AQUEOUS HUMOR DYNAMICS

FORMATION, OUTFLOW AND

IOP

INTRODUCTION

Aqueous humor is a dynamic intra ocular fluid that is vital

to the health of eye.

It is a relatively cell free protein free fluid formed by the

ciliary body epithelium in the posterior chamber.

Major functions of the aqueous humor include

 Maintains IOP and globe integrity.
 Provides essential nutrients and removes
metabolites from cornea, lens and trabecular
meshwork.
 Provides high concentrations of ascorbate which
helps to protect the eye against uv radiations and
scavenges free radicals.
 Facilitates cellular and humoral responses.
 Provides colorless and transparent medium for
optical system of the eye.
STRUCTURE OF CILIARY BODY

The ciliary body is a right triangular uveal structure lying

between the iris and choroid.

The ciliary body consists of

 Muscle
• Longitudinal - on contraction opens the
trabecular meshwork and schhlem’s canal.
• Circular – on contraction they relax the zonules
and helps accommodation.
• Radial – their function is not clear.
The ciliary muscle is innervated by
parasympathetic fibres from ciliary ganglion.

 Vascular stroma – formed by anastomosis between

long posterior ciliary artery and anterior ciliary
arteries
 Epithelium
Pigmented epithelium
Non-pigmented epithelium

The ciliary body consists of a folded anterior portion

pars plicata, and a flat posterior portion k/a pars plana.

The pars plicata consists of 70 – 80 ciliary processes having a

surface area of 6 cm2, for active transport and
ultrafiltration.

The pars plana and plicata are lined on the inner surface by
two layers of epithelium
• Outer pigmented layer- role in active
metabolic processes
• Inner non pigmented layer- abundance of
 Na+ – K+ ATPase, involved in fluid transport.

The two layers of epithelium have their apical surfaces in

apposition.

Each ciliary process is composed of central core of stroma

and capillaries covered by double layer of epithelium.

Adjacent cells in each epithelial layer and apical surfaces of

two layers of epithelium are connected by

• Gap junctions
• Puncta adherentia
• Desmosomes
• Zonulae occludens(NPE) – imp component of
blood aqueous barrier

The vascular supply is by long posterior ciliary arteries

branches of ophthalmic artery. It forms a major arterial
circle by anastomosis to supply the ciliary processes.
The ciliary body has a very high blood flow of about
154µl/min.

MECHANISM OF AQUEOUS HUMOR

FORMATION

Aqueous humor is formed by a complex process involving

• Ultrafiltration
• Active transport
• Diffusion
ULTRAFILTRATION

It is the process by which a fluid and its solutes cross a semi

permeable membrane under a pressure gradient.

In c/o ciliary body fluid movement is favored by hydrostatic

pressure difference between capillary pressure and IOP;
and resisted by difference between oncotic pressure of
plasma and aqueous humor.

As blood passes through the capillaries 4% of plasma filters

through the fenestrations in the capillary wall into
interstitial spaces between capillaries and ciliary epithelium.

Protein is expected in the stromal filtrate because of

fenestrated nature of ciliary capillaries.

ACTIVE TRANSPORT

It is an energy dependent process which selectively moves a

substance against its electrochemical gradient across a cell
membrane.

Aqueous humor formation mainly depends upon ions

actively secreted into the inter cellular clefts of non
pigmented epithelium beyond tight junctions.

These cells secrete aqueous humor to 1/3 rd of its own

intracellular volume per min.

The ions which are actively transported include sodium,

potassium and bicarbonate through a membrane bound NA
K ATPase pump in the non pigmented epithelium.
Sodium gradient is mainly responsible for aqueous humor
formation. Also some amount of chloride, potassium,
ascorbic acid and amino acids are actively secreted.

Bicarbonate is present in excess in newly formed aqueous

humor. It is formed by the foll mechanism –
c.a
CO2 + OH ↔ HCO3

Carbonic anhydrase is present in cell membrane of non

pigmented epithelial cells and it catalyzes the above reaction.
It possibly helps to maintain the proper pH for Na K
ATPase system for optimum active transport of sodium.
Therefore carbonic anhydrase inhibitors
• Decrease the rate of entry of bicarbonate into newly
formed aqueous humor.
• Decrease the rate of entry of water into posterior
chamber.
• Also they decrease aqueous humor formation by
causing systemic acidosis.

DIFFUSION

It is the movement of a substance across a membrane along

its concentration gradient.

