SECTION 2 PATHOGENESIS
5 Functional Morphology
of the Trabecular Meshwork
Outflow Pathways
ERNST R TAMM
Summary
Intraocular pressure is generated in the trabecular outflow
pathways in which aqueous humor passes through the
trabecular meshwork into Schlemm’s canal. The juxtacanalicular
region of the pathways provides outflow resistance for aqueous
humor. The resistance is under the influence of two contractile
systems, the anterior part of the ciliary muscle, and the
contractile myofibroblast-like cells in the trabecular outflow
pathways. Resistance is lowered through contraction of the
ciliary muscle or relaxation of the contractile cells in the
trabecular outflow pathways. In primary open-angle glaucoma,
resistance in the juxtacanalicular region is abnormally high. The
cause of the increase is related to an increase in transforming
growth factor-β/connective tissue growth factor signaling. The
cells of the trabecular meshwork outflow pathways are likely
stimulated to acquire a stronger contractile phenotype involving
both an increase in their actin cytoskeleton and in their
surrounding fibrillar extracellular matrix.
Introduction
Intraocular pressure (IOP), the main risk factor for primary
open-angle glaucoma (POAG), is determined by the produc-
tion, circulation, and drainage of aqueous humor.1–3 The
major drainage regions are the conventional or trabecular
outflow pathways, which are comprised of the trabecular
meshwork (made up by the uveal and corneoscleral mesh-
works), the juxtacanalicular connective tissue (JCT), the
endothelial lining of Schlemm’s canal, the collecting chan-
nels, and the aqueous veins. When aqueous humor has
passed through the trabecular outflow pathways it drains
into the episcleral venous system. In addition to the trabec-
ular meshwork outflow pathways, there is an unconventional
or uveoscleral outflow route which is open to the aqueous
humor at the chamber angle in the region of the anterior
insertion of the ciliary muscle, as there is no complete
endothelial or epithelial layer that covers the anterior
surface of the ciliary body. When passing through the uveo-
scleral outflow pathways, aqueous humor exits the anterior
chamber through the ciliary body into the supraciliary and
suprachoroidal space and out through the sclera into the
extraocular tissues. Fluid in the uveoscleral pathways ulti-
mately drains into the lymphatic system. Depending on the
method that is used to measure it, unconventional or uveo-
scleral outflow is found to account for 10%4 or 25–57%5 of
the total outflow in the human eye. Uveoscleral outflow is
40
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generally regarded as pressure-insensitive, whereas flow
from the anterior chamber across the trabecular mesh-
work into Schlemm’s canal is pressure-dependent. The
trabecular meshwork outflow pathways provide a resist-
ance to aqueous humor outflow and IOP builds up in
response to this resistance until it is high enough to drive
aqueous humor across the trabecular meshwork into
Schlemm’s canal. Aqueous humor passes through the
trabecular meshwork as bulk flow driven by the pressure
gradient; any active transport is not involved, as neither
metabolic poisons nor temperature affects this flow.6,7 At
steady-state IOP, fluid flow across the trabecular outflow
resistance is at the same rate as it is produced by the ciliary
body. Outflow resistance in the trabecular meshwork
outflow pathways increases with aging.8–10 In primary
open-angle glaucoma (POAG), IOP is elevated because the
resistance to aqueous humor outflow in the trabecular
meshwork is abnormally high.11,12 Outflow resistance is
increased in primary open-angle glaucoma, ocular hyper-
tension, and exfoliation and pigment dispersion syndromes
with accompanying ocular hypertension. When IOP is
normal in these syndromes, outflow resistance is normal.
This chapter will focus on the functional morphology of the
trabecular meshwork outflow pathways. For detailed infor-
mation on the overall structure of the trabecular meshwork
outflow pathways, the reader is referred to the electronic
text of this chapter available online at http://www.expert
consult.com
THE SITE OF OUTFLOW RESISTANCE
