How would nature see our corneal triumphs? The LXXIX Edward Jackson Lecture.

PURPOSE: To describe discrepancies between clinical observation and current teachings in corneal endothelial disease, particularly in Fuchs endothelial dystrophy and its potential association with primary open angle glaucoma.

DESIGN AND METHODS: Perspective on Fuchs dystrophy, a disorder that commonly presents with a compromised endothelium but minimal stromal edema, indicating that the corneal imbibition pressure is relatively 'too high'.

RESULTS: The discrepancy between the relative lack of stromal edema in the absence of an endothelial cell layer can not be explained by the current theories involving a circulatory pumping mechanism over the endothelial cell layer, but may point to 1) secondary involvement of the corneal endothelium in Fuchs dystrophy; 2) separate hydration systems for maintaining the imbibition pressure (vertical static hydration) and corneal nutrition (horizontal dynamic hydration); 3) the cornea as net contributor of aqueous humor; 4) a close relationship between the corneal imbibition and intraocular pressure, with potentially a shared regulatory system; 5) a potential steroid-type hormone dependency of this regulatory system.

CONCLUSION: Clinical observation shows that the stromal imbibition pressure is 'too high' in Fuchs endothelial dystrophy, indicating that it may not primarily be an endothelial disease, but a type of 'corneal glaucoma'.