Hence to maintain balance of the above secreted substances

actively water, chloride and other plasma constituents move
into posterior chamber by ultrafiltration and diffusion.

Sodium is primarily responsible for movement of water in

the posterior chamber and hence the major factor for
formation of aqueous.
Quantitatively the net movement of a substance across a
semi permeable membrane where only diffusion occurs is
expressed by FICK’S LAW
Rate of movement = K (C1 – C2)

K – constant which depends on the nature and permeability

of the membrane, nature of solute, solvent, temperature.

C1 – concentration of substance on side of higher

concentration

C2- concentration of substance on side of lower

concentration

In c/o aqueous production lipid soluble substances are

transported by diffusion though lipid portions of cell
membrane of ciliary processes proportional to concentration
gradient across the membrane.

As the aqueous humor passes from posterior to anterior

chamber it resembles plasma more closely as diffusional
exchange occurs with surrounding tissues like iris, lens, and
cornea, vitreous.

Provides glucose, amino acids, oxygen and potassium and

removes carbon dioxide, lactate and pyruvate.
CHEMICAL COMPOSITION

PHYSICO CHEMICAL PROPERTIES

Volume – 0.31 ml
Refractive index – 1.336
Density – slightly denser than water 1.025 to 1.040
Osmotic pressure - 3 to 5 mOsm/L
pH – acidic 7.2
Rate of formation- 2 to 3 µl / min

BIOCHEMICAL COMPOSITION

Relative to the plasma general characteristics of aqueous is

as follows

Slightly hypertonic
Acidic
Marked excess of ascorbate
Marked deficit of protein
Slight excess of chloride and lactic acid
Slight deficit of sodium, bicarbonate, CO2 , glucose.
Other constituents include
Amino acids
Sodium hyaluronate
Norepinephrine
Coagulation factors
tPA
Latent collagenase activity
Entry of various substances depend on a number of factors
such as molecular size, electrical charge, and lipid solubility.

Therefore large molecules like proteins penetrate the eye

poorly, and lipid soluble substances pass readily.

There are certain transport systems which actively transport

substances out of the eye hence preventing accumulation of
toxic substances in the eye.

BLOOD AQUEOUS BARRIER

It is a barrier to the movement of substances from the

plasma to the aqueous humor so as to prevent large size
molecules such as protein to enter the cavities of the eye
hence maintaining the clarity of the media of eye.

The barrier include

• vascular endothelium
• basement membrane
• stroma
• pigmented and non pigmented
epithelium

Of all the above the tight junctions or the zonae occludens of

the non pigmented epithelium are considered to be the
actual site of the barrier.

Although the name signifies but the junctions are not so

tight cause they allow the passage of some small ions and
water across them.

Many exogenous and endogenous stimuli increase the

permeability of the barrier hence increasing the protein
content of the aqueous, recognized clinically as the tyndaqll
effect.
Stimuli which break the blood aqueous barrier are as
follows

Trauma
• mechanical injury
• contusion
• paracentesis
Chemical irritants
• nitrogen mustard
• formaldehyde
• acid , alkali
Neural activity
• stimulation of the trigeminal nerve
Immunogenic activity
• bovine serum albumin
Endogenous mediators
• histamine
• bradykinin
• prostaglandins
• serotonin
• acetylcholine
Corneal and intra ocular infections

Miscellaneous
• bacterial endotoxins
• x radiation
• infrared radiation
• laser energy
• alpha melanocyte stimulating hormone
 In certain situations like intra ocular infections breach in
the barrier brings cellular and humoral immunity to the
eye
On the other hand it favours complications such as cataract
and synechia formation.

TECHNIQUES FOR MEASUREMENT OF AQUEOUS

HUMOR

1. Pressure dependent techniques

Depends on the following equation
Flow = C (Po – Pv)
C =facility of outflow
Po = IOP
Pv = episcleral venous pressure

• tonography
• suction cup
• perfusion

2. Tracer method
• photogrammetry
• fluorescein
• fluoresceinated dextrans
• paraminohippurate
• iodide
FACTORS AFFECTING AQUEOUS HUMOR
FORMATION

