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Glaucoma Basics – Aqueous humor dynamics and Intraocular pressure

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Volume of aqueous: 0.25 ml (Anterior chamber) + 0.06 ml (Posterior chamber)

Composition of aqueous: similar to plasma except-

  • higher concentration of ascorbate, pyruvate and lactate
  • lower concentration of protein, urea and glucose

Functions of aqueous:

  1. Maintains Intra-ocular Pressure (IOP)
  2. Provides nutrition to avascular lens and cornea
  3. Optical transparency
  4. Place of lymph that is absent in eyeball

Production of aqueous:

Aqueous humor production

  • Source: ciliary process of ciliary body
  • Rate: 2.3 µl/min
  • Stages:
    1. Convective delivery: of H2O, ions, proteins, metabolic fuel by ciliary circulation.
    2. Ultrafiltration and diffusion: from capillaries into the stroma, driven by oncotic pressure, hydrostatic pressure and concentration gradient.
    3. Active secretion: into the basolateral spaces between nonpigmented epithelium followed by water movement down the resultant osmotic gradient into posterior chamber.

Drainage of aqueous:

Ciliary process → Aqueous in posterior chamber → (though pupil) → Anterior chamber

Aqueous drainage pathway

From anterior chamber, the drainage pathway divides into 3 systems:

1. Trabecular/conventional/pressure dependent (90%):

Trabecular meshwork (innermost uveal, middle corneoscleral, outermost juxtacanalicular) → Schlemm’s canal (endothelial lined and present in scleral sulcus) → Collector channels (Direct – Aqueous vein; Indirect – Intrascleral plexus) → Episcleral veins

2. Uveoscleral/Unconventional/Extracanalicular/Pressure-independent (10%):

Ciliary body → Suprachoroidal space → Venous circulation of ciliary body, choroid and sclera

3. Iris outflow (<1%)

Intraocular Pressure (IOP):

Definition: Pressure exerted by intraocular fluids on the coats of the eyeball.

Normal value: 10-21 mmHg (16 +/- 2.5 mmHg)

Goldmann equation:

Pο = (F/C) + PV

Pο = IOP = 10-21 mmHg
F = Rate of aqueous production = 2 µl/min
C = Facility of outflow = 0.22-0.28 µl/min/mmHg
PV = Episcleral venous pressure = 8-12 mmHg

Influencing factors:

1. Long term: Heredity, age, sex, race, refractive error

2. Short term:

  • General:
    • Posture: increased in supine position, highly increased in head down position
    • Exercise: decreased by aerobic exercise, increased by isometric exercise
  • Systemic:
    • Valsalva: increased
    • Food/drugs:
      • lowers IOP: alcohol, fat-free diet, vasodilators, heroin, miotics
      • increases IOP: water drinking, caffeine, steroids, mydriatics
    • General anesthesia: lowers IOP except Ketamine and Succinylcholine
  • Rhythmic:
    • Cardiovascular: 1-2 mm
    • Respiratory: upto 5 mm
    • Diurnal (higher in morning): < 5 mm

IOP measurement:


a. All suspected cases of glaucoma:

  • Significant diurnal variation (>8 mm Hg)
  • Significantly positive water drinking provocative test (>8 mmHg)
  • > 0.2 asymmetry of cup to disc ratio in 2 eyes
  • Splinter hemorrhage over or near disc
  • Positive family history
  • IOP constantly > 30 mmHg
  • Diabetic and high myopic patient

b. Age: > 40 years

Palpation tonometry

Digital tonometry with index fingers


a. Digital palpation tonometry:

  1. The patient is asked to look downward
  2. Fluctuation of eyeball is elicited at upper lid with the help of index finger of 2 hands.
    • Increased IOP: firm and hard
    • Normal IOP: Soft (like a partially filled water bag)

b. Indentation (Schiotz) tonometry

c. Applanation (Goldmann’s) tonometry

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