air, no stitches are required; this enables maintaining much of the structural integrity of the cornea and induces minimal refractive change, suggesting distinct advantages over standard penetrating keratoplasty.[26] In vivolaser confocal microscopy analysis identified subclinical corneal abnormality after DSAEK with high resolution; this includes subepithelial haze, donor-recipient interface haze (Figure 8), and interface particles(Figure 8).[27, 28] Quantitative analysis showed that these postoperative hazes and particles decreased significantly over follow-up. [27, 28] The influence of these hazed on vision are still under investigation.

Figure 7.

Schema of DSAEK. Posterior portion of the donor cornea is transplanted inside the eye.

Figure 8.

In vivolaser confocal microscopy of donor-recipient interface after DSAEK. At the level of the donor-recipient interface, highly reflective particles and interface haze were observed(400×400μm).


8. Conclusion

In vivolaser confocal microscopy is able to identify histologic-like real time optical sectioning of the normal and diseased cornea/conjuctiva with high resolution. It is clinically useful in diagnosing Acanthamoebakeratitis, fungal keratitis, cytomegalovirus endotheliitis and corneal dystrophies. It is also useful to observe post surgical corneal anatomies. Further investigation using this device is required to understand in vivo histology of normal and diseased cornea/conjunctiva.


  1. 1. CavanaghH. DPetrollW. MAlizadehHHeY. GMcculleyJ. PJesterJ. VClinical and diagnostic use of in vivo confocal microscopy in patients with corneal disease. Ophthalmology199310010144454
  2. 2. KaufmanS. CMuschD. CBelinM. WCohenE. JMeislerD. MReinhartW. JUdellI. JVan MeterW. SConfocal microscopy: a report by the American Academy of Ophthalmology. Ophthalmology20041117396406
  3. 3. StaveJZinserGGrummerGGuthoffRDer modifizierte Heidelberg-Retina-Tomograph HRT. Erste ergebnisse einer in-vivo-darstellung von kornealen strukturen. [Modified Heidelberg Retinal Tomograph HRT. Initial results of in vivo presentation of corneal structures.] Ophthalmologe2002994276280In German.
  4. 4. EckardAStaveJGuthoffR. FIn vivo investigations of the corneal epithelium with the confocal Rostock Laser Scanning Microscope (RLSM). Cornea2006252127131
  5. 5. KobayashiAYokogawaHSugiyamaKIn vivo laser confocal microscopy of Bowman’s layer of the cornea. Ophthalmology.20061131222038
  6. 6. YokogawaHKobayashiASugiyamaKMapping of normal corneal K-structures by in vivo laser confocal microscopy. Cornea.2008278879883
  7. 7. KobayashiAYoshitaTSugiyamaKIn vivo findings of the bulbar/palpebral conjunctiva and presumed meibomian glands by laser scanning confocal microscopy. Cornea.2005248985988
  8. 8. KobayashiASugiyamaKIn vivo corneal confocal microscopic findings of palisades of Vogt and its underlying limbal stroma. Cornea.2005244435437
  9. 9. NagingtonJWatsonP. GPlayfairT. JPlayfairT. JMcgillJJonesB. RSteeleA. DAmoebic infection of the eye. Lancet19742789615371540
  10. 10. HammersmithK. MDiagnosis and management of Acanthamoeba keratitis. Curr Opin Ophthalmol.2006174327331Review.
  11. 11. WinchesterKMathersW. DSutphinJ. EDaleyT. EDiagnosis of Acanthamoeba keratitis in vivo with confocal microscopy. Cornea19951411017
  12. 12. MatsumotoYDogruMSatoE. AKatonoYUchinoYShimmuraSTsubotaKThe application of in vivo confocal scanning laser microscopy in the management of Acanthamoeba keratitis. Mol Vis.200713131926
  13. 13. KobayashiAIshibashiYOikawaYYokogawaHSugiyamaKIn vivo and ex vivo laser confocal microscopy findings in patients with early-stage acanthamoeba keratitis. Cornea.2008274439445
  14. 14. YokogawaHKobayashiAYamazakiNIshibashiYOikawaYTokoroMSugiyamaKBowman’s layer encystment in cases of persistent Acanthamoeba keratitis. Clin Ophthalmol.2012612451251
  15. 15. YamazakiNKobayashiAYokogawaHIshibashiYOikawaYTokoroMSugiyamaKEx vivo laser confocal microscopy findings of cultured Acanthamoeba trophozoites. Clinical Ophthalmol2012613651368
  16. 16. DasSSamantMGargPVaddavalliP. KVemugantiG. KRole of confocal microscopy in deep fungal keratitis. Cornea.20092811113
  17. 17. TakezawaYShiraishiANodaEHaraYYamaguchiMUnoTOhashiYEffectiveness of in vivo confocal microscopy in detecting filamentous fungi during clinical course of fungal keratitis. Cornea.2010291213461352
  18. 18. KobayashiASugiyamaKIn vivo laser confocal microscopy findings for Bowman’s layer dystrophies (Thiel-Behnke and Reis-Bücklers corneal dystrophies). Ophthalmology.200711416975
  19. 19. KobayashiAFujikiKFujimakiTMurakamiASugiyamaKIn vivo laser confocal microscopic findings of corneal stromal dystrophies. Arch Ophthalmol.2007125911681173
  20. 20. KobayashiAFujikiKMurakamiASugiyamaKIn vivo laser confocal microscopy findings and mutational analysis for Schnyder’s crystalline corneal dystrophy. Ophthalmology.2009116610291037
  21. 21. JapACheeS. PViral anterior uveitis. Curr Opin Ophthalmol.2011226483488Review.
  22. 22. KoizumiNYamasakiKKawasakiSSotozonoCInatomiTMochidaCKinoshitaSCytomegalovirus in aqueous humor from an eye with corneal endotheliitis. Am J Ophthalmol20061413564565
  23. 23. KoizumiNSuzukiTUnoTChiharaHShiraishiAHaraYInatomiTSotozonoCKawasakiSYamasakiKMochidaCOhashiYKinoshitaSCytomegalovirus as an etiologic factor in corneal endotheliitis. Ophthalmology20081152292297
  24. 24. CheeS. PBacsalKJapASe-thoeS. YChengC. LTanB. HClinical features of cytomegalovirus anterior uveitis in immunocompetent patients. Am J Ophthalmol.20081455834840
  25. 25. KobayashiAYokogawaHHigashideTNittaKSugiyamaKClinical significance of owl eye morphologic features by in vivo laser confocal microscopy in patients with cytomegalovirus corneal endotheliitis. Am J Ophthalmol.20121533445453
  26. 26. GorovoyM. SDescemet-Stripping Automated Endothelial Keratoplasty. Cornea2006258886889
  27. 27. KobayashiAMawatariYYokogawaHSugiyamaKIn vivo laser confocal microscopy after descemet stripping with automated endothelial keratoplasty. Am J Ophthalmol20081456977985
  28. 28. KobayashiAYokogawaHSugiyamaKIn vivo laser confocal microscopy after non-Descemet stripping automated endothelial keratoplasty. Ophthalmology2009116713061313

Written By

Akira Kobayashi, Hideaki Yokogawa and Kazuhisa Sugiyama

Submitted: July 6th, 2012 Reviewed: January 2nd, 2013 Published: March 20th, 2013