1. Diurnal variation
• Most commonly the IOP peaks in the afternoon
and is minimum at early morning and late
night.
• The rate of formation is half during sleep due
to decreased stimulation of ciliary epithelium
by circulating catacholamines.
2. Age and sex
• Similar rate in males and females.
• Reduction in aqueous humor formation
decrease with age of 60.
3. IOP
Many investigators have postulated a feed back
mechanism but many other observations have
negated such a relationship.
4. Blood flow to ciliary body
Profound vasoconstriction decreases the rate of
aqueous flow.
5. Neural control
The stimulation of cervical sympathetic chain,
hypothalamic centres alter the aqueous production.
At present the mechanisms are unclear
6. Hormonal effects
Systemic corticosteroids are responsible for the
circadian variations of IOP.
7. Intra cellular regulators like cAMP and cGMP can
also alter the rate of secretion.
 8. Pharmacologic agents
Stimulants of aqueous secretion – β adrenergic
agents, endogenously administered corticosteroids
and pilocarpine.
Decrease of aqueous secretion caused by variety of
drugs e.g. carbonic anhydrase inhibitors, β
adrenergic antagonists etc
9. Surgery
Cyclocryotherapy and cyclodiathermy reduce
aqueous formation.

AQUEOUS HUMOR OUTFLOW

ANATOMY OF THE OUTFLOW SYSTEM

The major pathway from anterior chamber to venous

system include
Trabecular meshwork
Juxtacanalicular tissue
Schlemm s canal
Aqueous veins
Episcleral veins

TRABECULAR MESHWORK

It is a sieve like structure through which aqueous humor

leaves the eye.

It bridges the scleral sulcus and converts it into a tube which

accomodates the schlemm’s canal
It consists of three parts
1. UVEAL MESHWORK

It is the inner most part of trabecular meshwork extending

from iris root and ciliary body to the schwalbes line.

The trabeculae are cord like and 2 to 3 layers thick having

irregular openings of 25 μ to 75 μ .

2. CORNEO SCLERAL MESHWORK

It forms the larger middle portion extending from scleral

spur to lateral wall of scleral sulcus.

The size of elliptical openings vary from 5 μ to 50 μ.

3. JUXTA CANALICULAR MESH WORK

It forms the outer most portion of trabecular mesh work

and offers the normal resistance to aqueous outflow.

It consists of a layer of connective tissue lined on either

side of endothelium and connects corneo scleral mesh
work with schlemms canal. (2 -20 μm thick).
SCHLEMM S CANAL

It is an endothelial lined circular channel which runs

circumferentially around the globe.

It resembles lymphatic channel in its structure.

The endothelial cells of its inner wall are irregular spindle

shaped and contain giant vacuoles.

The outer wall of schlemms canal has a single layer of

endothelium that lacks pores or vacuoles.

Generally it has a narrow slit like lumen that is 190 to 370 μ

in diameter.

COLLECTOR CHANNELS

Schlemm s canal is drained by a series of collector channels

which in turn drain into a complex system of intra scleral,
episcleral, and subconjunctival venous plexuses.

EPISCLERAL VEINS

Most of the aqueous vessels drain into these veins.

The episcleral veins ultimately drain into cavernous sinus

via anterior ciliary and superior ophthalmic veins.
PHYSIOLOGY OF THE OUTFLOW SYSTEM

Aqueous humor flows from posterior chamber to the

anterior chamber through the pupil against slight
physiologic resistance.

In the anterior chamber there exists convection (thermal)

current which results from a temperature gradient between
anterior and posterior parts of the anterior chamber, as
cornea is cooler than the iris due to evaporation.

From the anterior chamber the aqueous is drained by two

routes

Trabeculocanalicular outflow

Uveoscleral outflow

TRABECULOCANALICULAR OUTFLOW

It is the main outlet for aqueous accounting for 75 to 90 %of

drainage.
Most of the aqueous passes

Uveal meshwork
↓
Corneoscleral meshwork
↓
Juxtacanalicular tissue
↓
Endothelial lining of canal
↓
Collector channels
↓
Intrascleral venous plexus
↓
Episcleral venous plexus
↓
Anterior ciliary veins
FIGURE 1. Schematic diagram of the aqueous humor cycle

Llobet, A. et al. News Physiol Sci 18: 205-209 2003;

doi:10.1152/nips.01443.2003

Copyright ©2003 American Physiological Society

The trabecular meshwork schlemm s canal has been
described as a sponge like one way valve for egress of
aqueous humor as it permits bulk flow in one direction but
restricts flow in opposite direction.

It is therefore considered as a crucial part of the blood

aqueous barrier.

Also the trabecular endothelial cells have s phagocytic

function so it acts as the reticulo-endothelial system of the
eye.

