Textbook Corneal Transplantation 1St Edition Jesper Hjortdal Eds Ebook All Chapter PDF
Textbook Corneal Transplantation 1St Edition Jesper Hjortdal Eds Ebook All Chapter PDF
Textbook Corneal Transplantation 1St Edition Jesper Hjortdal Eds Ebook All Chapter PDF
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Jesper Hjortdal
Editor
Corneal
Transplantation
123
Corneal Transplantation
Jesper Hjortdal
Editor
Corneal Transplantation
Editor
Jesper Hjortdal
Department of Ophthalmology
Aarhus University Hospital
Aarhus
Denmark
Corneal transplantation has been performed for more than 100 years. Until 15
years ago the state-of-the art type of transplantation was penetrating kerato-
plasty, but since the start of this millennium, newly designed surgical tech-
niques have developed considerably. Today, the vast majority of keratoplasty
procedures are performed as delicate lamellar procedures either assisted with
fine microkeratomes or femtosecond lasers or using skilled surgical dissec-
tion procedures.
These advancements have helped patients undergoing keratoplasty to have
a much faster visual recovery and a more stable eye with less risk of rejection
episodes.
Besides covering updated chapters on penetrating keratoplasty, and ante-
rior and posterior lamellar procedures, this textbook also gives a thorough
overview of the history of corneal transplantation and a detailed presentation
of the microstructural components of the cornea essential to keratoplasty pro-
cedures. Corneal banking has changed over recent years as graft preparation
for anterior and posterior lamellar keratoplasty now often is performed within
the bank. Chapters have been devoted to description of graft registries, which
are an indispensable source of information of daily practices and outcomes,
and to economical evaluations of keratoplasty procedures. The optical conse-
quences of a keratoplasty procedure, especially in relation to simultaneous or
later cataract surgery, are discussed in addition to current methods for reduc-
ing post-keratoplasty astigmatism. Economic considerations on cost and ben-
efit of medical treatment and surgical procedures are today an integrated part
of the health system in many countries, and a chapter covers these aspects of
corneal transplantation.
This textbook is aimed at presenting an updated review of the new tech-
niques and to assist fellows and corneal surgeons in their advice and selection
of patients for the best surgical procedure considering benefits and risks.
v
Contents
vii
viii Contents
ix
x Contributors
Abstract
The concept of corneal transplantation is very old. However, it took
many centuries before this miraculous operation could be performed with
some success in both animals and humans. Knowledge of the history of
keratoplasty is obligatory for a better understanding of modern corneal
transplantation.
In the second half of the twentieth century, penetrating keratoplasty
became the gold standard in corneal transplantation. Good results became
more or less routine, due to a better knowledge of indications for treat-
ment, a better understanding and hence prevention and treatment of
allograft rejection and improvements in eye banking, operating micro-
scopes, instruments and suture materials.
The recent two decades have once more seen a paradigm shift towards
the selective replacement of only the diseased layers of the cornea. This
has resulted in a rapid rise in the popularity of (deep) anterior lamellar and
endothelial keratoplasty.
Keywords
History of keratoplasty • Corneal transplantation • Penetrating kerato-
plasty • Deep anterior lamellar keratoplasty (DALK) • Endothelial
keratoplasty (EK)
History of Keratoplasty
G. van Rij, MD, PhD, FEBOphth (*) In ancient times, cosmetical treatment of corneal
Department of Ophthalmology, scars had been performed by means of a tattoo-
Erasmus Medical Center, Rotterdam, like coloration of the scar. Lampblack or soot was
The Netherlands
e-mail: [email protected] used in old Egypt (±1500 BC), and copper sul-
phate reduced with nutgall was applied to achieve
B.T.H. van Dooren, MD, PhD
Department of Ophthalmology, reasonable cosmesis by Galenus (131–200 AD).
Amphia Hospital, Breda, The Netherlands In the eighteenth century, superficial removal of
scars was widely performed by surgeons in not introduced until 1846, chloroform anaesthe-
France and Germany [1]. The idea of removing sia in 1847 and topical cocaine anaesthesia in
scars from the cornea using a trephine was first 1858. His patient initially received more light in
proposed by Erasmus Darwin (the grandfather of his eye, but the cornea opacified and absorbed
Charles Darwin) in 1796 [2]. In 1789 Pellier De over a 2-week period [10]. The experiments on
Quengsy introduced his ideas on treating corneal corneal transplantation in humans and animals
opacification with what would now be called ker- conducted by Power, described in 1872, suffered
atoprosthesis, i.e. the replacement of opaque cor- the same fate [11].
neal tissue by man-made material. His concept Success in heterografting remained elusive
entailed an artificial cornea made from glass until the first successful lamellar heterograft in a
framed in silver [3]. Attempts in the second half human by Von Hippel. A leucoma corneae was
of the nineteenth century to actually treat patients excised from a young girl’s eye with Descemet’s
with artificial corneas, among others by von membrane and endothelium remaining, and a
Hippel and by Nussbaum, were not successful [4, rabbit cornea was transplanted into the wound
5]. The artificial cornea concept was in fact not bed. This procedure was performed in 1886 and
developed into a useful technique until 1963, was described in 1888 as the first in a series of 8
when among others Strampelli published on suc- lamellar operations, of which 4 were successful
cessful clinical application of keratoprostheses. [4]. Von Hippel performed anterior lamellar kera-
In Strampelli’s case, this was the osteo-odonto- toplasty because he felt that corneal transparency
keratoprosthesis, in which the optical element depended on the integrity of the corneal endothe-
was embedded in a biocompatible carrier made lium and Descemet’s membrane. Therefore, he
out of the patient’s own tooth and jawbone [1, 6]. abandoned full-thickness corneal grafts.
Recently the application of keratoprostheses It was not until 1905 that the first successful
made of artificial materials has increased, with penetrating homologous corneal graft was per-
variable results in patient groups with significant formed in a human patient. The Moravian oph-
high-risk eyes [7]. thalmologist Eduard Konrad Zirm transplanted a
The first widely known experiments with full- donor cornea obtained from an enucleated eye of
thickness tissue corneal transplantations in ani- a young boy into the eye of a 45-year-old labourer,
mals, conducted in 1818, either heterologous suffering from corneal scars caused by a chemi-
(between species a.k.a. xenografting) or homolo- cal lye injury. Zirm used general anaesthesia
gous (within species), are attributed to Reisinger. (chloroform) and strict asepsis [12].