Because of their high porosity, the uveal and corneoscleral
parts of the trabecular meshwork do not provide significant
resistance to aqueous humor outflow. Support for this
comes from experimental studies, which show that cutting
through the inner parts of the trabecular meshwork does
not affect outflow facility,32 and from theoretical calcula-
tions using Poiseuille’s law.33 In contrast, there is consider-
able evidence that normal aqueous humor outflow
resistance resides in the inner wall region of Schlemm’s
canal,8,29 which is formed by the juxtacanalicular tissue
and the inner wall endothelium. The extracellular spaces
between the cells and fibrillar elements of the juxtacanal-
icular tissue appear to be a likely site of outflow resistance.
Morphometric analyses of the juxtacanalicular aqueous
humor pathways as visualized by electron microscopy com-
bined with theoretical calculations indicate that the juxta-
canalicular tissue cannot account for a significant outflow
 5 • Functional Morphology of the Trabecular Meshwork Outflow Pathways
The Trabecular Meshwork
Outflow Pathways
The critical elements that form the trabecular meshwork
outflow pathways are mostly localized in the internal scleral
sulcus, a circular groove on the inner aspect of the corneo-
scleral limbus. The scleral sulcus extends from the periph-
eral edge of Descemet’s membrane of the cornea that is
called Schwalbe’s line to the scleral spur, a wedge-shaped
circular ridge. Schlemm’s canal, a circular vascular tube,
lies in the outer portion of the scleral sulcus, while the
trabecular meshwork occupies most of its inner aspects
(Fig. 5-1). The trabecular meshwork is a spongework of
connective tissue beams or lamellae that have a core of col-
lagenous and elastic fibers. Flat trabecular meshwork cells,
which rest on a basal lamina, cover each trabecular beam.
The beams attach to one another in several layers and form
a porous filter-like structure. Anteriorly, the trabecular
beams are attached near the end of Descemet’s membrane
and extend posteriorly to the stroma of ciliary body and iris
A
Figure 5-1 Light micrographs of meridional sections of the anterior
chamber angle (A) and the trabecular meshwork (B). The dotted line in
A marks the boundary between filtering and nonfiltering trabecular
meshwork. SC, Schlemm’s canal; TM, trabecular meshwork; SS, scleral
spur; Ir, iris; CB, ciliary body; PC, posterior chamber; AC, anterior
chamber; JCT, juxtacanalicular tissue; CSTM, corneoscleral trabecular
meshwork; UVTM, uveal trabecular meshwork. Magnification bars:
100 µm (A), 50 µm (B).
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40.e1
at their junction, and to the scleral spur (see Fig. 5-1).
Trabecular beams branch as they extend posteriorly, which
gives the trabecular meshwork a triangular shape with the
apex near Descemet’s membrane and the base at the scleral
spur. As Schlemm’s canal is shorter in the anterior–posterior
direction than the trabecular meshwork, a filtering portion
of the trabecular meshwork can be differentiated from a
nonfiltering portion which has no Schlemm’s canal behind
it (see Fig. 5-1). Iris processes, which are flat bands of iris
stroma, may bridge the chamber angle from the iris root to
the outer (uveal) beams of the trabecular meshwork into
which they merge (Fig. 5-2). Iris processes are phylogeneti-
cally homologous with remnants of the pectinate ligaments
in the chamber angle of the eyes of nonprimate mamma-
lian species such as rodents and ungulates. In most human
eyes, they are sparse in number.
STRUCTURE OF THE TRABECULAR MESHWORK
The trabecular meshwork consists of three regions that
differ in structure: the inner uveal meshwork, the deeper
corneoscleral meshwork and the juxtacanalicular tissue or
cribriform region that is localized directly adjacent to the
inner wall endothelium of Schlemm’s canal (see Fig. 5-1B).
The uveal meshwork, which originates from the anterior
aspect of the ciliary body, consists of one to three layers of
trabecular beams or lamellae (Fig. 5-3). The corneoscleral
meshwork forms 8–15 trabecular layers, which are thicker
than those of the uveal trabecular meshwork and originate
from the scleral spur (see Fig. 5-3). The juxtacanalicular
