Dr.

Padmaja Phade

 Aqueous humour is clear colourless watery solution

continuously circulated from posterior chamber of the eye through out the anterior chamber Maintenance of IOP and pathophysiology of glaucoma revolves around aq. Humour dynamics

ANATOMY
Ciliary body
Forward continuation of choroid at Ora serreta Triangular in cut section

Inner side of triangle is divided into Pars plicata- 2-2.5mm Pars plana- 5mm temporally, 3mm nasaly

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Microscopy
1.

2.

3. 4. 5.

Supraciliary lamina- outer most condensed part of the stroma Stroma- consist of collagen tissue and fibroblast with ciliary muscle, vasculature and nervs Layer of pigmented epithelium Layer of non pigmented epithelium Internal limiting membrane

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Ciliary processes

70-80 Whitish finger like projections 2 X 0.5mm Composed of central capillary network with fenestrated thin endothelium and pericytes surrounded by stroma and two layers of epithelium and ILM Inner nonpigmented and outer pigmented epithelium with juxta pposed apical surfaces Inner nonpigmented epi. Characterised by mitochondria, zonula occludentes (ZO)and lateral surface interdigitations The tight junctions contribute to the blood aqueous barrier

 Posterior chamber
Triangular space

0.06ml of aqueous
Divided into prezonular, zonular and retro

zonular space

 Anterior chamber 2.5mm deep in centre, Contains 0.25ml aqueous Bounded

ant-post surface of cornea, Post- anterior surface of ciliary body and iris Comunicates through the pupil with post. Chamber

Chamber volume decreases by 0.11l/year of life

Chamber depth decreases by 0.01mm/year of life

Chamber depth is shallower in hypermtropic than myopic Chamber depth is slightly decrease during accommodation

partly by lens curvature and partly by forward translocation of lens.

Angle of Anterior chamber

Peripheral recess of ant. Chamber
Formed mainly by TM Formed post. To ant. By 1. Ciliary band 2. Scleral spur 3. Trabecular meshwork 4. Schwalbes line

Gonioscopic grading of angle width

Grade Angle width configuratio n Wide open Open Moderately narrow Very narrow Chances of closure Nil Nil Closure possible High Structure visible on gonioscopy Schwalbes line to ciliary body Schwalbes line to scleral spur Schwalbes line to TM Schwalbes line only IV III II I 35-450 20-350 200 100

00

Closed

closed

none

Aqueous outflow system

Consist of two pathways Trabecular / conventional outflow Uveoscleral / unconventional outflow Trabecular meshwork

It is sieve like structure bridging the scleral sulcus cosist of 3 parts 1. Uveal meshwork inner most, extend from iris root and ciliary body to the schwalbes line. The trabeculea are chord like and 2-3 layer thick. Arrangement creates 25-75 Each trabeculae has 3 concentric layers with central collagenous core enclosed by abasement membrane and trabecular cells.

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2. Corneoscleral meshwork

From scleral spur to lateral wall of scleral sulcus Cosist of flat sheet of trabeculae with elliptical opening ranging from 5-50 become progressively smaller towards the schlemms canal

3. Juxtacanalicular meshwork
Outermost layer connects corneoscleral meshwork to schlemms canal Consists of 2-5 layers of loosely arranged cells embedded in ECM (hyluronic acid and other GAG) lined on either side by endothelial cells Offers main resistance to aqueous flow Outer endothelial layer of juxta canalicular meshwork comprises inner wall of schlemms canal Inner endothelial layer continue with corneo scleral meshwork

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Schlemms canal

Endothelium lined oval channel present in scleral sulcus Endothelial cells of inner wall are irregular and contain giant vacuoles 25-35 Intrascleral aq. Vessels Leaving schlemms canal at oblique angles to terminate into episcleral veins. Valveless, wide at their origin and taper towards the anastomosis with venous channel. 1. Direct system2. Indirect system

Collect or channel

Episcleral veins
Drain ultimately in cavernous sinus via ant. Ciliary and sup. Ophthalmic vein

Formation of Aqueous Humour

Ciliary processes are the site of aqueous formation

which is primarily derived from the plasma within capillaries of cilliary processes. Mechanisms involved
1. Diffusion-mol of gas/solution distribute themselves uniformly throughout the space in which they are contained by net flux of particles from area of higher conc. to area of lower conc.

continuation Ficks law of diffusion Rate of movt.=k( c1-c2) K is constant which depends on nature and permeability of memb, nature solute and solvent and temp. C1- conc of substance on side with higher conc. C2-conc of substance on side with lower conc.
2. Ultrafiltration- depends on hydrostatic pressure and solute conc of plasma in capillaries of cilliary processes 3. Secretion-active process against conc gradient water sol substances of large mol size and greater charge are actively secreted

STEPS OF AQUEOUS FORMATION

Secretion basically depends on transfer of solute from

stromal surface to post chamber This establishes an osmotic gradient driving water passively into aqueous . Composition of aqueous is similar to that of protein free plasma except for higher ascorbic acid and bicarbonate content.

