ANALIZA DATELOR BIBLIOGRAFICE REFERITOARE LA COMPONENTA UMORII

APOASE
AQUEOUS UMORS COMPOSITION
FORMATION AND SECRETION OF AQUEOUS HUMOR
Early in the twentieth century, aqueous humor was regarded as a stagnant
fluid.1 However, this misconception was revoked after a number of experiments
designed to investigate this were carried out, including Seidel's procedure, 2 in which
a cannula connected to a reservoir of indigo carmine dye was inserted into the
anterior chamber of the rabbit eye. The reservoir was raised, thus creating a
pressure of 15 mmHg, and the dye was seen to enter the anterior chamber and
subsequently the episcleral veins. From this, it was concluded that aqueous humor is
continuously formed and drained, and it is to a large extent from this historic work
that the modern study of aqueous humor dynamics has developed.
Other aspects of the anatomy and physiology of aqueous drainage were discovered
subsequently. Boerhaave3 first described the presence of the aqueous veins, and
Ascher4 observed a clear fluid in veins of the episclera and demonstrated by means
of external compression with a glass rod that these veins were interconnected with
veins containing blood. Goldmann5 demonstrated that these vessels contained
aqueous humor by injecting fluorescein intravenously and observing the dye enter
the anterior chamber and subsequently the aqueous veins. Ashton 6 identified an
aqueous vein in a living human eye, and postmortem examination showed that there
was a direct passage between the vessel and Schlemm's canal, using a neoprene
cast. Three physiologic processes are known to contribute to the formation and
chemical composition of the aqueous. These are diffusion, ultrafiltration (and the
related dialysis), and active secretion. The first two are passive and, therefore,
require no active cellular participation. Diffusion of solutes across cell membranes
occurs down a concentration gradient. Substances with high lipid solubility
coefficients that can easily penetrate biological membranes move readily in this way.
Ultrafiltration is the term used to describe the bulk flow of blood plasma across the
fenestrated ciliary capillary endothelia, into the ciliary stroma, which can be
increased by augmentation of the hydrostatic driving force. This process is
responsible for the formation of the reservoir of the plasma ultrafiltrate in the
stroma, from which the posterior chamber aqueous is derived, via active secretion
across the ciliary epithelium. Active secretion requires energy, normally provided via
the hydrolysis of adenosine triphosphate (ATP). The energy is used to secrete
substances against a concentration gradient.
Of these three processes, active secretion is believed to contribute the most to the
chemical composition and volume of the posterior chamber aqueous.
DIFFUSION
Diffusion arises from the fact that the molecules in a fluid are in constant, random
motion. The magnitude and rate of motion vary directly with the temperature. If the
molecules in a liquid or gas are not evenly distributed, then simply by the laws of
statistical probability the molecules will eventually reach a state of equilibrium
whereby they are redistributed equally. For example, if there is initially a cloud of
smoke particles on the right side of a closed room without air currents, more
particles will move from the right side to the left, than from left to right. This process
will continue until there is a relatively even distribution throughout the room, at
which time the number of particles going from right to left at any moment will be
equal to the number moving in the opposite direction.
A similar process occurs in single solutions and in situations in which two solutions
are separated by a membrane, as long as the membrane is permeable to at least
some of the constituents of the solution (semipermeable membrane). Most capillary
1

walls are permeable to water, dissolved gases, and many small molecules and ions.
In a stagnant system, substances of higher concentration on one side of a
semipermeable membrane show a net movement to the side of lower concentration
until the concentrations are equal on both sides. When equilibrium is reached,
movement across the membrane still occurs, but the number of particles going in
one direction equals the number going the other way, thus yielding
no net movement.
It should be noted that water (or another solvent) participates in this process. Net
movement of water is usually in the opposite direction of solute movement, since a
higher concentration of solute means, in effect, a lower concentration of solvent.
Fick's law describes quantitatively the net movement of a substance across a
semipermeable membrane where only diffusion is occurring:
The less permeable the membrane to the solute or solvent, the lower the
temperature, and the more viscous the fluid medium, then the longer will be the time
required for equilibration. Therefore, diffusion tends to occur more rapidly through
extracellular fluids than across cells. It should also be remembered that conditions
for diffusion are markedly altered in a dynamic system such as the ciliary processes,
in which blood is flowing rapidly, aqueous humor is constantly being formed and
carried away, and other processes occur, such as those described below.
DIALYSIS AND ULTRAFILTRATION
In most biological solutions, there exists a combination of salts, sugars, proteins, and
other large molecules. Most biological membranes are permeable to water, salt, and
some small organic molecules. However, these membranes are relatively
impermeable to larger molecules, such as proteins.
If a solution of protein and salt is separated from either water or a less concentrated
salt solution by a membrane permeable to the salt and water but not to the protein,
then there will be a net movement of water to the protein side by diffusion, and a
movement of salt away from the protein side. The protein, of course, cannot move
across the membrane. This process is called dialysis (Fig. 1) and is utilized, for
example, for removing unwanted salts and other toxic substances from the blood,
using the peritoneum as the membrane (peritoneal dialysis), or by using a synthetic
membrane such as that found in a dialysis machine (artificial kidney).
Fig. 1. Dialysis. The presence of protein molecules (large circles) induces a net
movement of water (small dots) across the semipermeable membrane to the protein
side. There is also a net movement of salt molecules (broken circles) away from the
protein side. With the exception of protein, movement of all molecules occurs in both
directions, but net movement is in the direction as indicated by the solid
arrows. (Courtesy of RL Stamper, MD)

By the addition of a hydrostatic pressure on the protein side of the system, the
exchange of salt and water can be accelerated. This process is called ultrafiltration
and differs from dialysis only because the hydrostatic pressure changes the rate of
movement of ions and slightly changes their final respective concentrations. The
fluid formed by the process of dialysis is called a dialysate, and that formed by
ultrafiltration is called an ultrafiltrate. Ultrafiltration is the process that occurs across
2

capillary walls due to the higher pressure and higher protein concentration in the
plasma as compared with the extracellular space (Fig. 2).
Fig. 2. Ultrafiltration. This process is similar to dialysis, but with the addition of a
hydrostatic pressure that increases the rate of net movement of water and salt
molecules across the semipermeable membrane. The final equilibrium
concentrations on either side of the membrane are the same as in dialysis. The
hydrostatic pressure merely increases the rate at which equilibrium is
achieved. (Courtesy of RL Stamper, MD)

GIBBS-DONNAN EQUILIBRIUM
The salt does not distribute itself equally on both sides of the membrane. Since the
protein carries an electrical charge (generally an overall negative charge at
physiologic pH), the positive ions in solution tend to be bound to the negatively
charged residues of the protein molecules. Thus, there is an excess of cations such
as Na+ or K+ on the protein side of the membrane.
This unequal distribution is called the Gibbs-Donnan effect, and the quantitative
relationships between the various ions (at least in simple systems) is predictable (Fig.
3). In order to maintain electrical balance, the total positive charges (e.g., number of
Na+ and K+ ions) on one side must equal the total negative charges (e.g., sum of
negative protein charges, Cl- ions, and any other negative ions). Furthermore, it has
been shown that the final equilibrium concentrations of Na + and Cl- on each side of
the membrane are related according to the following equation 7,8:
Fig. 3. Gibbs-Donnan effect. Because protein molecules carry an overall electrical
charge (usually negative) at physiological pH, the distribution of ions at equilibrium
is altered slightly to reflect the tendency of the protein molecules to attract
oppositely charged and repel like-charged ions. Therefore there is a higher
concentration of cations on the protein side and a higher concentration of anions on
the nonprotein side of the system. (Courtesy of RL Stamper, MD)

Thus, if the aqueous humor were like extracellular fluid in most capillary beds of
other parts of the body, we should expect to see a protein-free aqueous solution with
ionic concentrations like those on side 2 of a Gibbs-Donnan ultrafiltrate of plasma.
The Na+ and K+ concentrations should be less than plasma, and the Cl- and HCO 3concentrations should be slightly higher. Further, the actual values of the ratios of
the concentrations of each respective ion in aqueous to plasma would conform to the
values obtained experimentally when plasma is dialysed against its own ultrafiltrate.
In addition, no organic substance should be at higher concentration than in the
3

plasma, since diffusion and ultrafiltration can, at most, only equalize the
concentrations of organic substances. These processes cannot promote an excess
concentration on side 2 of the membrane.
Although aqueous humor resembles a dialysate of plasma in many ways, as will be
seen, the ionic concentrations do not quite fit the Gibbs-Donnan predictions, and
some nonionic substances have higher concentrations in aqueous than in plasma
(Table 1). Such a condition can only occur in the presence of some active metabolic
process.9
TABLE ONE. Aqueous Versus Dialysate
Concentration Ratio