tissue, which is localized directly to the endothelial lining of
Schlemm’s canal, is the smallest part of the trabecular
meshwork with a thickness of only 2–20 µm. The juxtaca-
nalicular tissue does not form trabecular lamellae or con-
nective tissue beams, but rather represents a typical loose
connective tissue with 2–5 layers of loosely arranged cells
that are embedded in a thinly distributed fibrillar extracel-
lular matrix (see Fig. 5-3).
Figure 5-2 Chamber angle of a human eye, meridional section.
Arrows indicate an iris process that bridges the chamber angle from
the iris root to the uveal trabecular meshwork. SC, Schlemm’s canal;
TM, trabecular meshwork; SS, scleral spur; CM, ciliary muscle. Magnifi-
cation bar: 100 µm.
40.e2 SECTION 2 • Pathogenesis
Figure 5-3 Meridional sections of the trabecular meshwork (light
micrographs). (A) Open arrows denote the beams of the uveal trabecu-
lar meshwork, and solid arrows the thicker ones of the corneoscleral
meshwork. (B) Inner wall region. Open arrows mark the boundary
between juxtacanalicular tissue and corneoscleral trabecular mesh-
work. The endothelium of the inner wall of Schlemm’s canal forms
numerous giant vacuoles (solid arrows). SS, scleral spur, SC, Schlemm’s
canal. Magnification bars: 10 µm.
THE TRABECULAR BEAMS
Each beam or lamella in the uveal or corneoscleral trabecu-
lar meshwork has a core region that is surrounded by a
cortical zone (Fig. 5-4).13,14 The cortical zone is separated
from the trabecular cells that cover the beams by their basal
lamina (Fig. 5-5). The core contains densely packed colla-
gen and elastic fibers (see Fig. 5-4). The collagen fibers are
mostly formed by collagen types I and III.15 The elastic fibers
differ in their ultrastructure from those in other parts of the
body, as they contain considerable amounts of electron-
dense material. The presence of elastin has been confirmed
by both enzymatic treatment with elastase and by immuno-
histochemistry with specific antibodies.16,17 The fibers are
surrounded by a sheath that thickens with age. The sheath
is less electron dense than the elastic fiber proper and may
show an 80–120 nm periodicity. Clumps of similar material
and periodicity are numerous in the cortical zone (so-called
long-spacing collagen) (see Fig. 5-5). Fine fibrils that enter
the aggregates of long-spacing collagen have been shown
to label with antibodies against collagen type VI.18 The
cells covering the trabecular meshwork beams have
long processes that connect with those of neighboring
beams (Fig. 5-6A). In addition, the cells may bridge inter-
trabecular spaces to cover two adjacent beams and to estab-
lish a three-dimensional network. Trabecular meshwork
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Figure 5-4 Electron micrograph of a corneoscleral trabecular mesh-
work beam. The core (Co) of the beam contains densely packed colla-
gen (C) and elastic fibers (E). The cortical region (CR) contains numerous
aggregates of long-spacing collagen (arrows). The beam is completely
covered by flat trabecular meshwork cells (TMC). Magnification bar:
2 µm.
cells are capable of phagocytosis19 and may contain pigment
particles (Fig. 5-6B). The phagocytic capabilities of trabecu-
lar meshwork cells may be important as self-cleaning mech-
anisms of the trabecular filter. The basal lamina of the
trabecular meshwork cells is rich in collagen type IV and
laminin.20,21
THE JUXTACANALICULAR TISSUE
The juxtacanalicular tissue is a loose connective tissue
where trabecular cells are surrounded by fibrillar elements
of the extracellular matrix. As the connective tissue fibrils
form an irregularly arranged network (in contrast to the
more regular structure of the beams in the inner parts of
the trabecular meshwork), some authors prefer the term
cribriform meshwork.17 The cells in the juxtacanalicular
tissue form elongated processes by which they attach to one
another, to extracellular matrix fibrils, or to the cells of the
endothelial lining of Schlemm’s canal (Fig. 5-7). Between
cells and extracellular matrix fibers, there are open spaces
that serve as pathways for aqueous humor. Although a
 5 • Functional Morphology of the Trabecular Meshwork Outflow Pathways 40.e3