Continuation
1.

Formation of stromal pool: formed by ultra filtration of plasma in capillaries of ciliary processes due to fenestrations in endothelium proteins are also present in the stromal pool this ultrafiltrate accumulates behind the tight junctions of the NPE.

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2. Uptake of fluid from stromal pool PE takes up solute(NaCl) by 2 major electroneutral processes

Na+ / H+ counter exchanger NHE1 antiport in parallel with the AE2 antiport anion counter exchanger causing Cl- influx and HCO3- eflux carbonic

anhydrase II stimulates NaCl uptake by increasing the delivery of H+ and HCO3- to the 2 antiports.

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Na +-K+ 2Cl- SYMPORT situated on basolateral

membrane of of PE cells rate of transport of the 3 ions depends on their conc gradient especially on ratio of extracellular to intracellular Cl- net solute transfer through symport is zero at intracellular Cl- conc of 50mM

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PASSIVE DIFFUSION mostly water diffuses along osmotic gradient established by Nacl transport. cell memb have low content of sphyngomyelin and cholesterol hence relative high water permeability
POTENTIAL SOLUTE RECYCLING In order to minimize fluctuations in the cell vol due to mismatch in rates of uptake of solutes and water by PE at stromal surf and their release at aqueous surf there is autocrine regulation of these processes at the PE level

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Excess fluid and solute uptake at stromal surf than release at the aqeous surf of PE , NPE Cellular swelling ATP release by PE and NPE cAMP formation Activation of Cl- channels on stromal surf

Efflux of excess Cl- and water from PE, NPE

CONTI

3. FLUID TRANSFER THROUGH GAP JUNCTIONS

Gap junctions between PE and NPE formed by

connexins Cx43 and Cx40 Gap junctions are also present within PE and NPE but are functionally less significant Aqueous is thus formed by parallel couplets of PE NPE cell gap junctions.

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4. FLUID TRANSFER INTO AQUEOUS HUMOUR final step in aqueous secretion. Solutes and water are transported across the basolateral membrane of NPE. Na+, K+ ATPase releases(70%) Na+ against electrochemical gradient into aqueous, remaining (30%/) transported passively or by ultra filtration. Cl- is released along its electrochemical gradient through Cl- channels. Water released along osmotic gradient established by solute transfer into aqueous through AQP1 and AQP4. Bicarbonate exits through HCO3-/Cl- exchangers as well as Cl- channels. K+ transported by secretion and diffusion Ascorbic acid secreted against a conc gradient Amino acids are secreted by 3 diff carrier proteins each for acidic , basic and neutral molecules.

RATE OF AQUEOUS HUMOUR FORMATION

2.5micro liters/min in an undisturbed human eye Rate of aqueous inflow is 2 times higher during waking

than in nocturnal hours

REGULATION OF AQUEOUS FORMATION 1.Adrenergic receptors 2 receptor stimulation lowers aqueous secretion via adeylate

cyclase inhibition. epinephrine stimulates PGF2 production which lowers IOP. 2 receptor stimulation leads to increased aqueous secretion via activation of adenylate cyclase.

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Catecholamines Stimulation of adenylate cyclase Icreased c-AMP formation activation of PK specific protien phosphorylation increased permeability of PE,NPE cells to solutes and water.

increased aqueous formation

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2. Ultrafiltration and diffusion
these passive mechanisms depend on blood pressure in

cilliary capillaries , plasma oncotic pressure,and IOP.

3. Vasopressin
vasopressin stimulates NaCl transport through PE ,NPE

and thus aqueous formation. vasopressin levels in turn are indirectly proportional to plasma osmolarity.

MEASUREMENT OF RATE OF AQUEOUS PRODUCTION

Class 1 methods measure rate of appearance and dissapearance of a substance from aqueous 1. Fluorescein techniques 2. Radioactive labeled isotopes 3. Intravenous PAH technique Class 2 methods flow= C(Po-Pv) C= facility of aqueous outflow Po= IOP Pv=episcleral venous pressure

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Perfusion of eyes at a constant pressure 2. Tonography 3. Perilimbal suction cup method
1.