Concentration Ratio

Substance

(aqueous/plasma)

(dialysate/plasma)

Na+

0.96

0.945

K+

0.955

0.96

0.58

0.65

Mg2+

0.78

0.80

Cl-

1.015

1.04

HCO3-

1.26

1.04

H2CO3

1.29

1.00

Glucose

0.86

0.97

Urea

0.87

1.00

Ca

2+

Values are for the rabbit eye. Although the chemical composition of aqueous humor
bears some similarities to a plasma dialysate, the small differences are significant.
These differences can only be accounted for theoretically by an active secretory
mechanism.
(Adapted from Davson H: The Aqueous Humor and the Intraocular Pressure. In:
Physiology of the Eye, 5th ed, pp 395. New York, Pergamon Press, 1990.)
SECRETION
Secretion implies an active process that selectively transports some substances
across the cell membrane. Since energy is consumed, substances can be moved
across a concentration gradient in a direction opposite to that which would be
expected by passive mechanisms alone. One example of this is the ability of the
thyroid gland to accumulate iodide at up to 40 times the circulating plasma
level.10 One would expect the iodide concentration in the plasma and the thyroid
gland to be similar if only diffusion and ultrafiltration were operating. Aqueous humor
exhibits increased ascorbate, lactate, and certain amino acid concentrations as
compared with plasma, as a consequence of active secretion.
Another way of testing for the presence of an active metabolic process is to apply
specific metabolic inhibitors to the ciliary body and observe the effect on aqueous
secretion. Ultrafiltration of fluid from the plasma to the posterior aqueous has been
suggested to be responsible for approximately 70% of aqueous formation. 11
15
However, the results of experiments where metabolic inhibitors have been used
have shown conclusively that this is not the case. For example, systemic 16 or
intravitreal injection17 of ouabain (an inhibitor of the enzyme sodium-potassium
activated adenosine triphosphatase--Na + /K+ ATPase) results in a decrease of up to
70% in aqueous formation, in a variety of species. The topical administration of
vanadate (also a Na+ /K+ATPase inhibitor) lowers aqueous secretion in rabbits 18,19 and
monkeys.20 If the greatest proportion of aqueous secretion was attributable to
4

ultrafiltration, then this could not occur. In addition, Bill 11 noted that the hydrostatic
and oncotic forces that exist across the ciliary epithelium-posterior aqueous interface
would favor resorption, not secretion, of aqueous humor. The ciliary process stroma
has an oncotic pressure of approximately 14 mmHg, because of its protein content.
Since IOP in the healthy eye is maintained at approximately 15 mmHg, a capillary
hydrostatic pressure of greater than 29 mmHg would be required to drive an
ultrafiltrate. Capillary hydrostatic pressure in the ciliary stroma has been estimated
to be 25 to 33 mmHg and 27 to 28 mmHg. 2It has been calculated14 that a capillary
pressure of greater than 50 mmHg would be necessary to promote ultrafiltration as
the major mechanism for the secretion of aqueous. The values of capillary
hydrostatic pressure in the ciliary processes and a consideration of the hydrostatic
and oncotic forces involved do not favor ultrafiltration as an important mechanism
for aqueous humor secretion. Acetazolamide, and other specific inhibitors of the
enzyme carbonic anhydrase, decrease the formation of aqueous by 40% to 60%. 21
24
A reduction in temperature, which inhibits most active metabolic processes, also
results in a decrease in aqueous formation, to a greater extent than would be
expected if only diffusion were operating.24
Active transport systems usually exhibit a limit beyond which an increase in
substrate concentration produces no further increase in transport. When this limit is
reached, the system is said to be saturated. Thus, the fact that a transport
mechanism for a substance can be saturated provides evidence of an active system.
It has been demonstrated that by increasing the ascorbate concentration in plasma,
a level of plasma ascorbate is reached above which no further increase in aqueous
ascorbate concentration will occur.36 This provides evidence that the ascorbate
transport system in the eye is saturable.
Several membrane active transport systems have been identified in the ciliary
epithelium that are known to pump various substances against a concentration
gradient, including Na+ /K+ ATPase and amino acid membrane transporters (Fig.
4).There are also passive transport proteins specific for HCO 3- and Cl-. Membrane
bound Na+ /K+ ATPase is one important system involved in Na +and K+ transport and is
present mainly along the lateral cellular interdigitations of the nonpigmented ciliary
epithelium.16,26-32 The transmembrane Na+ /K+ transport protein is energized by the
Gibbs free energy of hydrolysis of ATP, mediated by the ATPase enzyme intimately
associated with it in the membrane. The ATP required for this process is derived
predominantly from oxidative metabolism of glucose via the Krebs' citric acid cycle.
It is most likely that Na+ is pumped across the cell membrane and Cl)- is passively
carried with it in order to maintain electrical neutrality, although the relative rate of
transport of Cl- is unclear.33 The Na+ pump induces a potential difference across the
ciliary body, ranging from 6 to 10 mV. Measurements of the potential difference
across the ciliary epithelia indicate that the aqueous is positive with respect to the
stroma. The magnitude of this potential difference is reduced after poisoning with
ouabain.34These data are consistent with the hypothesis that Na + is the primary
mover. Active transport of Cl- is probably small in comparison to that of
Na+ .35 Interspecies differences in the aqueous-plasma ratios of Cl- (e.g., high in
human, low in rabbits) might be explained by the relative proportions of Cl- actively
transported.36 Transepithelial electrical measurements in the isolated rabbit irisciliary body indicate that Na+ /K+ ATPase and HCO3- are required for active ion
transport.37

Fig. 4. Diagram of possible secretory pathways in the ciliary processes. AA, ascorbic
acid; CA, carbonic anhydrase. (Adapted from Wiederholt M, Helbig H, Korbmacher C:
Ion transport across the ciliary epithelium: Lessons from cultured cells and proposed
role of the carbonic anhydrase. In: Carbonic Anhydrase, pp 232244. Basel, VerlagChemie, 1991)

Histochemical studies have demonstrated a number of active enzyme systems in the

ciliary epithelia. These include nucleotide phosphatases (especially ATPase, as
mentioned previously), adenylate cyclase, and carbonic anhydrase, the enzyme
which forms HCO3- (the body's alkaline ion) from CO2 and H2O.3842 The enzyme has
been shown to be localized in both the pigmented and the nonpigmented epithelial
cells of the rabbit ciliary processes, 43,44 and monkey and human pigmented and
nonpigmented epithelial cells, 45 most prominently in the basal and lateral
membranes, but also in the cytoplasm. A variety of carbonic anhydrase inhibitors will
reduce
aqueous
secretion,
including
acetazolamide, 46 methazolamide,
methoxazolamide,
ethoxzolamide,
dichlorphenamide,47,48 aminozolamide,49 trifluormethazolamide,50 6hydroxyethoxzolamide,51 MK-927, L-671,152 (MK-507, dorzolamide), 52,53-58 and several
biscarbonylamidothiadiazole compounds.23 The site of action of these drugs is
intraocular rather than systemic, because the unilateral injection of acetazolamide
into the carotid artery lowers the IOP of only the ipsilateral feline eye. 59 Precisely how
carbonic anhydrase helps mediate aqueous secretion has been a longstanding
debate. However, in recent years many advances in understanding of this system
have been achieved. In the past, it was suggested that acetazolamide caused
constriction of afferent iris or ciliary arteries, thereby decreasing ultrafiltration and
hence aqueous humor formation. 60,61This view is no longer held, however. For
example, Bill,62 using radiolabelled microspheres, concluded that acetazolamide had
no significant effect on the blood flow in the intraocular tissues in the rabbit eye, and
that it was unlikely that the drug had any effect on blood flow in the anterior uvea. It
has now been irrefutably demonstrated that acetazolamide exerts its ocular effects
via a reduction in aqueous secretion, mediated by a direct effect on the ciliary
epithelial cells.28 The ciliary carbonic anhydrase system is now thought to function as
described by Maren.63 Inhibition of the enzyme decreases the rate of Na + and HCO3transport into the posterior chamber by equimolar amounts, indicating a linkage of
the accession of these two solutes into the posterior chamber of dogs and
6

monkeys.64 Further, inhibition of carbonic anhydrase lowers the aqueous Clconcentration in primates and the HCO 3- concentration in rabbits.65,66 The mechanism
bywhich carbonic anhydrase activity is coupled to Na + and HCO3- movement into the
posterior chamber is still subject to much study. However, it is now known that the
primary reaction, which occurs within the cytosol of the nonpigmented ciliary
epithelial cells, is the proteolysis of water to yield OH- and H + ions (Fig. 5). The
hydroxide ions so formed react with CO 2 catalytically (or noncatalytically when the
enzyme is inhibited) to form HCO 3-, which is passively transported to the aqueous
humor, simultaneously with the active transport of Na+ . The protons liberated from
water pass into the blood circulation where they are buffered by proteins. The
theoretical rates of flow of HCO 3-, based on known constants and some assumptions
regarding cell volume and pH of the secretory region, are shown at the bottom
of Figure 5. The catalytic rate (i.e., when active carbonic anhydrase is present) is 7
mol/min, and the uncatalyzed is 0.07
Fig. 5. Model for HCO3- formation and its linkage to Na+ transport in the ciliary
processes. Observed rates are for monkey. Chemical rate constants (37C) taken
from the work of Maren. (Adapted with permission, from The Annual Review of
Physiology 50:695. Copyright 1988,
by Annual Reviews Inc)A