He also introduced the term “keratoplasty” for Shortly thereafter, the concept of auto-
corneal transplantation [8]. Wars at the end of the keratoplasty or homograft was initiated. In this
eighteenth and the beginning of the nineteenth concept the donor cornea was harvested from the
centuries made corneal blindness from smallpox, patient itself: from the fellow, blind eye, as
venereal disease and “Egyptian ophthalmia” (tra- described by Plange [1], or as a rotational graft in
choma) prevalent. With this background, Bigger which a small corneal scar can be rotated out of
performed the first successful corneal transplan- the visual axis in the diseased eye, as described
tation in animals. In 1837, during his captivity in by Kraupa [5].
Egypt by Sahara Bedouins, he performed a Allografting, in which the donor cornea is har-
homograft on his captor’s pet gazelle which had vested from another individual of the same spe-
been blinded by a corneal wound [9]. cies, is currently the most commonly practised
Heterologous transplantations of animal tissue form of corneal transplantation. However, it took
into humans were then attempted. In 1838, the quite some time after Zirm, before reproducible
New York ophthalmologist and general practitio- results with penetrating corneal allografts were
ner Richard Sharp Kissam transplanted a pig’s obtained. First the operative technique and donor
cornea into a human patient. Kissam operated tissue preservation and preparation had to be fur-
without any anaesthesia. Ether anaesthesia was ther developed and standardised. Much work in
1 The History of Corneal Transplantation 3
this respect was done and published in the 1920s button of diseased cornea is replaced by full-
and 1930s by Elschnig from Tsjechia, Filatov thickness corneal donor tissue. A successful out-
from Russia, Tudor Thomas in the UK and come after a penetrating keratoplasty is a clear
Castroviejo in the USA [13–18]. Improvements graft with low astigmatism, providing a good
in lamellar transplant technique were achieved by visual acuity. Irregular and high regular astigma-
the French ophthalmologists Paufique et al. [19] tism are the most frequent visual acuity impair-
and Switzerland’s Franceschetti [20], from the ing complications after penetrating keratoplasty.
1930s through the 1950s, leading to a temporar- At present there are three forms of penetrating
ily renewed popularity of this treatment keratoplasty: traditional penetrating keratoplasty;
modality. anterior mushroom keratoplasty, with a wider
The biggest hazard to a successful penetrating anterior than posterior diameter; and top-hat (or
corneal graft is allograft rejection. Paufique posterior mushroom) keratoplasty, with a wider
described the concept of “maladie du greffon”, posterior than anterior diameter. A top-hat kera-
i.e. opacification of a previously clear cornea, toplasty is indicated in patients with both endo-
which he attributed to sensitisation to the donor thelial failure and secondary stromal opacities.
by the recipient [19]. This seminal concept of Anterior mushroom keratoplasty has better astig-
immunological rejection of the donor graft was matic properties and can be applied in patients
proven by Maumenee in 1951 [21]. Much impor- with relatively healthy endothelium [26, 27].
tant work in the field of corneal allograft rejec- Femtosecond lasers have recently been
tion was done by Khodadoust and Silverstein applied to more reproducibly fashion several
[22, 23]. The use of corticosteroids realised a types of (mushroom and other) shaped corneal
breakthrough in the treatment and prevention of incisions in both donor and recipient corneas
corneal transplant rejection and opacification. [28].
This concurred with the introduction of antibiot- The graft survival in all types of PK is good in
ics, the introduction of the operation microscope, low-risk cases, with a success rate of 80 % or
the development of microsurgical techniques and more of having a clear graft after 10 years. The
of newer suture materials that ensued. Other cornea enjoys a relative immune privilege being
important developments included the better avascular tissue, and furthermore immunosup-
understanding of endothelial physiology and of pressive treatment can be directly applied in high
donor cornea preservation. US-based ophthal- concentrations using eye drops. Therefore, HLA
mologists and scientists such as Paton, Troutman, matching of donor tissue to recipient status is
Maurice, McCarey and Kaufman played impor- usually not performed in low-risk cases, and still
tant roles in these developments [24, 25]. All good graft survival rates are obtained. Allograft
these developments led to a substantial improve- rejection however is still one of the major causes
ment in the popularity of penetrating keratoplasty of corneal transplant failure in PK [29]. When a
and hence in the number of cases operated with cornea becomes vascularised, the risk for corneal
this technique. graft rejection is elevated. High-risk cases include
repeat transplantations, especially after previous
allograft rejection, and corneas with extensive
Recent and Current Developments deep blood (and lymph) vessel ingrowth [29, 30].
in Penetrating and Lamellar Other important reasons for graft failure in PK
Keratoplasty are (secondary) glaucoma, ocular surface prob-
lems and late endothelial failure [29]. The concept
Penetrating Keratoplasty of late endothelial failure is an intriguing prob-
lem. After PK, grafts lose endothelial cells at a
In the past, penetrating keratoplasty was consid- faster than physiological rate, even in the absence
ered the gold standard in corneal transplantation. of overt endothelial allograft rejection. The exact
In penetrating keratoplasty (PK), a full-thickness cause for the elevated endothelial cell loss rate
4 G. van Rij and B.T.H. van Dooren
needs yet to be determined. Hypothetically it may membrane could reproducibly be bared. In this
arise from prolonged cell redistribution onto the technique an air bubble is used to dissect through
recipient cornea or from chronic pro-apoptotic the corneal stroma and to split the stroma from
changes in the anterior chamber [31–33]. Descemet’s membrane. A nearly full-thickness
donor cornea, devoid of donor endothelium, is
sutured in. Visual results after deep ALK with the
Anterior Lamellar Keratoplasty big-bubble technique proved to be as good as or
even better than PK [38]. Injecting viscoelastic
In anterior lamellar keratoplasty (ALK), only the material into the deep stroma can also be used to
diseased epithelium, Bowman’s membrane and bare Descemet’s membrane [39].
(anterior) corneal stroma are removed and trans- Microkeratome and femtosecond laser-
planted, leaving the unaffected but vulnerable assisted approaches towards ALK have recently
endothelium of the patient in place. Indications gained some interest. Especially with the micro-
for ALK include many cases of keratoconus, epi- keratome, both the recipient and donor lamellar
thelial and (anterior) stromal corneal dystrophies interfaces can be cut very smoothly. For selected
and partial-thickness post-infective (i.e. non- cases, the results are promising [40].
active, of herpetic and non-herpetic origin) and
non-infective (e.g. traumatic) corneal scars.