Figure 5-5 Electron micrograph of a corneoscleral trabecular mesh-

work beam (higher magnification of Fig. 5-4). Open arrows denote the
basal lamina of the trabecular meshwork cells, while solid arrows point
to aggregates of long-spacing collagen. C, collagen fibers; E, elastic
fibers. Magnification bar: 2 µm.

ground substance of various proteoglycans and

hyaluronan22–24 has been described in these spaces, the
extent to which the ground substance fills the open spaces
is not clear. This uncertainty is due to the fact that prote-
oglycans are not readily retained during processing of tissue
for conventional electron microscopy. Indeed, recent studies
using quick-freeze/deep-etch methodology confirm that
there is more extracellular matrix in the juxtacanalicular
tissue as seen by conventional electron microscopy.25 A
characteristic structural element of the juxtacanalicular
tissue is a layer of elastic fibers (cribriform plexus) (see Fig.
5-7) which has been shown to form a fibrous network in B
sections tangential to the endothelial lining of Schlemm’s
canal.26 The elastic fibers of the cribriform plexus have an Figure 5-6 Electron microscopy of corneoscleral trabecular mesh-
electron-dense core and a sheath of banded material, and work cells. (A) A corneoscleral trabecular meshwork cell (TMC) that
show basically the same ultrastructural characteristics as covers trabecular meshwork beams forms long processes which
connect with those of neighboring beams. In addition, the cell bridges
those in the trabecular beams. So-called connecting fibrils an intertrabecular space to cover two adjacent beams. (B) Trabecular
consisting of elastic fiber material and fine fibrils emerge meshwork cells (TMC) containing phagocytosed pigment granules
from the cribriform plexus and connect it with the inner (arrows). Magnification bars: 2 µm.
wall endothelium of Schlemm’s canal (Fig. 5-8).

SCHLEMM’S CANAL
The inner wall endothelium of Schlemm’s canal forms large
outpouchings (so-called giant vacuoles) in response to the
flow of aqueous humor (Fig. 5-9A). Accordingly, giant vac-
uoles are only observed when the chamber angle tissue is
fixed by perfusion, but not when it is fixed by immersion.
Micrometer-sized pores are quite often associated with
the giant vacuoles and allow passage of microparticles
200–500 nm in sizes.27 Bill and Svedbergh calculated the
hydraulic conductivity and the flow resistance generated by
the pores and concluded that the inner wall endothelium
could generate not more than 10% of total trabecular
outflow resistance.28 Consistent with a minor role of the
inner wall endothelium for outflow resistance is the fact
that the endothelium has one of the highest hydraulic con-
ductivities in the body, comparable only to that of fenes-
trated endothelia.29 However, more recent experiments
indicate that the number of pores increases with the amount
of fixative perfused through an enucleated eye and that the
total number of pores identified by electron microscopy in
fixed tissues is likely considerably smaller than that in the
living eye.10,12 The pores in Schlemm’s canal endothelium
very likely originate from minipores with a diameter of
62–68 nm, which are bridged across their opening by a
thin 5-6 nm non-membranous diaphragm.30,31 Similar dia-
phragms cover the caveolae of Schlemm’s canal endothe-
lium.30 Plasmalemma vesicle-associated protein (PLVAP)
is essential for the formation of the diaphragms.30 The

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40.e4 SECTION 2 • Pathogenesis
Figure 5-7 Electron micrograph of the inner wall region including
juxtacanalicular tissue and Schlemm’s canal (SC) endothelium. The cells
in the juxtacanalicular tissue form elongated processes (open arrows).
Solid arrows mark the elastic fibers of the cribriform plexus. GV, giant
vacuole. Magnification bar: 5 µm.
Figure 5-8 Electron micrograph of connecting fibrils (open arrows) in
the juxtacanalicular tissue, which emerge from the cribriform plexus
(solid arrows) and connect it with the inner wall endothelium of Sch-
lemm’s canal (SC). Magnification bar: 1 µm.
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SC
GV
E SC
B C
SC
D
Figure 5-9 Electron micrographs of the endothelium of Schlemm’s
canal (SC) inner wall. (A) The inner wall endothelium forms giant vacu-
oles (GV) in response to flow of aqueous humor. Pores (arrow) are often
associated with the luminal side of the vacuoles. (B, C) Junctional
complex (arrow) between two neighboring inner wall endothelial cells.
(C) is higher magnification of (B). The arrow in (C) denotes a tight junc-
tion. (D) The basal side of Schlemm’s canal endothelial cells is in contact
with fine fibrillar material (asterisk) and is often not covered by a basal
lamina (open arrow). The solid arrow marks a junctional complex
between two adjacent endothelial cells. Magnification bars: 2 µm (A),
250 nm (B), 125 nm (C), 500 nm (D).
endothelial cells of Schlemm’s canal are connected by a
junctional complex that contains tight junctions which
should restrict paracellular flow (Fig. 5-9B, C). On the basal
side of the endothelial cells, there is fine fibrillar material
that varies in amount. The basal lamina of Schlemm’s
canal endothelium is often interrupted and considerable
areas of the basal cell membrane are in direct contact with
the open spaces of the juxtacanalicular tissue (Fig. 5-9D).
The lumen of Schlemm’s canal is frequently divided by
septa through which juxtacanalicular tissue is in direct
contact with tissue of the outer wall (Fig. 5-10A). Another
characteristic is diverticulae that extend from the lumen of
the canal into the juxtacanalicular tissue (Sondermann’s
canals) and which increase the surface area of the inner
wall of Schlemm’s canal (Fig. 5-10B).
 5 • Functional Morphology of the Trabecular Meshwork Outflow Pathways 40.e5