BIOCHEMICAL COMPOSITION OF AQUEOUS HUMOUR

Water: constitutes about 99.9% of aqueous Proteins: is about 5-16 mg/dl ie1/500 of plasma protein content

(6-7g/dl) A:G ratio is same as that of plasma IgG and IgM arepresent plasminogen and its proactivators are present FGF,TGF,IGF1 Amino acids:- conc varies with aqueous/plasma conc (0.08-3.14) Non colloidal constituents:- similar to that of plasma ascorbate, lactate, pyruvate is higher than that in plasma conc of glucose and urea is higher than that of plasma bicarbonate, ascorbate levels in post chamber is higher than in ant chamber chloride conc in post chamber is lower than in ant chamber

BLOOD OCULAR BARRIER

BLOOD AQUEOUS BARRIER : formed by tight junctions (zonula

occludens and zonula adherans) between cells of inner NPE of ciliary processes and non fenestrated epithelium of iris capillaries. BLOOD RETINAL BARRIER : INNER : tight junctions of retinal capillaries and endothelial cells OUTER: tight junctions between adjacent RPE Blood ocular barrier prevents proteins and large mol wt substances from entering the ocular cavities Lipid solubility facilitates ocular penetration Medium mol wt substances penetrate at a slower rate than their transit through capillary walls. With breakdown of blood aqueous barrier protein and antibody conc of aqueous equilibrates with that of plasma to form SECONDARY OR PLASMOID AQUEOUS. Fibrinogen may cause clotting .

CAUSES OF INTERRUPTION OF BLOOD OCULAR BARRIER

OCULAR TRAUMA
1.

2. 3.

mechanical : paracentesis corneal abrasion intraocular surgeries stroking iris Physical: X rays atomic radiation Chemical : alkali irritants

 PATHOPHYSIOLOGICAL
1. inflamations 2. intraocular and corneal infections 3.anterior segment ischemia

PHARMACOLOGICAL
1.MSH 2.Cholinergic drugs 3. Cholinesterase inhibitors 4. Nitrogen mustard

FUNCTIONS OF AQUEOUS HUMOUR

Maintenance of IOP
Metabolism of avascular stuctures of eye Optical function

Clearing function

PHYSIOCHEMICAL PROPERTIES OF AQUEOUS

VOLUME: 0.31 ml ( 0.25ml in AC ; 0.06 ml in post chamber)
Refractive index : 1.336

pH : 7.2 ( acidic)
Density: slightly denser than water ( 1.040: 1.025) Osmotic pressure: hyperosmotic to plasma by 3 to

5 m osmo/l

AQUEOUS HUMOUR DYNAMICS

Includes aqueous formation and drainage
Aqueous flows from post to ant chamber through

pupil and in AC flows along conventional current set up due to temp difference in ant part and post part of AC. From AC aqueous is drained by
1.

2.

Trabecular(conventional) outflow Uveoscleral( unconventional) outflow

Ciliary process Aq. In post. Chamber Anterior chamber Trabecular meshwork Schlemms canal ciliary body suprachoroidal space

Collector channel
Episcleral veins
Trabecular outflow 90%

venous circn. Cil. Body, sclera and orbit

Uveoscleral outflow 10%

TRABECULAR OUTFLOW
Drains 75 to 90% aqueous Free flow occurs through TM till the juxtacanalicular tissue

which offer some resistance to the outflow.

SPECIAL CHARACTERISTICS OF TM CELLS:

I. II. III. IV. V. VI. VII.

High levels of cytoskeletal actin and lower levels of microtubules Presence of cellular vimentin and desmin AQP1 PROTIENS High levels of surface tPA GAG degrading enzymes and acid phosphatases 2 adrenergic receptors and TIGR Specialized endocytic / phagocytic properties

MECHANISM OF AQUEOUS TRANSPORT THROUGH TM 1. VACUOLATION THEORY:- vesicles and vacuoles in endothelium open and close intermittently to transport aqueous from TM cells to Schlemms canal
Non Vacuolated state Oclusion of basal infolding

Early stage of basal infolding

Vacuolar transecellular channel formation

Macrovacuole formation

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2. LEAKY ENDOTHELIAL CELLS
3. SONDERMANS CHANNELS : microtubules in TM cells

help aqueous flow from corneoscleral trabecular meshwork into lumen of Schlemms canal . 4. CONTRACTILE MICROFILAMENTS : 5. PORES IN ENDOTHELIAL CELLS : (3m ) about 20,000

UVEOSCLERAL OUTFLOW
Drains 0.3l/min
Drains 10 to 25% of aqueous Independent of IOP

PG increase uveoscleral flow to lower the IOP

FACILITY OF AQUEOUS OUTFLOW

Pressure gradient of 10mm of Hg between IOP and

episcleral venous plexus helps in drainage C- value expressed as aq. Outflow in l/min/mm of Hg It represents quantitative aproximation of state of aq. Drainage system

Measurements of C value
1.

Perfusion method

C= flow rate / Pi Po Independent of ocular rigidity and corneal curvature C=0.28 l/min/mm of Hg Most commonly used non invasive method

2. Tonography 3. Suction cup method

97.5% population has C value >0.18 Most glaucoma pt. has C value <0.17 Significance of C value
1. 2.

3.

As adjuncting diagnosis of glaucoma C value < 0.10 or less in angle closure glaucoma after an acute attack suggest that peripheral iridectomy may not be sufficient Evaluation of drug mechanism and experimentally to study abnormality of various influences on aq. dynamics