The uncatalyzed rate is found experimentally by inhibiting the enzyme in vivo by a

large dose of acetazolamide or similar compound. Such inhibition, when complete,
should yield the uncatalyzed rate of HCO 3- formation. Measurements obtained
experimentally indicate that the observed inhibited rate (Fig. 5, right, 0.024
mol/min) is not very different from the calculated uncatalyzed rate of 0.07
mol/min. Considering the assumptions aboutpH and cell volume, the difference
between the calculated and experimentally measured inhibited rates of bicarbonate
flow lies within acceptable limits of error. Inhibition of the flow of bicarbonate also
leads to an inhibition of the flow of Na + . Several hypotheses have been put forward
to explain this: (1) inhibition of carbonic anhydrase causes a decrease in HCO 3available for movement with Na+ to the aqueous side to maintain electroneutrality;
(2) a reduction in intracellular pH may inhibit Na + -K+ATPase; and (3) decreased
availability of H+ produced by the reaction catalyzed by carbonic anhydrase
decreases H+ /Na+ exchange and reduces the availability of intracellular Na + for
transport into the intercellular channel.
A large excess of carbonic anhydrase has been found in the ciliary processes of all
species studied. This has pharmacologic implications when one hopes to reduce
7

aqueous secretion by inhibition of the enzyme. In order to achieve a clinically useful

reduction in secretion and hence IOP, more than 99% of the enzyme must be
inhibited. The sulfonamide carbonic anhydrase inhibitors have been in clinical use for
glaucoma since 1955, when their action on the eye was discovered as an offshoot of
their development as diuretics.48 They have also been extremely useful in research
on aqueous humor formation, because they are highly specific, having no other
actions at concentrations below 1 M. The major compound is acetazolamide, but
many ophthalmologists use methazolamide or related compounds, which have a
greater diffusibility than acetazolamide, and which act on the eye in lower doses,
thereby achieving the desired ocular effect but having lesser action on other systems
in the body where carbonic anhydrase is present, such as the secretory epithelia of
the kidney.21
Research to find carbonic anhydrase inhibitors that are active topically has
proceeded in recent years, in order to try to further improve the specificity of these
drugs for the eye. The systemic dose of sulfonamide carbonic anhydrase inhibitors
required to achieve greater than 99% blockade of ciliary carbonic anhydrase leads to
undesirable side effects, even with methazolamide. 67MK-927 and L-671,152 are
examples of such compounds.53 As a rule, the topically active carbonic anhydrase
inhibitors have a very high lipid and water solubility product, as well as a high
inhibitory potency and efficacy. Sufficient concentration is achieved in the ciliary
processes via transcorneal, aqueous humor and iris absorption after instillation of a
single drop.22,68 This results in essentially as large a drop in IOP as with the
sulfonamides.52,68 L-671,152 (MK-507, dorzolamide) is close to approval for clinical
use.69
In summary, then, aqueous humor is mainly a product of active cellular secretion
requiring metabolic energy. Na+ and K+ are transported from plasma to the posterior
chamber, with HCO3-, Cl- and water following passively to maintain electrical and
osmotic balance. Other substances such as certain amino acids are also actively
transported. Some other small molecules probably appear in the aqueous via
diffusion or ultrafiltration.
The process begins with an ultrafiltrate of plasma in the extravascular spaces of the
ciliary stroma. The ciliary epithelium (probably nonpigmented) then incorporates
certain molecules and ions selectively for concentration and direct active secretion
into the posterior chamber, whilst other substances are secreted passively.
THE BLOOD-AQUEOUS BARRIER
Very large molecules such as proteins are present in the aqueous in only very small
quantities, even if their respective concentrations in the plasma are raised to very
high levels. In humans, normal plasma total protein levels are 6 g/100 mL, compared
with less than 20 mg/100 mL in the aqueous, less than 0.5% that in plasma. 70,71 Thus,
a restraint in the free passage of many solutes from the blood vessels of the ciliary
stroma into the aqueous humor exists. This constitutes one component of the bloodaqueous barrier,72 the anatomical correlate of which are the tight junctions between
the interdigitating surfaces of the nonpigmented ciliary epithelial cells.
Bill73,74 demonstrated that albumin and other proteins pass through the ciliary
capillary walls at a much faster rate than they enter the aqueous humor and
concluded that a barrier to these substances existed at a site other than the vessel
walls. The intravenous injection of horseradish peroxidase into the monkey has been
shown to lead to a rapid filling of the ciliary stroma by the enzyme. 75 The enzyme
passes through the many fenestrations present in the blood capillaries of the ciliary
body, since these have few tight junctions (similar to choroidal capillaries), and also
fills the spaces between the pigmented cells. However, it is prevented from entering
the aqueous by the tight junctions of the nonpigmented layer, between the cell
apices. Comparable results have been reported in the mouse 76,77 and in the rabbit.78,79
The blood-aqueous barrier is not absolute. Water soluble substances of medium
molecular weight such as urea, creatinine, and certain sugars may penetrate at
8

varying rates, but all are slower than their transit across capillary walls. Generally,
the greater the lipid solubility coefficient of a substance, the greater its ability to
penetrate the blood-aqueous barrier and pass to the posterior aqueous chamber. 8082
In addition, regional differences of permeability in the ciliary body have been
noted. For instance, the epithelia of the anterior portions of the ciliary processes of
the rabbit are less permeable than the epithelia of the pars plana. 78
Substances such as mannitol are used clinically to reduce IOP. They function as
hyperosmotic agents, by exploitation of the fact that they penetrate the bloodaqueous barrier only poorly but are distributed widely within the extracellular spaces
of the body. Water is drawn from cells and the ocular fluids, balancing the high
osmotic pressure induced in the extracellular space via the high concentrations of
mannitol. The resulting loss of water from the eye leads to a reduction in the IOP. The
effect of hyperosmotic agents is most pronounced in eyes exhibiting pathologically
elevated IOP.83
Other examples of hyperosmotic agents include glycerin, urea, isosorbide, and
ethanol. Urea was the first substance to be used for this purpose; however, it will
slowly penetrate the blood-aqueous barrier, and hence the hyperosmotic effect of
urea on the eye is shorter lived than that of mannitol. Ethanol is not used clinically as
it penetrates the eye even more rapidly than urea and in the required doses has
undesirable effects on the sensorium.
Certain antibiotics (e.g. chloramphenicol, cephalothin, and ampicillin) are known to
penetrate the blood-aqueous barrier well, whereas others do so only poorly
(e.g., penicillin, methicillin, erythromycin, and gentamicin).
A similar barrier to the passage of solutes exists in the retinal pigment epithelium,
thus forming a blood-vitreous barrier between the vitreous and the blood capillaries
of the choroid. Blood capillaries with tight junctions in their endothelia form further
physiologic barriers (functionally similar to the blood-brain barrier) in the iris and
retina.
SECONDARY AQUEOUS
The blood-aqueous barrier is fragile and may bedisturbed by a variety of noxious
stimuli. A corneal abrasion, paracentesis (withdrawal of a small volume of aqueous
via a needle inserted into the anterior chamber), 8488 intraocular infection, uveal
inflammation, intraocular surgery, and certain drugs, applied topically (such as
nitrogen
mustard
or
an
anticholinesterase, e.g.,echothiopate,
diisopropyl
flurophosphate [DFP], demecarium, neostigmine, or physostigmine), or delivered by
intracarotid infusion, such as hyperosmotic agents (causing separation of the ciliary
epithelial layers, opening of the blood-aqueous barrier, and severe, permanent
damage to the pigmented epithelial cells 89), are all capable of breaking down the
blood-aqueous barrier and inducing changes in the aqueous humor composition
(Table 2). Disruption of the blood-aqueous barrier has also been reported in the
contralateral eyes of patients who have had cataract extraction and lens
implantation surgery,90 and after argon laser trabeculoplasty. 91 Severe damage to the
blood-aqueous barrier occurs with cyclodestructive procedures used to treat
advanced glaucoma and is evidenced by the prolonged or chronic presence of flare
(the scattering of light upon slit-lamp examination by increased levels of protein in
the anterior chamber).
TABLE TWO. Factors Interrupting the Blood-Aqueous Barrier
I.
Traumatic
A.
Mechanical
1.
Paracentesis
2.
Corneal abrasion
3.
Blunt trauma
4.
Intraocular surgery
5.
Stroking of the iris
9

II.