In the 1960s and 1970s, the frequency with Endothelial Keratoplasty
which anterior lamellar keratoplasty was per-
formed sank inversely with the increase in PK’s Endothelial keratoplasty (EK) is a treatment con-
success and hence popularity. This was mainly cept aimed at replacing only the diseased endo-
caused by ALK’s disappointing visual results. A thelium and posterior corneal layers, which have
large part of these poor results stem from the irreg- caused corneal clouding through oedema.
ular scattering of light (diffraction) at the recipient- Disorders that may be treated with EK include
donor wound interface. The need for a very smooth endothelial dystrophies, especially Fuchs endo-
recipient and host surface at the wound interface, thelial dystrophy, iridocorneal endothelial (ICE)
which was to be obtained more readily at a deeper syndrome and pseudophakic bullous keratopathy.
corneal plane, was recognised early on. However, The main advantage of this concept is an
to attain this goal required both surgical skills and untouched anterior corneal curvature, resulting in
time [34]. Yet, the advantages of ALK over PK in much less suture-induced high and irregular
suitable indications remained tempting. There astigmatism, as can be seen after PK. Other
were less complications to be expected, as ALK suture- and full-thickness wound-related compli-
was not truly an intraocular surgery. There was no cations such as infections and wound dehiscence
risk of postoperative endothelial rejection and can also be avoided.
probably less risk of late endothelial failure and Barraquer was the first to publish on the
open globe after traumatic wound dehiscence. concept of selective transplantation of an
In spite of this, comparative studies from the endothelium-containing posterior corneal
late 1970s kept on showing that visual results lamella for the treatment of corneal oedema.
were better after PK than after ALK for keratoco- In 1951 he reported for the first time on such a
nus – one of the most apt indications for ALK design, which involved the (manual) cutting of a
[34–36]. However, good visual results were actu- hinged anterior lamellar corneal flap, followed
ally shown to be obtainable, when the lamellar by the excision and replacement of a deep corneal
dissection could be made at or just above the stroma lamella including the endothelium [41].
level of Descemet’s membrane which presented a In 1964 he reported on the first results obtained
natural, very smooth optical interface [37]. It with this technique in two patients, who obtained
was not until the introduction of the “big-bubble” clear grafts and good visual acuities. In 1983 he
technique by Anwar, however, that Descemet’s introduced the motor-driven microkeratome in
1 The History of Corneal Transplantation 5
EK for the cutting of the anterior flap in both particularly remarkable because the posterior
donor and recipient and reported a good result in donor disc was not kept in place by sutures. The
one patient [42]. pressure of an air bubble in the anterior chamber
Apparently unaware of Barraquer’s work, helps to keep the disc in place in the first postop-
Tillet published a report in 1956 on the selective erative hours. The supposed mechanism that
transplantation of a posterior donor corneal maintains good donor disc apposition thereafter
lamella with endothelium, performed success- might be the mere pumping action of the endo-
fully in a patient with Fuchs’ endothelial dystro- thelial cells. Other postulated appositional mech-
phy, in 1954. The posterior recipient disc had anisms include the inherent adhesive quality of
been excised after a manual lamellar dissection bare stromal surfaces and fibrils, assisted by the
through a 180° superior corneal incision. The intraocular pressure [54, 55]. In 1999 and 2000,
half-thickness donor posterior disc was posi- the first encouraging results in the first seven
tioned onto the posterior surface of the recipient’s patients in Melles’ series were reported, with all
anterior cornea and fixated with silk sutures. The transplants attached and all corneas clear [56,
graft remained clear for at least 1 year. However, 57]. In the next few years, technical improve-
the visual results were disappointing because of a ments included the use of a smaller incision com-
poorly controlled glaucoma [43]. bined with the insertion into the anterior chamber
In the late 1970s, the concept of selective of a folded donor disc. Later, Descemet’s mem-
endothelial transplantation gained new interest, brane stripping or “descemetorhexis”, instead of
when experimental models were developed for the previously used deep lamellar cross-corneal
the transplantation of cultured human and heter- dissection of the recipient corneal disc, was intro-
ologous corneal endothelial cells. Experiments duced [58].
were performed with seeding the endothelial Terry introduced PLK in the USA with slight
cells on animal and human donor corneas, modifications under the name deep lamellar
Descemet’s membranes, amnion membranes and endothelial keratoplasty (DLEK) and reported on
artificial carrier devices [44]. Experiments on large series of patients operated successfully with
bioengineered corneal constructs with cultured this technique [59, 60]. Price adopted the tech-
human corneal endothelial cells have continued nique involving the descemetorhexis. He named
into the present time [45]. Although progress has this technique Descemet’s stripping with endo-
been made, none of these techniques has reached thelial keratoplasty (DSEK) or Descemet’s strip-
the clinical phase yet. ping automated endothelial keratoplasty
The microkeratome-assisted approach towards (DSAEK) when a microkeratome was used to cut
EK, as conceptualised by Barraquer, was revived the donor cornea. This reproducible technique
in the 1990s. A number of patients were operated provided excellent results regarding visual acu-
with these techniques. These attempts however ity, speed of visual recovery, astigmatism and
suffered from very unpredictable refractive out- postoperative refractive error and showed a low
comes [46–50]. A quite different approach for donor disc detachment rate [60, 61]. Midterm
EK, more in line with the technique described by donor endothelial cell survival after EK seems
Tillet, was initiated by Ko et al. in 1993. They comparable or even favourable to PK, and graft
used a technique of EK in a rabbit model, in survival is also very comparable [62]. DSAEK
which the posterior lamella was introduced has currently become the most often used tech-
through a superior limbal incision and sutured nique for EK worldwide. Not only EK rates but
against the recipient corneal surface [51]. also comprehensive corneal transplant rates have
In 1997 and 1998, Melles reported on a model gone up since DSAEK’s introduction [63].
for EK or posterior lamellar keratoplasty (PLK): Recent improvements in DSAEK include the use
the transplantation of a posterior corneal lamella of thinner and pre-cut (i.e. microkeratome dissec-
with endothelium through a 9 mm corneoscleral tion in eye banks instead of in the OR) donor
tunnel incision [52, 53]. This technique was lamellae [64, 65].