Figure 5-10 Light micrographs of Schlemm’s canal (SC). (A) The

lumen of Schlemm’s canal is divided by a septum (arrows) through
which juxtacanalicular tissue is in direct contact with tissue of the outer
wall. (B) A diverticulum (Sondermann’s canal) extends from the lumen
of the canal into the juxtacanalicular tissue (arrows) SC, Schlemm’s
canal. Magnification bars: 10 µm.

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 5 • Functional Morphology of the Trabecular Meshwork Outflow Pathways 41

resistance, unless the pathways are filled with an extracel-

lular matrix gel of unknown nature that is not visualized
by conventional microscopy.34 Another possible site
of outflow resistance is the inner wall endothelium of
Schlemm’s canal, a concept that would require that most
inner wall pores are indeed artefacts caused by prolonged
perfusion with fixative (see electronic text of this chapter
available online at http://www.expertconsult.com). There
is currently much active debate and research regarding the
specific role of the inner wall endothelium of Schlemm’s
canal or the juxtacanalicular connective tissue for the for-
mation of trabecular outflow resistance. Trabecular mesh-
work cells have some contractile properties and an increase
in their tone causes an increase in outflow resistance pre-
sumably by changing the geometry of the trabecular mesh-
work outflow pathways.35,36 In contrast, relaxation of A
trabecular meshwork cells leads to a decrease in outflow
resistance. Studies of genetically engineered mouse models
provided evidence for a role of nitric oxide (NO) as a
pressure-dependent regulator of trabecular outflow resist-
ance. Presumably, NO is released from Schlemm’s canal
endothelial cells upon increased shear stress and causes
relaxation of trabecular meshwork cells.37

CILIARY MUSCLE AND SCLERAL SPUR B

The muscle bundles of the radial portion of the ciliary

muscle and the inner bundles of its longitudinal portion
form tendons in the region of their anterior insertion that
are continuous with the extracellular matrix of the trabecu-
lar meshwork beams (Fig. 5-11A, B). The tendons of the
inner muscle bundles of the longitudinal portion pass the
scleral spur at its inner aspect to continue to the trabecular
meshwork (Fig. 5-11B). The same banded material that
forms the sheaths of the elastic fibers in the core region of
the trabecular beams is the main structural element of the
tendons. The banded material comes in direct contact with
the cell membrane of the muscle cell which forms dense
bands at the cytoplasmic site (Fig. 5-11C). In the region of
contact with the tendons, the muscle bundles taper and C
form deep furrows which are filled with banded material.
The outer muscle bundles of the longitudinal portion of the Figure 5-11 Light (A, B) and electron microscopy (C) of anterior ciliary
muscle tendons. (A, B) The muscle bundles of the radial portion of the
ciliary muscle also form tendons, but connect with the ciliary muscle (RCM, A) and the inner bundles of its longitudinal portion
extracellular matrix fibers of the scleral spur. The scleral (LCM, B) form tendons (arrows) in region of their anterior insertion that
spur contains collagen and elastic fibers that are circumfer- are continuous with the extracellular matrix of the trabecular mesh-
entially arranged (Fig. 5-12A). The elastic fibers are con- work beams. CCM, circular portion of the ciliary muscle. (A) The tendons
tinuous with those of the core of the corneoscleral of the radial portion continue to the uveal trabecular meshwork (UTM).
(B) The tendons of the inner muscle bundles of the longitudinal portion
meshwork beams or the cribriform plexus in the juxtaca- pass the scleral spur (SS) at its inner aspect to continue to the corneo-
nalicular tissue. The outermost muscle bundles of the lon- scleral trabecular meshwork (CTM). (C) The banded material of the
gitudinal portion of the ciliary muscle bend clockwise ciliary muscle tendons (solid arrows) comes in direct contact with the
or counterclockwise before they attach to the scleral spur cell membrane of the muscle cell (MC) which forms dense bands at the
cytoplasmic site (open arrows). In region of contact with the tendon,
(Fig. 5-12B).38 More inwardly, they do not bend, but insert the muscle cell forms deep furrows which are filled with banded mate-
to elastic fibers that are continuous with the circumferen- rial. Magnification bars: 10 µm (A, B), 500 nm (C).
tially arranged elastic fibers of the scleral spur (Fig. 5-12C).
Because of the structural connections between ciliary
muscle and scleral spur, contraction of the ciliary muscle
pulls the spur posteriorly and widens the trabecular spaces,14 scleral spur have a myofibroblast-like character as they
thereby inducing changes in the geometry of the trabecular contain numerous actin filaments (Fig. 5-13A) that stain
meshwork that lead to a reduction in outflow resistance. with antibodies against α-smooth muscle actin (Fig. 5-14A,
In addition to ciliary muscle cells, there is another con- C). In contrast to the muscle cells of the longitudinal portion
tractile cell population in this area which affects the tone of of the ciliary muscle, scleral spur cells are circumferentially
the trabecular meshwork.38 The resident cells within the oriented (Fig. 5-14C) and do not stain for desmin, the