B.

Physical
1.
X-ray
2.
Nuclear radiation

C.

Chemical
1.
Alkali
2.
Irritants (e.g., nitrogen mustard)

Pathophysiologic
A.
Vasodilation
1.
Histamine
2.
Sympathectomy
B.
C.
D.
E.

III.

Corneal and intraocular infections

Intraocular inflammation
Prostaglandins
Anterior segment ischemia

Pharmacologic
A.
Melanocyte-stimulating hormone
B.
Nitrogen mustard
C.
Cholinergic drugs, especially cholinesterase inhibitors
D.
Plasma hyperosmolality

After breakdown of the blood-aqueous barrier, the resultant aqueous produced is

known as secondary or plasmoid aqueous. 19,66,92 The most notable change is a
marked increase in protein concentration. In this situation, the ionic composition of
the aqueous approaches that of a simple dialysate of plasma, and substances that
are normally barred from entering the aqueous now do so with ease. The unusually
rapid rate of entry of substances such as fluorescein, Evan's blue dye, albumin, or
fibrinogen (which actually may allow the aqueous to coagulate) can be used as a
diagnostic indicator of barrier breakdown.
Many of the processes that disrupt the blood-aqueous barrier also lead to
vasodilation. Vasodilation can occur by means of an axon reflex (as may be seen
after abrasion of the cornea), a sudden drop in IOP, or inflammation. 93,94 In any case,
vasodilation may be associated with loss of some of the tight junctions in the iridial
vessels, which may help explain the breakdown of the barrier. 93
In addition, it has been suggested that plasma proteins and other constituents can
leak in a retrograde manner through Schlemm's canal, and, therefore, account for
the breakdown of the barrier after paracentesis. 95 In this study, no changes in the
permeability of the ciliary epithelium or iris to horseradish peroxidase were found
after paracentesis, contradicting previous studies and conventional views of the
mechanism of barrier breakdown.
Release of prostaglandins causes vasodilation and many other findings associated
with inflammation. Evidence points to the possible involvement of this class of
compounds with breakdown of the blood-aqueous barrier. 92,96-102 Prostaglandins have
been implicated in the irritative response after mechanical trauma to the eye, and
cause miosis, vasodilation, release of protein into the aqueous, and elevated IOP.
Prostaglandins applied topically to the eye in sufficiently high concentration cause
breakdown of the tight junctions of the nonpigmented ciliary epithelium and increase
the protein content of the aqueous humor, the highest levels of protein being found
in the posterior chamber. 103,104 Pretreatment with inhibitors of prostaglandin synthesis
such as indomethacin or aspirin will inhibit breakdown of the blood-aqueous barrier,
as well as some of the other manifestations of inflammation ordinarily induced by the
10

aforementioned process.105109 It may well be that prostaglandin release represents a

final common pathway for the action of many different kinds of trauma and irritants.
However, small doses of particular prostaglandins (especially PGF 2 and certain
congeners) applied topically to the eyes of cynomolgus monkeys and humans result
in a large increase in uveoscleral outflow, with a concomitantly large decrease in IOP,
without clinically evident ocular inflammation. 100,101,110115 PGF2 analogues thus show
promise as possible antiglaucoma drugs.
AQUEOUS HUMOR COMPOSITION
In the healthy eye, the aqueous humor has a refractive index taken to be constant at
a value of 1.336.116 Since this index of refraction is lower than that of the cornea,
there is a slight divergence of light rays as they pass the cornea-aqueous interface.
Both the viscosity and density of aqueous humor are a little higher than that of pure
water, while the osmolality is slightly higher than that of plasma. 9,117120
The volume of the human anterior chamber is approximately 200 L, while that of
the posterior chamber is approximately 60 L. This makes chemical analysis of the
aqueous quite difficult, due to the tiny volume of fluid as well as the relatively poor
accessibility of the posterior chamber. Further, it may account for the differences in
values for the concentrations of many substances obtained by different investigators.
The greatest difference between aqueous and plasma resides in the very low protein
concentration in the aqueous (Table 3), which is in the region of 0.5% that of
plasma.70,71 However, thecomposition of protein in the aqueous is also different from
that in plasma. The ratio of the levels of the lower molecular weight plasma proteins
(such as albumin and the -globulins) to the higher molecular weight proteins (such
as the -lipoproteins and the heavy immunoglobulins) is much higher in aqueous in
the normal healthy eye than in plasma. 112 However, when the blood-aqueous barrier
breaks down (as in uveitis), the composition and concentrations of protein in the
aqueous are similar to that of plasma. 71 The levels of immunoglobulin in the aqueous
have been determined, both in the normal eye and in eyes in which the barrier has
broken down.122124 In the healthy eye, immunoglobulin G (IgG) is present at a
concentration of approximately 3 mg/100 mL, 124 while IgM, IgD, and IgA are absent,
presumably because of their larger molecular structure. In eyes with uveitis, the
concentration of IgG increases, and IgM and IgA appear also. In the normal aqueous,
trace concentrations of active complement C2, C6, and C7 globulins are also
present.125
TABLE THREE. Aqueous and Serum Protein Concentration
Human
Protein

Rabbit

Aqueous (g/100 Serum

mL)
mL)

(g/100 Aqueous (g/100 Serum

mL)
mL)

Total
protein

0.013

7.5

0.050

5.6

Globulin

0.003

2.5

0.025

2.5

Albumin

0.010

0.025

3.1

(g/100

(Adapted from Davson H: The Eye. In: Vegetative Physiology and Biochemistry,Vol 1,
2nd ed, New York, Academic Press, 1969; and Duke-Elder S: The Aqueous Humour.
The Physiology of the Eye and of Vision, Vol 4, pp 104200. In Duke-Elder S (ed):
System of Ophthalmology. St. Louis, CV Mosby, 1968)
There are also trace quantities of several components of the fibrinolytic and
coagulation system present in the aqueous, with the exception of plasminogen and
plasminogen proactivator, which are present at more significant concentration. Only
11

trace quantities of the inhibitors of plasminogen activation are present in the

aqueous,126 thereby ensuring that the aqueous outflow pathways remain free of
fibrin. The aqueous humor of diseased eyes incorporates significant quantities of all
of the major components of coagulation and fibrinolysis, giving rise to formation of
intracameral clots; however, the composition of these clots is different from those
that occur in blood vessels.66
The and lens crystallins are also present in only small amounts in the aqueous
humor of healthy eyes, although the concentration of these proteins increases in
cataract.127,128
It has been calculated that in the normal healthy eye, the blood-aqueous barrier
behaves as a semiporous membrane with a pore radius of approximately 10.4 nm.
Recently, it has been proposed that anterior diffusion of proteins from the stroma of
the ciliary body and the stroma of the iris, by passing ciliary and iridial epithelial
barriers, accounts for the major fraction of protein in normal rabbit aqueous. 129
The concentration of amino acids, on the other hand, is frequently higher in the
aqueous than in the plasma. 130 In the canine eye, however, there is a lower
concentration of amino acids in the aqueous than in the plasma. 131 At least three
transport systems for amino acids have been proposed in the eye, 36 one each for the
acidic, basic, and neutral groups. A statistical study of the covariation of the
concentration of amino acids and related compounds in human aqueous suggested
the existence of six transport systems in the ciliary epithelia: three independent
mechanisms for neutral amino acids, and independent mechanisms for basic amino
acids, acidic amino acids, and urea. 132
The distribution of ions varies greatly amongst different species. For example, the
monkey has a higher concentration of H + and Cl- and a lower concentration of HCO 3as compared with plasma. On the other hand, rabbit aqueous has a lower
concentration of Cl- and H+ and a higher concentration of HCO 3- as compared with
plasma.133 Active transport of Cl- across the feline isolated ciliary epithelium has
been reported.33 Theconcentration of Na+ in the aqueous is almost the same as in the
plasma in many species.9,134 However, the osmotic pressure of aqueous is slightly
higher than that of plasma with respect to Na + , because of Gibbs-Donnan
equilibrium.
Most species tested have very high concentrations of ascorbate and lactate in the
aqueous. Ascorbate is actively secreted into the posterior chamber, and the
secretion mechanism will only function in the presence of ATP and a Na + gradient.
The physiologic function of ascorbate remains to be elucidated; however, it is known
to be concentrated by the lens epithelium.135 Ascorbate may function as an
antioxidant, regulate the sol-gel balance of mucopolysaccharides in the trabecular
meshwork, or partially absorb ultraviolet radiation, 136 as diurnal mammals have
approximately 35 times the concentration of aqueous ascorbate than nocturnal
mammals.137
Lactate is produced as a result of the glycolytic degradation of glucose by both the
ciliary body and the retina.138 It diffuses into the posterior chamber but is present at
only marginally higher concentration than in the plasma at this site. However, it is
accumulated in the anterior chamber at considerably higher concentration than in
the plasma.
Glucose, urea, and nonprotein nitrogen concentrations are slightly less than in
plasma.9 Glucose is thought to diffuse into the aqueous, where its concentration is
approximately 80% that of plasma. Glucose also diffuses into the cornea. Its
concentration within the corneal endothelium is approximately half that in the
aqueous. In diabetes mellitus, the aqueous concentration of glucose is increased.
Oxygen is also present in the aqueous humor, at a tension determined to lie between
13 to 80 mmHg, depending upon the method of measurement. 139143 The tension of
oxygen in the aqueous can be decreased by topical epinephrine, possiblyas a result
of uveal vasoconstriction143 or by the wearing of polymethylmethacrylate (perspex)
contact lenses, which, by restricting the normal passage of oxygen across the
12