6 G. van Rij and B.T.H. van Dooren
In Descemet’s membrane endothelial kerato- 12. Zirm E. Eine erfolgreiche totale Keraoplastik. Albrecht
Von Graefes Arch Ophthalmol. 1906;54:580–93.
plasty (DMEK), the thickness of the transplanted
13. Elschnig A. Keratoplasty. Arch Ophthalmol.
layer of stroma is further reduced. Different tech- 1930;4:165–73.
niques were recently developed by Melles and 14. Castroviejo R. Keratoplasty. An historical and experi-
later Price, Kruse and others. The donor material, mental study, including a new method. Part I. Am J
Ophthalmol. 1932;15:825–38.
mainly consisting of endothelium and Descemet’s
15. Castroviejo R. Keratoplasty. An historical and experi-
membrane, spontaneously forms a roll, with the mental study, including a new method. Part II. Am J
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introduced into the recipient eye using an inserter. 16. Filatov VP. Transplantation of the cornea. Arch
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The advantage of DMEK is an even faster and
17. Tudor Thomas JW. The results of corneal transplanta-
better visual rehabilitation than after DSAEK, tion. Br Med J. 1937;1:114–6.
although possibly at the cost of higher disloca- 18. Filatov VP. Transplantation of the cornea from pre-
tion rates [66–69]. served cadaver’s eyes. Lancet. 1937;I;1395–7.
19. Paufique L, Sourdille GO, Offret G. Les greffes de la
So far, the application of femtosecond lasers
cornée. Paris: Masson et Cie; 1948.
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keratoplasty [70, 71]. neal graftin and their indications. Am J Ophthalmol.
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2009;116:2361–8.
Anatomy and Physiology:
Considerations in Relation 2
to Transplantation
Ursula Schlötzer-Schrehardt
and Friedrich E. Kruse
Abstract
Over the past decade, corneal transplantation has evolved rapidly from
full-thickness penetrating keratoplasty toward partial-thickness or lamel-
lar keratoplasty. Lamellar corneal surgery is in continuous evolution,
which requires an understanding of the structural, biomechanical, and his-
tological characteristics of corneal layers involved. In this chapter, we
describe the anatomy and physiology of the human cornea in order to pro-
vide the structural basis for understanding the newly developed tech-
niques. The chapter provides detailed information on morphological,
histological, ultrastructural, and physiological characteristics of the five
anatomical corneal layers, i.e., epithelium, Bowman’s layer, corneal
stroma consisting of regularly arranged collagen fibrils interspersed with
keratocytes, Descemet’s membrane, and endothelial cells, in relation to
corneal transplantation. In particular, it outlines regional and age-related
differences in structure, biomechanical properties, mechanisms of wound
healing and restoration of corneal transparency, causes of stromal haze,
cleavage planes and interface characteristics in lamellar transplantation
techniques, and reasons for graft failure. Patterns of corneal innervation
and the molecular mechanisms of antiangiogenic and immune privileges,
which determine the success of allogeneic corneal transplantation, are
described in addition.
Keywords
Epithelium • Bowman’s layer • Stroma • Descemet’s membrane •
Endothelium • Anatomy • Histology • Electron microscopy • Corneal
innervation • Immune privilege
foreign bodies and pathogens, and contributes, Gross Anatomy and Physiology
together with the tear film, two-thirds of the eye’s
refractive power. It is nourished and provided In adults, the cornea has a horizontal diameter of
with oxygen anteriorly by tears and posteriorly 11.0–12.0 mm, a vertical diameter of 10.0–
by the aqueous humor. It has to maintain the 11.0 mm, and a thickness of approximately 500–
intraocular pressure and to withstand the forces 550 μm at the center, which gradually increases
applied by the extraocular muscles during eye to 600–800 μm toward the periphery [18]. The
movement. Corneal shape and curvature, which cornea has an aspheric anterior surface being
are relevant for refraction, are achieved by the steeper in the center and flatter in the periphery.
specific arrangement of collagen lamellae in the Average refractive power is 43.25 diopters, aver-
stroma, and corneal transparency, which is criti- age radius of curvature is 7.8 mm, and the corneal
cally important for vision, is the result of many index of refraction is 1.376. It is composed of five
factors including avascularity of the corneal tis- anatomical layers, i.e., corneal epithelium,
sue, the integrity of the corneal epithelium, and Bowman’s layer, corneal stroma, Descemet’s
the regular arrangement of the extracellular and membrane, and corneal endothelium (Fig. 2.1a).
cellular components of the stroma, which in turn Besides these conventional layers of the cornea,
depends on the state of hydration regulated by the an additional pre-Descemet’s stromal layer has
corneal endothelium [18]. been recently described [19], which has, how-
Corneal transplantation remains the mainstay ever, been subsequently disproved by a multi-
treatment for patients with corneal blindness. The center study [66].
success of allogeneic corneal transplantation Confocal microscopy with the Heidelberg
benefits from the immunologically privileged retina tomograph (HRT) II and Rostock Cornea
state of the cornea [55]. Penetrating keratoplasty Module can be used for in vivo imaging of all
(PKP) has been the gold standard for corneal anatomical layers and corneal cell types includ-
transplantation for almost a century. Over the ing nerve plexi and immune cells (Fig. 2.2).
past decade, corneal transplantation has evolved
rapidly from full-thickness PKP toward partial-
thickness or lamellar keratoplasty to only remove Corneal Epithelium
and replace damaged or diseased layers of the
cornea allowing more rapid visual rehabilitation The epithelial surface of the cornea represents the
and reduced rates of rejection [4, 63, 69]. Current physical barrier to the outer environment and an
developments in lamellar keratoplasty include integral part of the smooth tear film–cornea inter-
deep anterior lamellar keratoplasty (DALK) for face that is critical for the refractive power of the
anterior corneal disorders [3], such as keratoco- eye. It is responsible for protecting the eye against
nus or stromal scars, as well as Descemet’s strip- loss of fluid and invasion of foreign bodies and
ping (automated) endothelial keratoplasty pathogens and for absorbing oxygen and nutri-
(DSEK, DSAEK) and Descemet’s membrane ents from the tear film.