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42 SECTION 2 • Pathogenesis

B C

Figure 5-12 Meridional (A) and tangential sections (B, C) of the scleral spur (SS) and the anterior insertion of the ciliary muscle (CM). (A) The scleral
spur contains numerous elastic fibers (white arrows) which are continuous with those of the trabecular meshwork (TM). Solid arrows denote anterior
tendons of the longitudinal portion of the ciliary muscle. (B) Near its insertion to the scleral spur, a muscle bundle bends in the circular direction
(arrows). (C) Ciliary muscle bundles insert to the scleral spur by means of elastic tendons which form arcades, finally bending in a circular direction
(arrows). Magnification bars: 10 µm (A), 30 µm (B, C). ((B) and (C) are from Tamm E, Flügel C, Stefani FH, et al. Contractile cells in the human scleral spur.
Exp Eye Res 1992; 54:531–43.)

intermediate filament that is characteristic for ciliary
muscle cells (Fig. 5-14B, D). Scleral spur cells are inner-
vated and coupled to each other by gap junctions (see Fig.
5-13C). They form tendon-like contacts with the banded
material that surrounds the elastic fibers of the scleral spur
(see Fig. 5-13A, B). As this material is continuous with the
elastic fibers in the core of the trabecular meshwork beams
and the cribriform plexus, changes in the tone of scleral
spur cells are likely to modulate outflow resistance by alter-
ing trabecular meshwork architecture.
Throughout the entire circumference of the scleral spur,
club-shaped nerve endings are found (Fig. 5-15A, B), which
have a diameter of about 3–5 µm and derive from myeli-
nated axons.39 The structure of the nerve endings is very
similar to that of mechanosensors in other parts of the
body. The endings contain abundant neurofilaments,
numerous granular and agranular vesicles, mitochondria,
and lamellated lysosome-like structures. The cell membrane
of the nerve endings is in direct contact with the elastic
fibers of the scleral spur. The contact between nerve termi-
nal and connective tissue fibers is a very characteristic
feature of mechanosensors, as it is required to measure the
tone of the extracellular fibers. The mechanosensors of the
scleral spur may act as proprioreceptive tendon organs for
the ciliary muscle, or modulate the tone of the scleral spur
cells. Alternatively, they could perform a baroreceptor func-
tion in response to changes in intraocular pressure. Indeed,
physiological studies indicate that such sensors might exist,
as sensory discharges have been recorded in response to
changes in intraocular pressure.40,41

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 5 • Functional Morphology of the Trabecular Meshwork Outflow Pathways 43

Figure 5-13 Meridional (A, B) and tangen-

tial sections (C, D) through ciliary muscle
(CM), scleral spur (SS), and trabecular mesh-
work (TM) stained with antibodies against
α-smooth muscle actin (A, C) or desmin (B,
D). (A) Ciliary muscle cells and vascular
smooth muscle cells stain positively with A B
antibodies against α-smooth muscle actin.
Arrows indicate the scleral spur, where all
cells show intense immunoreactivity for
α-smooth muscle actin. (B) Immunostaining
with antibodies against desmin. Ciliary
muscle cells stain brightly positive, whereas
the scleral spur is not labeled for desmin. (C)
Tangential section of scleral spur, trabecular
meshwork, and ciliary muscle. The plane of
the section is the same as in Fig. 5-12C. Posi-
tively stained cells oriented in a circular
direction are seen throughout the entire
spur tissue. While ciliary muscle cells also
stain positive, no staining is seen in the
trabecular meshwork. (D) Tangential section
of scleral spur and ciliary muscle after stain-
ing for desmin. The plane of the section is
the same as in Figures 5-14B and 5-12C.
Ciliary muscle cells stain brightly positive,
whereas the cells of the scleral spur remain
unstained. Magnification bars: 30 µm. (From
Tamm E, Flügel C, Stefani FH, et al. Contractile
cells in the human scleral spur. Exp Eye Res
1992; 54:531–43.) C D