corneal epithelium, cause corneal hypoxia and thus an increase in movement of

oxygen from the aqueous, across the corneal endothelium. 143
Berzelius144 first demonstrated the presence of lipids in bovine aqueous. Since then,
sphingomyelin, phosphatidyl choline, and lysophosphatidyl choline have all been
shown to be present in the aqueous, 145 although at a concentration of less than 1
mg/100 mL, as lipids are largely barred from entry to the aqueous by the bloodaqueous barrier.146
Other
substances,
such
as
corticosteroids, 147monoamine
148
3+
149
150
151
metabolites, Cr ions, vitamin B12, sialic acid, and hyaluronic acid152 have all
been found to exist in the aqueous of a number of different species. The role of these
compounds within the aqueous is not understood.
As the aqueous flows from the posterior chamber to the anterior chamber, changes
occur. Nutrients diffuse into the lens, iris, and vitreous. 153 Diffusion from the posterior
aqueous into the vitreous is a major contributor to the existence of concentration
gradients of low molecular weight substances in the vitreous. 154 Waste products, such
as lactate diffuse from the lens, iris, and corneal endothelium into the aqueous.
Some exchanges of small molecules occur across the iridial vessels. Predictably, the
chemical compositions of posterior chamber aqueous and anterior chamber aqueous
are different.9 To complicate the matter further, some substances appear to be
actively transported out of the eye. Para-aminohippurate (PAH), Diodrast, and
penicillin are examples of large anions that are actively transported out of the eye.
The system appears to be similar to that occurring in the renal tubules. This active
transport system can be saturated and can also be inhibited by low temperatures
and probenecid.9 The nonpigmented ciliary epithelium has been implicated as the
site of this active transport system within the anterior eye. Another independent
transport system actively excretes injected iodide from the aqueous. This latter
system resembles iodide transport mechanisms in the thyroid and salivary
glands.155 The significance to the normal physiology of the eye of these outwarddirected transport systems has not been established. With the discovery that
prostaglandins may be actively transported out of the eye, 156,157 some have
suggested that such mechanisms may be useful to rid the eye of biologically active
substances no longer needed, or which may even be detrimental. 24 Their removal
from the eye to the blood facilitates their excretion via the hepatic route. There are
other outwardly directed ion-uptake mechanisms present in the eye. The anterior
uvea of the rabbit eye, for example, accumulates the anions cholate, glycocholate,
deoxycholate, chenodeoxycholate, iodipamide, and o-iodohippurate. 158,159 Atleast one
inwardly directed anion pump mechanism also operates--ascorbate is accumulated in
the anterior chamber and lens, its concentration in the aqueous humor being about
20 times that in plasma.135 This may help protect the anterior ocular structures from
oxidative damage. Brny,160 making analogy to the ion pump located at the renal
peritubular cell border adjacent to the blood, which pumps simple cations from the
blood to the kidney tubule, investigated whether there are any inwardly directed
cation pump mechanisms from blood to aqueous. He concluded, however, that such
mechanisms probably do not exist, at least within the rabbit eye. But outwardly
directed cationic pump mechanisms have been reported. For example, iris-ciliary
body
preparations
have
been
shown
to
accumulate
the
cation
emepronium,161 although a later report162questioned whether any other cations are
actively eliminated from the eye.
REFERENCES:
1. Davson H: The Aqueous Humor and the Intraocular Pressure. In: Physiology of the
Eye, 5th ed, pp 395. New York, Pergamon Press, 1990
2. Brubaker RF: Flow of aqueous humor in humans [The Friedenwald Lecture]. Invest
Ophthalmol Vis Sci 32:3145, 1991
3. Hogan MJ, Alvarado JA, Weddell JE: Histology of the Human Eye. An Atlas and
Textbook, pp 136153, 260319. Philadelphia, WB Saunders, 1971
13

4. Cole DF: Aqueous humor formation. Documenta Ophthalmol 21:116 1966

5. Alm A, Bill A: Ocular and optic nerve blood flow at normal and increased intraocular
pressure in monkeys (Macaca irus): A study with radioactively labelled microspheres,
including flow determinations in brain and some other tissues. Exp Eye Res 15:15,
1973
6. Morrison JC, van Buskirk EM: Anterior collateral circulation in the primate eye.
Ophthalmology 90:707, 1983
7. Morrison JC, van Buskirk EM: Ciliary process microvasculature. Am J Ophthalmol
97:372, 1984
8. Morrison JC, van Buskirk EM: Sequential microdissection and scanning electron
microscopy of ciliary microvascular castings. Scan Electron Microsc 2:857, 1984
9. Caprioli J, Sears ML, Mead A: Ocular blood flow in phakic and aphakic monkey eyes.
Exp Eye Res 39:1, 1984
10. Morrison JC, de Frank MP, van Buskirk EM: Comparative microvascular anatomy of
mammalian ciliary processes. Invest Ophthalmol Vis Sci 28:1325, 1987
11. Morrison JC, de Frank MP, van Buskirk EM: Regional microvascular anatomy of the
rabbit ciliary body. Invest Ophthalmol Vis Sci 28:1314, 1987
12. Funk R, Rohen JW: Scanning electron microscopic study on the vasculature of the
human anterior eye segment, especially with respect to the ciliary processes. Exp Eye
Res 51:651, 1990
13. Bill A: Blood circulation and fluid dynamics in the eye. Physiol Rev 55:383, 1975
14. Seidel E: Weitre experimentelle Untersuchungen ber die Quelle und den Verlauf
der intraokularen Saftsrmung. XII. Mitteilung. <auU>ber den manometrischen
Nachweis
des
physiologischen
Druckgeflles
zwishen
Vorderkammer
und
Schlemmshen Kanal. Graefes Arch Clin Exp Ophthalmol 107:101, 1921
15. Seidel E: Weitre experimentelle Untersuchungen ber die Quelle und den Verlauf
der intraokularen Saftsrmung. XII. Mitteilung. Uber der Abfluss des Kammerwassers
aus der vorderen Augenkammer. Graefes Arch Clin Exp Ophthalmol 104:357, 1921
16. Knutson SL, Sears ML: Herman Boerhaave and the history of vessels carrying
aqueous humor from the eye. Am J Ophthalmol 76:648, 1973
17. Ascher KW: Aqueous veins: Preliminary note. Am J Ophthalmol 25:31, 1942
18. Goldmann H: Enhalten die Kammervasservener Kammervasser? Ophthalmologica
117:240, 1949
19. Ashton N: Anatomical study of Schlemm's canal and aqueous veins by means of
neoprene casts: Part I. Aqueous veins. Br J Ophthalmol 35:291, 1951
20. Duke-Elder S: The Physiology of the Eye and of Vision. System of Ophthalmology,
Vol IV. St. Louis, CV Mosby, 1968
21. Saier MH Jr: Neurotransmission. In Zubay G (ed): Biochemistry, pp 11471167.
Menlo Park, CA, Addison-Wesley, 1983
22. Bill A: The role of ciliary blood flow and ultrafiltration in aqueous humor formation.
Exp Eye Res 16:287, 1973
23. Chattoraj SC, Watts NB: Endocrinology. In Tietz NW (ed): Textbook of Clinical
Chemistry, pp 11161117. Philadelphia, WB Saunders, 1986
24. Weinbaum S, Langham ME, Goldgraben JR, Green K: The role of secretion and
pressure-dependent flow in aqueous humor formation. Exp Eye Res 13:266, 1972
25. Green K, Pederson JE: Contribution of secretion and filtration to aqueous humor
formation. Am J Ophthalmol 222:1218, 1972
26. Green K, Pederson JE: Aqueous humor formation. Exp Eye Res 16:273, 1973
27. Bonting SL, Becker B: Inhibition of enzyme activity and aqueous humor flow in the
rabbit eye after intravitreal injection of ouabain. Invest Ophthalmol 3:523, 1964
28. Becker B: Ouabain and aqueous humor dynamics in the rabbit eye. Invest
Ophthalmol 2:325, 1963
29. Becker B: Vanadate and aqueous humor dynamics. Invest Ophthalmol Vis Sci
19:1156, 1980
30. Krupin T, Becker B, Podos SM: Topical vanadate lowers intraocular pressure in
rabbits. Invest Ophthalmol Vis Sci 19:1360, 1980
14