MECHANISMS OF AQUEOUS TRANSPORT ACROSS

INNER WALL OF SCHLEMMS CANAL

1. vacuolation theory
It has been suggested that aqueous humor enters the
schhlem’s canal by traversing the trans-cellular channels in
the endothelial cells

These channels form and recede in a cyclic fashion

The cycle begins with the invaginations on the trabecular

side of the endothelial cells and progresses to a trans cellular
channel with a small pore opening into the schlemms canal
At one time only a small fraction of invaginations open into
the canal and they account for majority of normal resistance
to outflow.

2. leaky endothelial cells

3. sondermans channels
4. contractile micro filaments
5. pores in endothelial cells

Newer advances- it has been suggested that there is

involvement of extracellular matrix of the trabecular
meshwork in aqueous humor outflow.

A pressure gradient between IOP and intrascleral venous

pressure is responsible for unidirectional flow of aqueous.
UVEOSCLERAL OUTFLOW

It is responsible for 10 to 25 % of total aqueous flow

Aqueous passes across ciliary body into the suprachoroidal

space and is drained by venous circulation in the ciliary
body, choroid, sclera into the orbital tissues.

The main resistance to the uveoscleral outflow is the tone of

ciliary muscle.

Therefore pilocarpine which contracts the ciliary muscle

lowers the uveoscleral outflow.

Atropine relaxes the ciliary muscle and increases the

outflow.

Uveoscleral outflow is raised significantly by the

prostaglandins therefore they are the most potent low dose
IOP lowering agents.

METHODS FOR MEASURING THE OUTFLOW

FACILITY

The facility of outflow can be measured by the goldmann

equation

C = F/Po - Pv

C = facility of outflow (μl/min/mmHg)

F = aqueous humor production (μl/min)
Po = IOP (mm of Hg)
Pv = episcleral venous pressure (mm of Hg)
The following methods are used for measuring outflow
facility

Tonography
Perfusion
Suction cup

TONOGRAPHY

It is a non invasive technique for determining the facility of

aqueous outflow.

During tonography a schiotz tonometer is placed on the

cornea for a few mins.

The weight of the tonometer increases the IOP and increases

the outflow of aqueous above its normal rate. The tonometer
is connected to a continuous recording device.

Using tables one can infer the change in IOP readings to be

inferred as the volume of aqueous displaced from the eye
(▲V).

Rate of fluid outflow = ▲V/t

If the tonometer raises IOP from initial P0 to average value

of Pt the outflow facility, C

C = ▲V/t
-----------
Pt - P0
ASSUMPTIONS

1. An acute rise in IOP alters nothing besides the rate

of aqueous humor flow.
2. All eyes respond with similar distension of the ocular
coats to acute rise in IOP.
3. Raising IOP does not affect the ocular blood volume.

ERRORS

1. operator errors
2. patient errors
3. instrument errors
4. reading errors

CLINICAL IMPLICATIONS OF FACILITY OF

OUTFLOW

The mean outflow facility in normal eyes range from 0-22 to

0.28 μl/min and mean Po ratio ranges from 55 to60

Both the above variable are not distributed in a normal or

Gaussian fashion and there is a considerable overlap
between normal and glaucomatous eyes

Therefore tonography is neither sufficiently sensitive no

specific to make the diagnosis of glaucoma.

Thus clinicians abandoned the test because the added value

of the test was minimal when compared with time and effort
it took to obtain quality results.
Some other uses of tonography are as follows

1. To predict the development of POAG

2. To assess the adequacy of anti glaucoma therapy
3. To detect the wide diurnal swings of IOP
4. To help diagnosis of angle closure glaucoma
5. To determine the mechanism of action of ocular
hypotension medications and different glaucoma
operations

FACTORS AFFECTING THE FACILITY OF OUTFLOW

1. AGE
Modest decline in aqueous formation as well as outflow
with age

2. HORMONES
Corticosteroids administered topically, systemically or
periocularly would ↓ outflow facility

Other hormones such as prostaglandins, progesterone,

thyroxin, relaxin, and chorionic gonadotrophin are
postulated to influence the outflow facility

3. CILIARY MUSCLE TONE

↑ tone of the muscle ↑ the outflow facility which can
occur during the following conditions

• Accommodation
• Electric stimulation of the oculomotor nerve
• Posterior depression of the lens
• Administration of parasympathomimetics eg
pilocarpine

4. DRUGS
↑outflow
• Pilocarpine
MOA- contracts the ciliary muscle which pulls the
scleral spur posteriorly and internally opening the
intratrabecular spaces and schlemms canal
• Cholinergic drugs
MOA – constricts the pupillary sphincter(miosis)
Tightens the iris
↓the volume of iris tissue in the angle
pulls the peripheral iris away from the
trabecular meshwork