A B C

Figure 5-14 Electron microscopy of scleral spur cells. (A) Scleral spur cells (SSC) are in close contact with banded sheath material (asterisks) of elastic
fibers. The cytoplasm of the cells is filled with abundant 6–7 nm thin (actin) filaments which run parallel to the long axis of the cells (solid arrows). The
cell membrane shows numerous membrane-bound caveolae (open arrows). (B) Scleral spur cells may form long processes to contact the elastic fibers
(asterisk) in the scleral spur. In region of contact, dense bands (arrows) are formed at the cell membrane of the scleral spur cell. (C) Scleral spur cells
are connected by gap junctions (arrow). Magnification bars: 1 µm (A, B), 125 nm (C). ((A and C) are from Tamm E, Flügel C, Stefani FH, et al. Contractile
cells in the human scleral spur. Exp Eye Res 1992; 54:531–43.)

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44 SECTION 2 • Pathogenesis

A B

Figure 5-15 Mechanosensors in the scleral spur. (A) Whole mount of the scleral spur stained with antibodies against neurofilament proteins. Axons
are labeled that terminate as bulb- or club-shaped structures (arrows). (B) Electron micrograph of a mechanoreceptive nerve terminal in the scleral
spur. The terminal is bulb- or club-shaped and contains numerous neurofilaments, mitochondria, and vesicles of different sizes. The elastic fibers of
the scleral spur (E, open arrows), and the scleral spur cells (solid arrows) are in close proximity to the terminal. SS, scleral spur. Magnification bars: 5 µm
(A), 1 µm (B).

THE TRABECULAR MESHWORK IN PRIMARY OPEN-

ANGLE GLAUCOMA
The most characteristic structural change of the trabecular Normal
outflow pathways in primary open-angle glaucoma is an
increase in extracellular material in the juxtacanalicular
region.14 The material is referred to as sheath-derived
plaque material, as it involves mainly the sheaths of the
elastic fibers which form the cribriform plexus underneath
the endothelial lining of Schlemm’s canal. Although CTGF TGF-β
the amount of sheath-derived plaque material correlates
with glaucomatous axonal damage in the optic nerve, it
does not correlate with intraocular pressure, indicating
that the material alone is not causative of the increase
in trabecular outflow resistance in primary open-angle
glaucoma.42 Another structural change in chronic open- POAG
angle glaucoma involves the number of pores in Schlemm’s
canal endothelium, which is decreased significantly
from normal eyes, even after accounting for the volume of
fixative perfused.12 Multiple studies have found higher
than normal concentrations of transforming growth Figure 5-16 Schematic drawing depicting the change in the pheno-
type of a trabecular meshwork cell that is under the influence of
factor-β2 (TGF-β2) in the aqueous humor of patients with increased TGF-β and CTGF signaling in primary open-angle glaucoma
primary open-angle glaucoma.43 TGF-β2 increases extra- (POAG). A myofibroblast-like phenotype is induced as the actin
cellular matrix synthesis and contractility of trabecular cytoskeleton (red) becomes more pronounced causing an increase in
meshwork cells, effects that are largely mediated through contractility. Simultaneously, the cell synthesizes more and thicker
connective tissue growth factor (CTGF). In genetically fibrillary extracellular matrix (green) to transmit force. The fibrillary
extracellular matrix is connected with the trabecular meshwork cell by
modified mice, CTGF induces a myofibroblast-like pheno- integrin-based cell–matrix adhesions (blue circles) which are also in
type in trabecular meshwork cells, quite similar to contact with the intracellular actin fibers.
that observed in the human scleral spur.44 The phenotype
includes both an increase in actin-mediated contractility
and fibrillary extracellular matrix that is connected to Acknowledgment
the cells via integrin-mediated cell–matrix adhesions The author gratefully acknowledges the excellent technical
(Fig. 5-16). In the mouse eye, the changed nature of trabec- help of Margit Schimmel and Anthonie Maurer’s expert
ular meshwork cells causes an increase in intraocular processing of photographs.
pressure, optic nerve damage, and primary open-angle
glaucoma.44 A similar scenario may well be responsible for Access (additional text and Figures 5-1, 5-2, 5-3, 5-4, 5-5,
the increase in outflow resistance in humans with primary 5-6, 5-7, 5-8, 5-9, 5-10) online at http://www
open-angle glaucoma. .expertconsult.com.