31. Podos SM, Lee PY, Severin C, Mittag T: The effect of vanadate on aqueous humor
dynamics in cynomolgus monkeys. Invest Ophthalmol Vis Sci 25:359, 1984
32. Friedland BR, Maren TH: Carbonic anhydrase: Pharmacology of inhibitors and
treatment of glaucoma. In Sears ML (ed): Pharmacology of the Eye, pp 279309.
Berlin, Springer-Verlag, 1984
33. Brechue WF, Maren TH: A comparison between the effect of topical and systemic
carbonic anhydrase inhibitors on aqueous humor secretion. Exp Eye Res 57:67, 1993
34. Pierce WM, Sharir M, Waite KJ et al: Topically active ocular carbonic anhydrase
inhibitors--novel biscarbonylamidothiadiazole sulfonamides as ocular hypotensive
agents. Proc Soc Exp Biol Med 203:360, 1993
35. Becker B: Hypothermia and aqueous humor dynamics of the rabbit eye. Trans Am
Ophthalmol Soc 58:337, 1960
36. Kinsey VE: Transfer of ascorbic acid and related compounds across the bloodaqueous barrier. Am J Ophthalmol 30:1262, 1974
37. Bonting SL, Simon KA, Hawkins NM: Studies on sodium-potassium-activated
adenosine triphosphatase. I. Quantitative distribution in several tissues of the cat. Arch
Biochem Biophys 95:416, 1961
38. Riley MV: The sodium-potassium-stimulated adenosine triphosphatase of rabbit
ciliary epithelium. Exp Eye Res 3:76, 1964
39. Cole DF: Secretion of the aqueous humor. Exp Eye Res 25(Suppl):161, 1977
40. Riley MV, Kishida K: ATPases of ciliary epithelium: cellular and subcellular
distribution and probable role in secretion of aqueous humor. Exp Eye Res 42:559,
1986
41. Coca-Prados M, Lopez-Briones LG: Evidence that the a and the a(+ ) isoforms of
the catalytic subunit of (Na+ , K+ )-ATPase reside in distinct ciliary epithelial cells of the
mammalian eye. Biochem Biophys Res Commun 145:460, 1987
42. Flgel C, Ltjen-Drecoll E: Presence and distribution of Na + /K+ -ATPase in the ciliary
epithelium of the rabbit. Histochemistry 88:613, 1988
43. Usukura J, Fain GL, Bok D: [3H] Ouabain localization of (Na+ , K+ )-ATPase in the
epithelium of the rabbit ciliary body pars plicata. Invest Ophthalmol Vis Sci 29:606,
1988
44. Holland MG, Gipson CC: Chloride ion transport in the isolated ciliary body. Invest
Ophthalmol 9:20, 1970
45. Cole DF: Electrochemical changes associated with the formation of the aqueous
humor. Br J Ophthalmol 45:202, 1961
46. Cole DF: Evidence for active transport of chloride in ciliary epithelium of the rabbit.
Exp Eye Res 8:5, 1969
47. Kinsey VE, Reddy DVN: Chemistry and dynamics of aqueous humor. In Prince JH
(eds): The Rabbit in Eye Research, pp 218319. Springfield, IL, Charles C. Thomas,
1964
48. Krupin T, Reinach PS, Candia OA, Podos SM: Transepithelial electrical
measurements on the isolated rabbit iris-ciliary body. Exp Eye Res 38:115, 1984
49. Wistrand PJ: Carbonic anhydrase in the anterior uvea of the rabbit. Acta Physiol
Scand 24:144, 1951
50. Ballintine EJ, Maren TH: Carbonic anhydrase activity and the distribution of Diamox
in the rabbit eye. Am J Ophthalmol 40:148, 1955
51. Bhattacherjee P: Distribution of carbonic anhydrase in the rabbit eye as
demonstrated histochemically. Exp Eye Res 12:356, 1971
52. Tsukahara S, Maezawa N: Cytochemical localization of adenyl cyclase in the rabbit
ciliary body. Exp Eye Res 26:99, 1978
53. Mishima H, Sears M, Bausher L, Gregory D: Ultracytochemistry of cholera toxin
binding sites in ciliary processes. Cell Tiss Res 223:241, 1982
54. Muther TF, Friedland BR: Autoradiographic localization of carbonic anhydrase in the
rabbit ciliary body. J Histochem Cytochem 28:1119, 1980
55. Ltjen-Drecoll E, Lnnerholm G: Carbonic anhydrase distribution in the rabbit eye
by light and electron microscopy. Invest Ophthalmol Vis Sci 21:782, 1981
15

56. Ltjen-Drecoll E, Lnnerholm G, Eichorn M: Carbonic anhydrase distribution in the

human and monkey eye by light and electron microscopy. Graefes Arch Clin Exp
Ophthalmol 220:285, 1983
57. Maren TH, Mayer E, Wadsworth BC: Carbonic anhydrase inhibition. I. The
pharmacology of Diamox 2-acetylamino-1,3,4-thiadiazole-5-sulfonamide. Bull Johns
Hopkins Hosp 95:199, 1954
58. Maren TH: Carbonic anhydrase: Chemistry, physiology and inhibition. Physiol Rev
47:595, 1967
59. Maren TH: The development of ideas concerning the role of carbonic anhydrase in
the secretion of aqueous humor: Relation to the treatment of glaucoma. In Drance SM,
Neufeld AH (ed): Glaucoma, Applied Pharmacology in Medical Treatment, pp 325355.
Orlando, FL, Grune & Stratton, 1984
60. Eller MG, Schoenwald RD, Dixson JA et al: Topical carbonic anhydrase inhibitors. III.
Optimization model for corneal penetration of ethoxzolamide analogues. J Pharm Sci
74:155, 1985
61. Maren TH, Jankowska L, Sanyal G, Edelhauser HF: The transcorneal permeability of
sulfonamide carbonic anhydrase inhibitors and their effect on aqueous humor
secretion. Exp Eye Res 36:457, 1983
62. Schoenwald RD, Eller MG, Dixson JA, Barfknecht CF: Topical carbonic anhydrase
inhibitors. J Med Chem 27:810, 1984
63. Sugrue MF, Gautheron P, Grove J et al: MK-927: A topically active ocular
hypotensive carbonic anhydrase inhibitor. J Ocul Pharmacol 6:9, 1990
64. Sugrue MF, Mallorga P, Schwamm H et al: A comparison of L-671, 152 and MK927,
two topically effective ocular hypotensive carbonic anhydrase inhibitors, in
experimental animals. Curr Eye Res 9:607, 1990
65. Wang RF, Serle JB, Podos SM, Sugrue MF: The ocular hypotensive effect of the
topical carbonic anhydrase inhibitor L-671, 152 in glaucomatous monkeys. Arch
Ophthalmol 108:511, 1990
66. Wang R-F, Camras CB, Lee P-Y, Podos SM: Effect of BW245C, a prostaglandin (PG)
D2-sensitive (DP) agonist, on aqueous humor dynamics after topical application in
monkeys and rabbits (abstr). Invest Ophthalmol Vis Sci 32 (suppl):990, 1991
67. Lippa EA, Carlson LE, Ehinger B et al: Dose response and duration of action of
dorzolamide, a topical carbonic anhydrase inhibitor. Arch Ophthalmol 110:495, 1992
68. Wilkerson M, Cyrlin M, Lippa EA et al: Four-week safety and efficacy study of
dorzolamide, a novel, active topical carbonic anhydrase inhibitor. Arch Ophthalmol
111:1343, 1993
69. Gunning FP, Greve EL, Bron AM et al: Two topical carbonic anhydrase inhibitors
sezolamide and dorzolamide in Gelrite vehicle: A multiple-dose efficacy study. Graefes
Arch Clin Exp Ophthalmol 231:384, 1993
70. Wistrand P: Local action of the carbonic anhydrase inhibitor, acetazolamide, on the
intraocular pressure in cats. Acta Pharm Tox 14:27, 1957
71. Macri FJ: The constrictive action of acetazolamide on the iris arteries of the cat.
Arch Ophthalmol 66:570, 1961
72. Macri FJ, Cevario SJ: A possible vascular mechanism for the inhibition of aqueous
humor formation by ouabain and acetazolamide. Exp Eye Res 20:563, 1975
73. Bill A: Effects of acetazolamide and carotid occlusion on the ocular blood flow in
unanesthetized rabbits. Invest Ophthalmol 13:954, 1974
74. Maren TH: Biochemistry of aqueous humor inflow. In Podos SM, Yanoff M (eds):
Textbook of Ophthalmology, Vol 7, pp 1.421.46. London, Mosby, 1994
75. Maren TH: The rates of movement of Na + , Cl-, and HCO3- from plasma to posterior
chamber: Effect of acetazolamide and relation to the treatment of glaucoma. Invest
Ophthalmol 15:356, 1976
76. Becker B: The mechanism of the fall in intraocular pressure induced by the
carbonic anhydrase inhibitor Diamox. Am J Ophthalmol 39:177, 1955
77. Caprioli J: The ciliary epithelia and aqueous humor. In Hart WM Jr (ed): Adler's
Physiology of The Eye, 9th ed, pp 228247. St. Louis, Mosby Year-Book, 1992
16

