Добавил:
kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз: Предмет: Файл:
Ординатура / Офтальмология / Английские материалы / Becker-Shaffer's Diagnosis and Therapy of the Glaucomas_Stamper, Lieberman, Drake_2009.pdf
Скачиваний:
0
Добавлен:
28.03.2026
Размер:
61.47 Mб
Скачать

 

chapter

Aqueous humor outflow system overview

3

 

 

CSW

SC

TM

SCV

(A)

(B)

(C)

(D)

(E)

Fig. 3-9  Trabecular meshwork (TM) is collapsed and Schlemm’s canal (SC) is widely dilated. Schlemm’s canal valves (SCV) arise from inner wall of Schlemm’s canal, then course across the canal to attach to the external or corneoscleral wall (CSW). (A) Intraocular pressure below episcleral venous pressure. Schlemm’s canal valves are stretched across the dilated canal, the valve walls recoil and the valve lumen is small. Pressure surrounding the valves is higher than pressure in the lumen so blood cannot easily reflux through the valve lumen. (B) Aqueous outflow system appearance with IOP at physiologic levels. Schlemm’s canal valves are oriented circumferentially in Schlemm’s canal, the valve walls distend and the valve lumen is large. (C, D, E) Aqueous discharge to Schlemm’s canal during one systolic pulse wave in the human eye. The transparent trabecular meshwork (TM) permits visualization of blood intentionally refluxed into Schlemm’s canal. (C) Clear aqueous in funnel-shaped area at base of trabecular meshwork (arrow). (D) Regularly recurring sequential aqueous flow into more distal cylindrical region with site of initial swirling eddies of aqueous and blood indicating initial aqueous entry to Schlemm’s canal (arrow). (E) Clear aqueous column ejected into Schlemm’s canal as indicated by swirling eddies of mixing aqueous and blood cause circumferential flow along Schlemm’s canal for a considerable distance (arrow) beyond initial mixing area identified in D.

(A and B from Johnstone MA: Pressure-dependent changes in the configuration of the endothelial tubules of Schlemm’s canal, Am J Ophthalmol 78 : 630–8, 1974. Copyright by American Journal of Ophthalmology.) (C–E, video courtesy of Robert Stegmann.)

Because of their oblique orientation, in single sections septa some­ times appear to be attached to Schlemm’s canal posterior wall, but suspended unattached in Schlemm’s canal anteriorly.15 Septa are composed of dense parallel collagen bundles that are continuous with and have staining characteristics identical to collagen bun­

dles of the sclera.15 The septa typically join the collagenous walls of the canal rather than attaching to the trabecular meshwork.15,139

Although the canal is occasionally separated into channels, it is usually a single lumen.139 Collector channels are at times quite large (50–70 micron) and course circumferentially adjacent to the canal for a considerable distance.87,139 In individual histologic sec­ tions, collagenous partitions between large collector channels and

Schlemm’s canal may be confused with septa within the canal and thus appear to divide the canal into more than one channel.87,139

Schlemm’s canal valves spanning across Schlemm’s canal

Schlemm’s canal valves arise from the inner wall endothelium of

Schlemm’s canal, develop a cylindrical configuration and course across the canal to attach to the external wall (Fig. 3-9).15,73,78,140–142 The

valve walls are continuous with Schlemm’s canal inner wall endothe­

lium as documented by light, scanning, and transmission electron microscopy.15,73,78,140,141 Laboratory evidence of a lumen continuous

with the juxtacanalicular space consists of studies with the dissecting,

light, scanning, and transmission electron microscope.15,73,140–143 Tracer studies demonstrate a communication between the anterior chamber and Schlemm’s canal through the lumen of the structures using both antegrade and retrograde techniques.15,141 Pigment gran­ ules and amorphous extracellular matrix material are present in the

lumen of the aqueous valves, a finding like that in the juxtacanalicu­ lar space.15,73,78,140–142 The valve walls distend and recoil in response to changes in IOP (see Fig. 3 9).15,140 The presence of Schlemm’s

canal valves is documented at the operating microscope in liv­ ing human eyes during Schlemm’s canal surgery.15 In vivo, aqueous enters Schlemm’s canal in a pulsatile fashion through structures with a size and configuration like those characterized in the laboratory (see Fig. 3-9).15 Functionally, the aqueous valves have been proposed

as part of a mechanical pump discharging aqueous to Schlemm’s canal.15,140 The lumen of the valves is compressed between the walls

of Schlemm’s canal at a relatively low IOP of 25 mmHg.78

Herniations or protrusions of Schlemm’s canal inner wall

As the inner wall endothelium of Schlemm’s canal distends outward

in response to pressure, the distending endothelial wall forms pro­ jections, herniations or protrusions into Schlemm’s canal.27,28,72,79, 89,96,140 These protrusions do not attach between the walls of the

canal, and the distention is completely reversible with movement

33