endothelial keratoplasty (DMEK) for posterior The corneal surface is covered by a stratified,
corneal disorders, such as Fuchs’ corneal endo- nonkeratinizing, squamous epithelium, about
thelial dystrophy [47, 61]. Lamellar corneal sur- 50 μm in thickness, comprising 5–7 cell layers
gery is in continuous evolution, which requires collectively. It can be structured into three layers,
an understanding of the structural, biomechani- the superficial or squamous cell layer, the supra-
cal, and histological characteristics of corneal basal wing cell layer, and the basal columnar cell
layers involved. In this chapter, we describe the layer (Fig. 2.1b) [18, 60]. Desmosomes promote
anatomy and physiology of the human cornea in strong adhesion between cells of all epithelial
order to provide the structural basis for the subse- layers. The superficial layer is formed by 2–3 lay-
quent chapters on corneal transplantation ers of flat polygonal cells, which form intercel-
techniques. lular tight junctions to provide an effective barrier
2 Anatomy and Physiology: Considerations in Relation to Transplantation 11
Fig. 2.1 Light (a) and transmission electron (b–h) micro- fibrils. (f) Descemet’s membrane (DM), the basement
graphs of anatomical corneal layers. (a) Semithin cross membrane of the corneal endothelium, being composed of
section of the cornea showing three cellular layers, i.e., interfacial matrix (IFM), anterior banded layer (ABL), and
epithelium, stroma with keratocytes, and endothelium. (b) posterior nonbanded layer (PNBL). (g) “Bowman’s-like
Corneal epithelium showing three layers, the superficial layer” (BL), a meshwork of randomly arranged collagen
or squamous cell layer, the suprabasal wing cell layer, and fibrils at the interface between Descemet’s membrane and
the basal columnar cell layer resting on Bowman’s layer. stroma. (h) Connecting collagen fibrils (arrows) project-
(c) Anchoring complexes formed by hemidesmosomes ing from “Bowman’s-like layer” into the interfacial matrix
(arrows) and anchoring fibrils (arrowheads) mediating zone (IFM) of Descemet’s membrane (magnification
attachment of basal epithelial cells to basement membrane bars = 100 μm in a; 15 μm in b and d; 5 μm in f; and
(BM) and Bowman’s layer. (d) Bowman’s layer represent- 0.5 μm in c, e, h) (e, g Reproduced from Schlötzer-
ing the most anterior portion of the corneal stroma. (e) Schrehardt et al. [66], and h Reproduced from Schlötzer-
Interface (dotted line) between Bowman’s layer and cor- Schrehardt et al. [64], with permission from Elsevier)
neal stroma showing differing arrangement of collagen
12 U. Schlötzer-Schrehardt and F.E. Kruse
and numerous surface microvilli, which increase spreading of the tear film with each eyelid blink
the cellular surface area and enhance oxygen and [26, 70]. The tear film also supplies immunologi-
nutrient uptake from the tear film. The microvillar cal and growth factors that are critical for epithe-
glycocalyx coat interacts with and helps to stabi- lial health, proliferation, and repair, and defects
lize the pre-corneal tear film, which is composed in tear film, e.g., in neurotrophic keratopathy
of three layers: a superficial lipid layer to provide after corneal surgery, can cause epithelial wound
protection from evaporation, an aqueous layer healing problems and surface inflammation. The
providing nutrients and oxygen supply to the cor- wing cell layer is formed by 2–3 layers of wing-
neal epithelium, and a basal mucin layer, which shaped cells which have laterally interdigitated
interacts closely with the epithelial cell glycoca- cell membranes with numerous desmosomes
lyx to allow lubrication of the ocular surface and (Fig. 2.2a). The basal layer consists of a single
2 Anatomy and Physiology: Considerations in Relation to Transplantation 13
layer of columnar cells (Fig. 2.2b), which are known as limbal stem cell deficiency [1]. In these
attached to the underlying basement membrane cases, epithelium of conjunctival phenotype may
by hemidesmosomes (Fig. 2.1c). The epithelial replace the corneal surface. Transplantation of
basement membrane has a critical role in corneal limbal autografts or allografts [35] and ex vivo
wound healing, because defects in this delicate expanded limbal epithelial stem cells are estab-
layer allow penetration of growth factors from lished therapeutic strategies to regenerate the
the epithelium into the stroma [71]. Corneal epi- damaged corneal surface [67].
thelial adhesion to Bowman’s layer is maintained The corneal epithelium responds to injury in
by an anchoring complex including anchoring three phases, i.e., migration, proliferation, and
fibrils (type VII collagen) and anchoring plaques differentiation with reattachment to the basement
(type VI collagen) (Fig. 2.1c) [25]. Abnormalities membrane [80]. Following injury, cells adjacent
in these anchoring complexes may result clini- to an epithelial defect migrate to cover the wound
cally in recurrent corneal erosions or nonhealing within few hours. Following wound closure,
epithelial defects. basal epithelial and limbal stem cells proliferate
Besides epithelial cells, there are numerous and differentiate to repopulate the epithelium. In
nerve endings in between the cells (Fig. 2.2c), the final phase, hemidesmosomes replace focal
which exert important trophic influences on the contacts in order to anchor the basal epithelial
corneal epithelium and which have been esti- cells tightly to the basement membrane and
mated to amount to a density of 7000 nociceptors stroma. If the basement membrane remained
per mm2, which is 400 times more than in the intact, a tight adhesion is established in only a
skin [52]. Mechanical stress to these nerves, such few days. If the basement membrane was dam-
as in bullous keratopathy, can therefore cause tre- aged, its repair can take up to 6 weeks. During
mendous pain. Furthermore, resident MHC class this time, the epithelial attachment to the newly
II-expressing cells, i.e., CD11c+-dendritic cells deposited basement membrane tends to be unsta-
and CD207+-Langerhans cells, were identified in ble and weak, and the regenerated epithelium is
the human basal epithelium and anterior stroma very susceptible to damage. Following PKP, re-
(Fig. 2.2d), which are capable of rapidly mobiliz- epithelialization is usually observed within 1
ing to the site of epithelial trauma and viral infec- week, although morphological abnormalities,
tion within the cornea [37]. The corneal detected by specular microscopy, may persist up
epithelium itself exerts strong anti-inflammatory to 6 months postoperatively [74]. Corneal grafts
and antiangiogenic properties, and transplanta- showed some recovery of the subbasal nerve
tion of donor corneas without the epithelium, plexus, at least in the graft periphery, but not
e.g., after abrasion, leads to increased postopera- complete recovery of function [68].
tive inflammation and neovascularization [17].