78. Kaufman PL, Mittag TW: Therapy of glaucoma. Section II. Medical therapy of
glaucoma. In Podos SM, Yanoff M (ed): Textbook of Ophthalmology, Vol 7, pp 9.79.30.
London, Mosby, 1994
79. Maren TH, Bar-Ilan A, Conroy CW, Brechue WF: Chemical and pharmacological
properties of MK-927, a sulfonamide carbonic anhydrase inhibitor that lowers
intraocular pressure by the topical route. Exp Eye Res 50:27, 1990
80. Wang RF, Serle JB, Podos SM, Sugrue MF: MK-507 (L-671, 152), a topically active
carbonic anhydrase inhibitor, reduces aqueous humor production in monkeys. Arch
Ophthalmol 109:1297, 1991
81. Krause U, Raunio V: Proteins of the normal human aqueous humor.
Ophthalmologica 159:178, 1969
82. Krause U, Raunio V: The proteins of the normal aqueous humor. Ophthalmologica
160:280, 1970
83. Rodriguez-Peralta L: The blood-aqueous barrier in five species. Am J Ophthalmol
80:713, 1975
84. Bill A: The drainage of albumin from the uvea. Exp Eye Res 3:179, 1964
85. Bill A: Capillary permeability to and extravascular dynamics of myoglobin, albumin,
and gammaglobulin in the uvea. Acta Physiol Scand 73:204, 1968
86. Vegge T: An epithelial blood-aqueous barrier to horseradish peroxidase in the
ciliary processes of the vervet monkey (Cercopithecus aethiops). Z Zellforsch 114:309,
1971
87. Shiose Y: Electron microscopic studies on blood-retinal and blood-aqueous barriers.
Jpn J Ophthalmol 14:73, 1970
88. Smith RS: Ultrastructural studies of the blood-aqueous barrier. 1. Transport of an
electron dense tracer in the iris and ciliary body of the mouse. Am J Ophthalmol
71:1066, 1971
89. Uusitalo R, Palkama A, Stjernschantz J: An electron microscopic study of the bloodaqueous barrier in the ciliary body and iris of the rabbit. Exp Eye Res 17:49, 1973
90. Uusitalo R, Stjernschantz J, Palkama A: Studies on the ultrastructure of the bloodaqueous barrier in the rabbit. Acta Ophthalmol 123:61, 1974
91. Davson H, Duke-Elder WS, Maurice DM: Changes in ionic distribution following
dialysis of aqueous humor against plasma. J Physiol (Lond) 109:32, 1949
92. Ross EJ: The transfer of non-electrolytes across the blood-aqueous barrier. J Physiol
(Lond) 112:229, 1951
93. Davson H, Matchett PA: The kinetics of penetration of the blood-aqueous barrier. J
Physiol (Lond) 122:11, 1953
94. Hart WM Jr: Intraocular pressure. In Hart WM, Jr (ed): Adler's Physiology of the Eye,
pp 248267. St. Louis, Mosby Year-Book, 1992
95. Bairati AJ, Orzalesi N: The ultrastructure of the epithelium of the ciliary body: A
study of the junctional complexes and of the changes associated with the production
of plasmoid aqueous humor. Z Zellforsch Milrosk Anat 69:635, 1966
96. Okisaka S: Effects of paracentesis on the blood-aqueous barrier: A light and
electron microscopic study on cynomolgus monkey. Invest Ophthalmol 15:824, 1976
97. Al-Ghadyan A, Mead A, Sears ML: Increased pressure after paracentesis of the
rabbit eye is completely accounted for by prostaglandin synthesis and release plus
pupillary block. Invest Ophthalmol Vis Sci 18:361, 1979
98. Bartels SP, Pederson JE, Gaasterland DE, Armaly MF: Sites of breakdown of the
blood-aqueous barrier after paracentesis of the rhesus monkey eye. Invest Ophthalmol
Vis Sci 18:1050, 1979
99. Ohnishi Y, Tanaka M: Effects of pilocarpine and paracentesis on occluding junctions
between the nonpigmented ciliary epithelial cells. Exp Eye Res 32:635, 1981
100. Gaasterland DF, Barranger JA, Rapoport SI et al: Long-term ocular effects of
osmotic modification of the blood-brain barrier in monkeys. 1. Clinical examination,
aqueous ascorbate and protein. Invest Ophthalmol Vis Sci 24:153, 1983
101. Miyake K, Asakura M, Maekubo K: Consensual reactions of human blood-aqueous
barrier to implant operations. Arch Ophthalmol 102:558, 1984
17

102. Kondo K, Coca-Prados M, Sears ML: Human ciliary epithelia in monolayer culture.
Exp Eye Res 38:423, 1984
103. Jampol L, Neufeld A, Sears M: Pathways for the response of the eye to injury.
Invest Ophthalmol 14:184, 1975
104. Shabo AL, Maxwell DS, Krieger AE: Structural alterations in the ciliary process and
the blood-aqueous barrier of the monkey after systemic urea injections. Am J
Ophthalmol 81:162, 1976
105. Raviola G: Blood-aqueous barrier can be circumvented by lowering intraocular
pressure. Proc Natl Acad Sci USA 73:638, 1976
106. Raviola G: Effects of paracentesis on the blood-aqueous barrier: An electron
microscopic study on Macaca mulatta using horseradish peroxidase as a tracer. Invest
Ophthalmol 13:828, 1974
107. Whitelocke RA, Eakins KE: Vascular changes in the anterior uvea of the rabbit
produced by prostaglandins. Arch Ophthalmol 89:495, 1973
108. Whitelocke RAF, Eakins KE, Bennett A: Acute anterior uveitis and prostaglandins.
Proc R Soc Med 66:429, 1973
109. Green K, Kim K: Pattern of ocular response to topical and systemic prostaglandin.
Invest Ophthalmol 14:36, 1975
110. Laties AM, Neufeld AH, Vegge T, Sears ML: Differential reactivity of rabbit iris and
ciliary process to topically applied prostaglandin-E 2 (dinoprostone). Arch Ophthalmol
94:1966, 1976
111. Crawford K, Kaufman PL, True-Gabelt B: Prostaglandins and aqueous humor
dynamics. In Shields MB, Pollack IP, Kolker AE (eds): Perspectives in Glaucoma.
Transactions of the First Scientific Meeting of the American Glaucoma Society, pp 259
267. Thorofare, NJ, Slack, 1988
112. Kaufman PL, Crawford K, Gabelt BT: The effects of prostaglandins on aqueous
humor dynamics. In Kooner KS, Zimmerman TJ (eds): New Ophthalmic Drugs.
Ophthalmol Clin North Am 2:141, 1989
113. Kaufman PL, Rohen JW, Gabelt BT et al: Parasympathetic denervation of the
ciliary muscle following panretinal photocoagulation. Curr Eye Res 10:437, 1991
114. Green K: Permeability properties of the ciliary epithelium in response to
prostaglandins. Invest Ophthalmol 12:752, 1973
115. Neufeld AH, Sears ML: Prostaglandin and eye. Prostaglandins 4:157, 1973
116. Neufeld AH, Jampol LM, Sears ML: Aspirin prevents the disruption of the bloodaqueous barrier in the rabbit eye. Nature 238:158, 1972
117. Bhattacherjee P: Autoradiographic localization of intravitreally or intracamerally
injected [3H]-prostaglandins. Exp Eye Res 18:181, 1974
118. Bhattacherjee P, Hammond BR: Inhibition of increased permeability of the bloodaqueous barrier by nonsteroidal anti-inflammatory compounds as demonstrated by
fluorescein angiography. Exp Eye Res 21:499, 1975
119. Bengtsson E: The effect of imidazole on the disruption of the blood-aqueous
barrier in the rabbit eye. Invest Ophthalmol 15:315, 1976
120. Chavis RM, Vygantis CM, Vygantis A: Experimental inhibition of prostaglandin-like
inflammatory response after cryotherapy. Am J Ophthalmol 82:310, 1976
121. Giuffr G: The effects of prostaglandin F 2 in the human eye. Graefes Arch Clin
Exp Ophthalmol 222:139, 1985
122. Gabelt BT, Kaufman PL: Prostaglandin F 2 increases uveoscleral outflow in the
cynomolgus monkey. Exp Eye Res 49:389, 1989
123. Kaufman PL, Crawford K: Aqueous humor dynamics: How PGF 2 lowers intraocular
pressure. Prog Clin Biol Res 312: 387, 1989
124. Nilsson SFE, Samuelsson M, Bill A, Stjernschantz J: Increased uveoscleral outflow
as a possible mechanism of ocular hypotension caused by prostaglandin F 2-1isopropyl ester in the cynomolgus monkey. Exp Eye Res 48:707, 1989
125. Villumsen J, Alm A, Soderstrom M: Prostaglandin F 2-isopropylester eye drops:
Effect on intraocular pressure in open angle glaucoma. Br J Ophthalmol 73:975, 1989
18