Hence increasing aqueous outflow

• Epinephrine and dipivefrin

MOA – it ↑both the conventional as well as
unconventional outflow from the eye
• Prostaglandins
MOA- ↑uveoscleraloutflow
• Bradykinin

↓outflow

• Parasympatholytics
• Ganglion blocking agents

5. SURGICAL THERAPY
Filtering operations and argon laser trabeculoplasty ↑ the
outflow facility
Cyclodialysis ↑ the uveoscleral outflow.
 6. DIURNAL FLUCTUATION
Considerable controversy

7. GLAUCOMA
Outflow facility is reduced in most forms of glaucoma

Primary infantile laucoma

Angle closure glaucoma
Secondary open angle glaucoma
POAG

Episcleral venous pressure

It can be measured using

• Pressure chambers
• Torsion balance devices
• Force displacement transducers
• Air jets
• Direct canulation

Normally ranges from 8 to 11.5 mm of Hg

INTRA OCULAR PRESSURE

The IOP refers to the pressure exerted by intraocular

contents on the coats of the eyeball.
The normal level of IOP is maintained by a dynamic
equilibrium between aqueous humor formation , outflow
and episcleral venous pressure.

Normal IOP varies between 10.5 and 20.5 mm of Hg with a

mean pressure of 15.5 ± 2.57 mm of Hg

The IOP serves as the tissue pressure of vascularized

internal structures of the eye and is thus much higher than
the tissue pressure elsewhere in the body (5 mm of Hg)

Normal IOP is pulsatile reflecting its vascular origin and

effects of blood flow on the ocular structures

INSTRUMENTS FOR MEASURING IOP

Direct method – manometry

Indirect method – tonometry

Tonometry is broadly divided into two types

• Indentation tonometry
Measures the force required to flatten a small standard
area of the cornea
• Applanation tonometry
Measures the amount of deformation or indentation of
the globe in response to a standard weight applied to the
the cornea .

Indentation instruments

• Schiotz tonometer
 • Electronic schiotz tonometer

Applanation instruments

• Goldmann tonometer
• Perkins tonometer
• Draeger tonometer
• MacKay – Marg tonometer
• Pneumatic tonometer
• Noncontact tonometer
• Maklakow tonometer

DISTRIBUTION OF IOP IN THE GENERAL

POPULATION

Several population based studies have been done to

comment on the frequency distribution of normal IOP

The most frequently cited study is that of Leydhecker and

associates and the conclusions drawn are as follows:

• The distribution of pressures observed resembled a

Gaussian curve but was skewed towards the right
• It has been assumed that perhaps two different
population groups account for skewed distribution ; a
large normal group and a smaller group that was felt
to be glaucomatous without any optic nerve head
damage
• The mean IOP of the normal group was 15.5 ± 2.57 mm
of Hg
• 95 %of the population had an IOP between 10.5 and
20.5 mm of Hg
Some important conclusions drawn from the other
population based studies are as follows

• a slight increase of mean IOP in each decade over 40

yrs
• a slight higher pressure exists in women than men in
population above 40 yrs
• IOP difference between right and the left eye rarely
exceeds 4 mm of Hg
• Level of IOP is inherited as a polygenic multi factorial
trait

FACTORS AFFECTING IOP

1. AGE
Mean IOP increases with increasing age

2. SEX
Higher IOP in women

3. RACE
Higher IOP among blacks

4. HEREDITY
Polygenic trait

5. DIURNAL VARIATION
IOP varies an average of 3 to 6 mm of Hg in normal
individuals
Max pressure in mid morning hours
Min pressure at late night or early in the morning
However some individuals show no consistent pattern
6. SEASONAL VARIATION
Higher IOP in winter months

7. CARDIOVASCULAR FACTORS
IOP increases with ↑BP

8. EXERCISE
Strenuous exercise produces a transient reduction in IOP

9. POSTURE
IOP ↑from sitting to supine posture

10. NEURAL FACTORS

As of today there is no proof for this hypothesis
Cholinergic and adrenergic input alters the IOP

11. HORMONES
corticosteroids ↑the IOP.
Diabetics have higher IOP

12. DRUGS
13. REFRACTIVE ERROR
Myopes have higher ↑IOP

14. OTHERS
Eyelid movements, lid closure, inflammation and surgery
also alter the IOP