Corneal epithelial cells routinely undergo
apoptosis and desquamation from the surface. Bowman’s Layer
This process results in complete turnover of the
corneal epithelial layer every 5–7 days as deeper Bowman’s layer represents the most anterior,
cells replace the desquamating superficial cells in acellular portion of the corneal stroma (Fig. 2.1d).
an orderly, apically directed fashion. Two popu- It is approximately 8–12 μm thick and structur-
lations of cells, the basal epithelial cells and lim- ally composed of randomly oriented collagen
bal stem cells, help renew the epithelial surface fibrils, 20–25 nm in diameter, consisting of col-
[7]. The epithelial stem cells and their progeni- lagen types I, III, V, and VI (Fig. 2.1e) [77]. Its
tors are located at the bottom of the palisades of thickness has been reported to decline with age
Vogt at the corneoscleral limbus [15]. Depletion by 0.06 μm per year, thus losing one-third of its
of this stem cell reservoir, e.g., after chemical thickness between 20 and 80 years of age [23].
burns, can cause severe ocular surface disease Unmyelinated nerve axons penetrate Bowman’s
and significant visual deterioration, a condition layer to terminate within the epithelium. The
14 U. Schlötzer-Schrehardt and F.E. Kruse
functional role of Bowman’s layer is not com- with adjacent lamellae being oriented at right
pletely known, but it is believed to serve as a bar- angles, although there are organizational differ-
rier that protects corneal stroma and nerves from ences in the collagen bundles between anterior
traumatic injury. In addition, it has been sug- and posterior stroma [45]. In the anterior third of
gested to ensure epithelial anchorage to the cor- the stroma, lamellae are oriented more obliquely,
neal stroma and helps to maintain the shape and mediating a tighter cohesive strength and rigid-
tensile strength of the cornea. Bowman’s layer ity, which appears particularly important in main-
also functions as an important UV shield protect- taining corneal curvature [51], whereas in the
ing the inner eye and a nearly insurmountable posterior two-thirds, lamellae run in parallel to
barrier against the invasion of epithelial tumors the corneal surface. These differences in stromal
into the corneal stroma [60]. collagen organization may also explain why the
When disrupted, Bowman’s layer does not anterior stroma resists changes to stromal hydra-
regenerate but forms a scar. Therefore, diseases tion much better [46] and why surgical dissec-
or surgical procedures leading to defects in tion in a particular plane is easier in the posterior
Bowman’s layer increase the risk for corneal rup- depths of the stroma, e.g., in DALK. Moreover,
tures and ectasias. On the other hand, sutures the peripheral stroma is thicker than the central
have to extend through Bowman’s layer to ensure stroma, and the collagen fibrils may change direc-
tight and effective suturing [17]. tion to form a circumferentially oriented network,
which is thought to be pivotal in maintaining cor-
neal stability and curvature, as they approach the
Corneal Stroma limbus [45]. Any disturbance of this fine-tuned
arrangement, either by deposition of abnormal
The stroma is the thickest layer of the cornea extracellular matrix, e.g., deposition of muco-
measuring approximately 500 μm in width and polysaccharides in macular corneal dystrophy,
represents a dense avascular connective tissue of or the irregular arrangement of collagen fibrils in
remarkable and unique regularity. It is composed stromal scars, can cause corneal opacity.
of regularly arranged bundles of collagen fibrils The collagen lamellae are interspersed with
embedded in a glycosaminoglycan-rich extracel- flattened stellate keratocytes, which are inter-
lular matrix, which are interspersed with flattened connected by gap junctions and arranged in a
fibroblast-like cells termed keratocytes [18]. circular, corkscrew pattern forming a coherent
Collagen organization in the stroma is crucial to network (Fig. 2.2e) [50, 59]. The density of kera-
corneal functions such as light transmission and tocytes in the anterior stroma is 20,000–24,000
maintenance of corneal curvature, tensile strength, cells/mm2 and the density decreases posteri-
and rigidity [27]. The individual collagen fibrils, orly. Keratocytes are metabolically active cells
being mainly composed of collagen types I and involved in synthesis and turnover of extracellu-
V, are extremely uniform in diameter measur- lar matrix components, i.e., collagen molecules
ing about 25–30 nm [38, 44] and are organized and glycosaminoglycans. They contain water-
into approximately 250–300 2 μm thick sheets or soluble proteins, corneal “crystallins,” which
lamellae. Regular spacing of fibrils within these appear to be responsible for reducing backscatter
lamellae is maintained by interactions of colla- of light from the keratocytes and for maintaining
gens with proteoglycans forming bridges between corneal transparency [32]. In addition, sensory
the fibrils [53]. The major proteoglycans of the nerve fibers are present in the anterior stroma,
stroma are keratan sulfate proteoglycans, such as which are cut during PKP leading to a mild neu-
keratocan and lumican, and chondroitin/dermatan rotrophic keratopathy [68], and MHC class II
sulfate proteoglycans, such as decorin [27, 48], antigen-presenting cells, which seem to migrate
which also regulate stromal hydration by means out of the cornea during organ preservation,
of their ability to bind water molecules. The col- thereby explaining the reduced rates of immune
lagenous lamellae form a highly organized ply, rejections of longer organ-cultured grafts [17].
2 Anatomy and Physiology: Considerations in Relation to Transplantation 15
Following injury to the stroma, e.g., in PKP, three-center study provided evidence that there is
keratocytes adjacent to the wound undergo apop- no distinctive acellular pre-Descemet’s stromal
tosis [71, 78, 80]. About 24 h after wounding, the zone justifying the term “layer” apart from a thin
remaining keratocytes begin to proliferate and (0.5–1.0 μm) intermediary “Bowman’s-like
transform into activated fibroblasts, which zone” of randomly arranged collagen fibers at the
migrate into the wound region and produce extra- Descemet’s membrane–stromal interface
cellular matrix components, a process that may (Fig. 2.1g). The collagen fibers of this intermedi-
last up to 1 week. Inflammatory cells, including ary layer partly extend into Descemet’s mem-
monocytes, granulocytes, and lymphocytes, infil- brane serving a connecting function (Fig. 2.1h).
trate the stroma from the limbal blood vessels. Stromal keratocytes were found to approach
Fibroblasts transform into myofibroblasts, which Descemet’s membrane up to 1.5 μm (mean
contract the wound and secrete extracellular 4.97 ± 2.19 μm) in the central regions and up to
matrix, a process which may last up to 1 month. 4.5 μm (mean 9.77 ± 2.90 μm) in the peripheral
Deposition of large amounts of disorganized regions of the cornea. The intrastromal cleavage
extracellular matrix may lead to loss of corneal plane after pneumodissection, which seemed to
transparency causing stromal haze. Matrix occur at multiple stromal levels along rows of
remodeling by repopulating keratocytes thereby keratocytes offering the least resistance to
restoring transparency is the last phase of stromal mechanical forces, was obviously determined by
wound healing and can last for years [71]. In pen- the variable distances of keratocytes to
etrating or lamellar keratoplasty, a rather com- Descemet’s membrane. Consistently, the residual
plete wound healing response is usually noted at stromal sheet separated by air injection into the
donor-recipient interfaces. However, abnormal stroma varied in thickness from 4.5 to 27.5 μm,
collagen fiber size and arrangement, indicating being usually thinnest in the central and thickest
incomplete stromal wound remodeling and per- in the peripheral portions of the bubble (Fig. 2.3d).