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Spotlight 1 Lymphatics and Uveolymphatic Outflow from the Eye
Neeru Gupta and Yeni Yucel
Most intraocular pressure-lowering glaucoma therapies target
conventional and uveoscleral aqueous outflow pathways and
improve drainage of aqueous humor. Lymphatics play a major
role in maintaining tissue–fluid balance in most organs by
draining extracellular fluid, solutes, and proteins. They are
also critical for immune surveillance. The eye, with optically
clear aqueous humor with minimal amounts of protein despite
high metabolic activity, has been considered to be devoid of a
lymphatic system for over a century.
We have reported the presence of lymphatics in the ciliary
body of the human eye using cell-specific markers1 and
electron microscopy with evidence for distinct lymphatic
channels within the human eye ciliary body. These findings
have been confirmed in sheep, with fluorescent nanospheres
identified in lymphatic channels also located within the
ciliary body.1 More recently, lymphatic drainage from the eye
Quantum Dot Drainage Rate (hours–1)
has been measured in a sheep model.2
Lymphatics likely contribute to fluid drainage from the eye,
and developing methods to visualize lymphatic flow in vivo is
relevant to glaucoma studies. We used a combination of
nanotracers and in vivo hyperspectral imaging to map ocular
lymphatic drainage in mouse.3 Quantum dots have unique
physical and near-infrared characteristics that make them
suitable during non-invasive in vivo imaging. Intracamerally
injected quantum dots were detected in vivo in the
submandibular node and this finding was confirmed by
examining immunofluorescence stained sections (Fig. 1).3
A
B lymphatic drainage from the mouse eye. Nanotechnology
Figure 1 Quantum dots in red are contained within the lymph
node surrounded by capsule in blue (anti-collagen IV) against a
green background of cell nuclei (Sytox green). Scale = 250 µm.
(Reprinted with permission from Tam AL, Gupta N, Zhang Z, Yucel
YH. Nanotechnology 2011; 21;22(42):425101.)
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Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2018. Elsevier Inc. Todos los derechos reservados.
Among the anti-glaucoma drugs, prostaglandin F2-alpha
analogs such as latanoprost are the most potent, and this is
ascribed to its action on the uveoscleral pathway. We have
demonstrated that latanoprost stimulates lymphatic drainage
from the eye (Fig. 2).4 The combined use of near-infrared
tracer and hyperspectral in vivo imaging is a novel tool to
study potential new treatments to reduce eye pressure in
glaucoma models.
2.5
*
2.0
1.5
1.0
0.5
0.0
Latanoprost Control
Figure 2 Histogram shows mean and SD of QD drainage
rate (hours−1) for latanoprost-treated (black) and control
(white) groups. *P < 0.05. (Reprinted with permission from Tam
AL, Gupta N, Zhang Z, Yucel YH. Latanoprost stimulates ocular
lymphatic drainage: an in vivo nanotracer study. Trans Vis Sci Tech
2013;2(5):3.)
Lymphatic outflow from the eye is a novel pathway
that has yet to be exploited as it relates to our
understanding of normal physiological outflow, and to
glaucoma and its treatment. Our finding that latanoprost
increases ocular lymphatic drainage suggests that selective
stimulation of lymphatic drainage from the eye may provide
a new class of drug treatment options to reduce blindness
from glaucoma.
References
1. Yucel YH, Johnston MG, Ly T, et al. Identification of
lymphatics in the ciliary body of the human eye: a novel
‘uveolymphatic’ outflow pathway. Exp Eye Res
2009;89(5):810–19.
2. Kim M, Johnston MG, Gupta N, et al. A model to measure
lymphatic drainage from the eye. Exp Eye Res
2011;93(5):586–91.
3. Tam AL, Gupta N, Zhang Z, et al. Quantum dots trace
2011;22(42):425101.
4. Tam AL, Gupta N, Zhang Z, et al. Latanoprost stimulates
ocular lymphatic drainage: an in vivo nanotracer study.
Translat Vis Sci 2013;2(5):3.
46 SECTION 2 • Pathogenesis
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