126. Camras CB, Siebold EC, Lustgarten JS et al: Maintained reduction of intraocular
pressure by prostaglandin F2-1-isopropylester applied in multiple doses in ocular
hypertensive and glaucoma patients. Ophthalmology 96:1329, 1989
127. Jaffe NS, Jaffe MS, Jaffe GF: Cataract Surgery and its Complications, 5th ed, p 148.
St. Louis, CV Mosby, 1990
128. Benham GH, Duke-Elder WS, Hodgson TH: The osmotic pressure of the aqueous
humor in the normal and glaucomatous eye. J Physiol (Lond) 92:355, 1938
129. Roepke RR, Hetherington WA: Osmotic relation between aqueous humor and
blood plasma. Am J Physiol 130:340, 1940
130. Kinsey VE: The chemical composition and the osmotic pressure of the aqueous
humor and plasma of the rabbit. J Gen Physiol 34:389, 1950
131. Cole DF: Electrolyte composition of anterior and posterior aqueous humor in the
sheep. Ophthalmic Res 4:1, 1973
132. Stjernschantz J, Uusitalo R, Palkama A: The aqueous proteins of the rat in the
normal eye and after aqueous withdrawal. Exp Eye Res 16:215, 1973
133. Ghose T, Quigley JH, Landrigan PL, Asif A: Immunoglobulins in aqueous humor
and iris from patients with endogenous uveitis and patients with cataract. Br J
Ophthalmol 57:897, 1973
134. Sen DK, Saren GS, Saha K: Immunoglobulins in human aqueous humor. Br J
Ophthalmol 61:216, 1977
135. Fielder AR, Rahi AHS: Symposium on immunology: Immunoglobulins of normal
aqueous humor. Trans Ophthalmol Soc UK 99:120, 1979
136. Mondino BJ, Rao H: Complement levels in normal and inflamed aqueous humor.
Invest Ophthalmol Vis Sci 24:380, 1983
137. Pandolfi M, Nilsson IM, Martinsson G: Coagulation and fibrinolytic components in
primary and plasmoid aqueous humor. Acta Ophthalmol 42:820, 1964
138. Sandberg HO, Class O: The alpha and gamma crystallin content in aqueous
humor of eyes with clear lens and with cataracts. Exp Eye Res 28:601, 1979
139. Fujiwara H: Lens crystallin reactive protein in the aqueous humor of cataract
patients. Jpn J Ophthalmol 33:418, 1989
140. Freddo TF, Bartels SP, Barsotti MF, Kamm RD: The source of proteins in the
aqueous humor of the normal rabbit. Invest Ophthalmol Vis Sci 31:125, 1990
141. Reddy DVN, Kinsey VE: Chemistry and dynamics of aqueous humor. In Prince JH
(eds): The Rabbit in Eye Research, p 218. Springfield, IL, Charles C. Thomas, 1966
142. Bito LZ, Davson H, Levin E: The relationship between the concentrations of amino
acids in the ocular fluids and blood plasma of dogs. Exp Eye Res 4:374, 1965
143. Ehlers N, Kristensen K, Schonheyder F: Amino acid transport in human ciliary
epithelium. Acta Ophthalmol 56:777, 1978
144. Kinsey VE: Further study of the distribution of chloride between plasma and
intraocular fluids of the rabbit eye. Invest Ophthalmol 6:395, 1967
145. de Berardinis E, Tieri O, Polzella A, Iuglio N: The chemical composition of the
human aqueous humor in normal and pathological conditions. Exp Eye Res 4:179,
1965
146. DiMatteo J: Active transport of ascorbic acid into lens epithelium of the rat. Exp
Eye Res 49:873, 1989
147. Ringvold A: Aqueous humor and ultraviolet radiation. Acta Ophthalmol 58:69,
1979
148. Koskela TK, Reiss GR, Brubaker RF, Ellefson RD: Is the high concentration of
ascorbic acid in the eye an adaptation to intense solar radiation? Invest Ophthalmol
Vis Sci 31:2265, 1989
149. Riley MV: Intraocular dynamics of lactic acid in the rabbit. Invest Ophthalmol
11:600, 1972
150. Heald K, Langham ME: Permeability of the cornea and the blood-aqueous barrier
to oxygen. Br J Ophthalmol 40:705, 1956

19

151. Kleinstein RN, Kwan M, Fatt I, Weissman BA: In vivo aqueous humor oxygen
tension--as estimated from measurements on bare stroma. Invest Ophthalmol Vis Sci
21:415, 1981
152. Khodadoust AA, Stark WJ, Bill WR: Coagulation properties of intraocular humors
and cerebrospinal fluid. Invest Ophthamol Vis Sci 24:1616, 1983
153. Stefansson E, Wolbarsht ML, Landers MB: The corneal contact lens and aqueous
humor hypoxia in cats. Invest Ophthalmol Vis Sci 24:1052, 1983
154. Stefansson E, Robinson D, Wolbarsht ML et al: Effects of epinephrine on PO 2 in
anterior chamber. Arch Ophthalmol 101:636, 1983
155. Berzelius JJ cited by Caprioli J: The ciliary epithelia and aqueous humor. In Hart
WM Jr (ed): Adler's Physiology of the Eye, 9th ed, p 241. Philadelphia, Mosby, 1992
156. Varma SD, Reddy DVN: Phospholipid composition of aqueous humor plasma and
lens in normal and alloxan diabetic rabbits. Exp Eye Res 13:120, 1972
157. Kim JO, Cotlier E: Phospholipid distributions and fatty acid composition of
lysophosphatidylcholine in rabbit aqueous humor, lens and vitreous. Exp Eye Res
22:569, 1976
158. Obenberger J, Starka L, Hampl R: Quantitative determination of endogenous
corticosteroids in the rabbit plasma and aqueous humor. Graefes Arch Clin Exp
Ophthalmol 183:203, 1971
159. Andersson H: Monoamine metabolites in aqueous humor. J Pharm Pharmacol
24:998, 1972
160. Farkas TG, Plusec J: The occurrence of trivalent chromium in the aqueous and lens
of rats. Invest Ophthalmol 5:398, 1966
161. Ainley RG, Phillips CI, Gibbs A et al: Aqueous humor vitamin B 12 and intramuscular
cobalamins. Br J Ophthalmol 53:854, 1969
162. Falbe-Hansen L, Degn JK: Sialic acid in the aqueous humor and the vitreous of
normal human eyes and of eyes with malignant melanoma of the choroid. Acta
Ophthalmol 47:972, 1969

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