sistence of fibrotic scar tissue, have been observed This phenomenon has been well documented as
within the graft margin after PKP [11]. Similarly, “residual stroma” in previous studies, providing
the presence of fibrocellular tissue, probably evidence that the big-bubble technique in DALK
derived from myofibroblasts, has been found in is not consistently a Descemet-baring technique
the graft–host interface in about 20 % of corneas [31, 36, 43].
after DSAEK failure [79]. Therefore, stroma-to-
stroma interface haze may occur in DALK or
DSAEK and can degrade visual acuity, even if Descemet’s Membrane
the microkeratome or femtosecond laser is used
to achieve a smooth resection [4]. Descemet’s membrane represents the thickened
Recently, the existence of a novel, previously (10–12 μm), specialized basement membrane of
unrecognized layer of the pre-Descemet’s cor- the corneal endothelium consisting of collagen
neal stroma, which can be separated by air injec- types IV, VIII, and XVIII and non-collagenous
tion into the stroma during DALK using components including fibronectin, laminin, nido-
big-bubble technique, has been reported [19]. gen, and perlecan as well as dermatan, keratan,
This distinct layer was reported to measure about heparan, and chondroitin sulfate proteoglycans
10 μm in width and was characterized to lack any [64]. Apart from providing structural integ-
keratocytes and to show a pronounced immunos- rity of the cornea, Descemet’s membrane has
taining for collagen types III, IV, and VI [20]. been suggested to play a role in several impor-
However, the description of this hypothesized tant physiological processes including corneal
new anatomic layer was critically commented on hydration, endothelial cell differentiation and
in the literature and eventually refuted by a proliferation, and maintenance of the corneal
detailed ultrastructural reinvestigation of the curvature. It is composed of an anterior banded
human corneal stroma [66]. The findings of this (fetal) layer, approx. 3 μm in thickness, and a
16 U. Schlötzer-Schrehardt and F.E. Kruse
posterior nonbanded (postnatal) layer that gradu- thickened fusion site, known as Schwalbe’s line,
ally thickens with age reaching up to 10 μm in is a gonioscopic landmark that defines the end of
elderly individuals (Fig. 2.1f) [33, 54]. In the Descemet’s membrane and the beginning of the
periphery, Descemet’s membrane forms wart- trabecular meshwork.
like excrescences (Hassall-Henle warts) and Descemet’s membrane is attached to the
merges into the trabecular meshwork beams. The corneal stroma by a narrow (about 1 μm thick)
Fig. 2.3 Light (D) and transmission electron (a–c, e–g) are shown in higher magnification on the left illustrating
micrographs showing cleavage planes in lamellar kerato- the stromal sheet forming the bubble wall of variable
plasty and usability of Descemet’s membrane ultrastruc- thickness with remnants of keratocytes (arrow). (e–g)
ture as indicator of endothelial function. (a, b) Ultrastructural analysis of Descemet’s membrane show-
Physiological cleavage plane between the posterior stro- ing normal structure (e), abnormal collagen inclusions
mal collagen lamellae (a) and interfacial matrix zone (arrows) within posterior nonbanded layer (PNBL) (f),
(IFM) of Descemet’s membrane in DMEK. (c) Lamellar and a posterior collagenous layer (PCL) deposited onto a
splitting of Descemet’s membrane between anterior normal Descemet’s membrane (g) (IFM interfacial matrix,
banded layer (ABL) and posterior nonbanded layer ABL anterior banded layer; magnification bars = 2 mm in
(PNBL) (arrow) of a donor cornea with unsuccessful d; 2.5 μm in c, e, f, g; and 1 μm in a and b) (a, c, e repro-
stripping due to strong adhesion of Descemet’s membrane duced from Schlötzer-Schrehardt et al. [65], and c repro-
to the corneal stroma (dotted line). (d) Semithin section of duced from Schlötzer-Schrehardt et al. [66], with
a donor cornea showing big-bubble formation after air permission from Elsevier)
injection into the corneal stroma; the boxed areas (1, 2, 3)
2 Anatomy and Physiology: Considerations in Relation to Transplantation 17
SUN CHIA-NAI
This official, chiefly known to fame among his countrymen as one
of the tutors of His Majesty Kuang-Hsü, was a sturdy Conservative of
the orthodox type, but an honest and kindly man. His character and
opinions may be gauged from a well-known saying of his: “One
Chinese character is better than ten thousand words of the
barbarians. By knowing Chinese a man may rise to become a Grand
Secretary; by knowing the tongues of the barbarians, he can at best
aspire to become the mouth-piece of other men.”
Ceiling and Pillars of the Tai Ho Tien.
In his later years he felt and expressed great grief at the condition
of his country, and particularly in regard to the strained relations
between the Empress Dowager and the Emperor. He traced the first
causes of these misfortunes to the war with Japan, and never
ceased to blame his colleague, the Imperial Tutor Weng T’ung-ho,
for persuading the Emperor to sign the Decree whereby that war was
declared, which he described as the act of a madman. Weng,
however, was by no means alone in holding the opinion that China
could easily dispose of the Japanese forces by land and by sea. It
was well-known at Court, and the Emperor must have learned it from
more than one quarter, that several foreigners holding high positions
under the Chinese Government, including the Inspector-General of
Customs (Sir Robert Hart), concurred in the view that China had
practically no alternative but to declare war in view of Japan’s high-
handed proceedings and insulting attitude. Prestige apart, it was
probable that the Emperor was by no means averse to taking this
step on his own authority, even though he knew that the Empress
Dowager was opposed to the idea of war, because of its inevitable
interference with the preparations for her sixtieth birthday; at that
moment, Tzŭ Hsi was living in quasi-retirement at the Summer
Palace. After war had been declared and China’s reverses began,
she complained to the Emperor and to others, that the fatal step had
been taken without her knowledge and consent, but this was only
“making face,” for it is certain that she had been kept fully informed
of all that was done and that, had she so desired, she could easily
have prevented the issue of the Decree, and the despatch of the
Chinese troops to Asan. Sun Chia-nai’s reputation for sagacity was
increased after the event, and upon the subsequent disgrace and
dismissal of Weng T’ung-ho he stood high in Her Majesty’s favour.
Nevertheless his loyalty to the unfortunate Emperor remained
unshaken.
In 1898, his tendencies were theoretically on the side of reform,
but he thoroughly disapproved of the methods and self-seeking
personality of K’ang Yu-wei, advising the Emperor that, while
possibly fit for an Under-Secretaryship, he was quite unfitted for any
high post of responsibility. When matters first approached a crisis, it
was by his advice that the Emperor directed K’ang to proceed to
Shanghai for the organisation of the Press Bureau scheme. Sun,
peace-loving and prudent, hoped thereby to find an outlet for K’ang
Yu-wei’s patriotic activities while leaving the Manchu dovecots
unfluttered. Later, after the coup d’état, being above all things
orthodox and a stickler for harmonious observance of precedents, he
deplored the harsh treatment and humiliation inflicted upon the
Emperor. It is reported of him that on one occasion at audience he
broke down completely, and with tears implored the Empress
Dowager not to allow her mind to be poisoned against His Majesty,
but without effect.
Upon the nomination of the Heir Apparent, in 1900, which he, like
many others, regarded as the Emperor’s death sentence, he sent in
a strongly worded Memorial against this step, and subsequently
denounced it at a meeting of the Grand Council. Thereafter, his
protests proving ineffective, he resigned all his offices, but remained
at the capital in retirement, watching events. At the commencement
of the Boxer crisis, unable to contain his feelings, he sent in a
Memorial through the Censorate denouncing the rabid reactionary
Hsü T’ung, whom he described as “the friend of traitors, who would
bring the State to ruin if further confidence were placed in him.”
Throughout his career he displayed the courage of his convictions,
which, judged by the common standard of Chinese officialdom, were
conspicuously honest. He was a man of that Spartan type of private
life which one finds not infrequently associated with the higher
branches of Chinese scholarship and Confucian philosophy; it was
his boast that he never employed a secretary, but wrote out all his
correspondence and Memorials with his own hand.
A pleasing illustration of his character is the following: He was
seated one day in his shabby old cart, and driving down the main
street to his home, when his driver collided with the vehicle of a well-
known Censor, named Chao. The police came up to make enquiries
and administer street-justice, but learning that one cart belonged to
the Grand Secretary Sun, they told his driver to proceed. The
Censor, justly indignant at such servility, wrote a note to Sun in which
he said: “The Grand Secretary enjoys, no doubt, great prestige, but
even he cannot lightly disregard the power of the Censorate.” Sun,
on receiving this note, proceeded at once on foot in full official dress
to the Censor’s house, and upon being informed that he was not at
home, prostrated himself before the servant, saying: “The nation is
indeed to be congratulated upon possessing a virtuous Censor.”
Chao, not to be outdone in generosity, proceeded in his turn to the
residence of the Grand Secretary, intending to return the
compliment, but Sun declined to allow him to apologise in any way.
TUAN FANG
In 1898, Tuan Fang was a Secretary of the Board of Works; his
rapid promotion after that date was chiefly due to the patronage of
his friend Jung Lu. For a Manchu, he is remarkably progressive and
liberal in his views.
In 1900, he was Acting-Governor of Shensi. As the Boxer
movement spread and increased in violence, and as the fears of
Jung Lu led him to take an increasingly decided line of action against
them, Tuan Fang, acting upon his advice, followed suit. In spite of
the fact that at the time of the coup d’état he had adroitly saved
himself from clear identification with the reformers and had penned a
classical composition in praise of filial piety, which was commonly
regarded as a veiled reproof to the Emperor for not yielding implicit
obedience to the Old Buddha, he had never enjoyed any special
marks of favour at the latter’s hands, nor been received into that
confidential friendliness with which she frequently honoured her
favourites.
In his private life, as in his administration, Tuan Fang has always
recognised the changing conditions of his country and endeavoured
to adapt himself to the needs of the time; he was one of the first
among the Manchus to send his sons abroad for their education. His
sympathies were at first unmistakably with K’ang Yu-wei and his
fellow reformers, but he withdrew from them because of the anti-
dynastic nature of their movement, of which he naturally
disapproved.
As Acting-Governor of Shensi, in July, 1900, he clearly realised
the serious nature of the situation and the dangers that must arise
from the success of the Boxer movement, and he therefore issued
two Proclamations to the province, in which he earnestly warned the
people to abstain from acts of violence. These documents were
undoubtedly the means of saving the lives of many missionaries and
other foreigners isolated in the interior. In the first a curious passage
occurs, wherein, after denouncing the Boxers, he said:
After prophesying for them the same fate which overtook the
Mahomedan rebels and those of the Taiping insurrection, he
delivered himself of advice to the people which, while calculated to
prevent the slaughter of foreigners, would preserve his reputation for
patriotism. It is well, now that Tuan Fang has fallen upon evil days, to
remember the good work he did in a very difficult position. His
Proclamation ran as follows:—
“If the rain has not fallen upon your barren fields,” he said,
“if the demon of drought threatens to harass you, be sure that
it is because you have gone astray, led by false rumours, and
have committed deeds of violence. Repent now and return to
your peaceful ways, and the rains will assuredly fall. Behold
the ruin which has come upon the provinces of Chihli and
Shantung; it is to save you from their fate that I now warn you.
Are we not all alike subjects of the great Manchu Dynasty,
and shall we not acquit ourselves like men in the service of
the State? If there were any chance of this province being
invaded by the enemy, you would naturally sacrifice your lives
and property to repel him, as a matter of simple patriotism.
But if, in a sudden access of madness, you set forth to
butcher a few helpless foreigners, you will in no wise benefit
the Empire, but will merely be raising fresh difficulties for the
Throne. For the time being, your own consciences will accuse
you of ignoble deeds, and later you will surely pay the penalty
with your lives and the ruin of your families. Surely, you men
of Shensi, enlightened and high-principled, will not fall so low
as this? There are, I know, among you some evil men who,
professing patriotic enmity to foreigners and Christians, wax
fat on foreign plunder. But the few missionary Chapels in this
province offer but meagre booty, and it is safe to predict that
those who begin by sacking them will certainly proceed next
to loot the houses of your wealthier citizens. From the burning
of foreigners’ homes, the conflagration will spread to your
own, and many innocent persons will share the fate of the
slaughtered Christians. The plunderers will escape with their
booty, and the foolish onlookers will pay the penalty of these
crimes. Is it not a well-known fact that every anti-Christian
outbreak invariably brings misery to the stupid innocent
people of the district concerned? Is not this a lamentable
thing? As for me, I care neither for praise nor blame; my only
object in preaching peace in Shensi is to save you, my
people, from dire ruin and destruction.”