Primary open angle glaucoma (POAG) is a leading cause of blindness worldwide. Elevated intraocular pressure (IOP), resulting from increased aqueous humor outflow resistance, is a major risk factor for the development and progression of POAG. Outflow resistance in the trabecular outflow pathway is mainly (50-75%) generated in the juxtacanalicular connective tissue (JCT), and partially (25-50%) in the portion distal to the inner wall of Schlemm’s canal. The details of how aqueous humor flows through these tissues and how resistance in these tissues is regulated are not fully understood in normal and POAG eyes. Aqueous humor outflow was shown to be “segmental”, with discontinuous active regions of aqueous humor filtration along the trabecular outflow pathway that can be labeled with perfused fluorescent tracers and measured as effective filtration area (EFA). In this study, we investigated the relationship between changes in EFA along the trabecular outflow pathway and outflow facility/IOP under two experimental conditions. The first experiment was designed to increase outflow facility by using netarsudil, a recently approved Rho kinase inhibitor class glaucoma medication, in normal human donor eyes. The second experiment was designed to increase IOP with topical steroid treatment for 5 weeks in mice. The purpose of this study is to verify whether EFA can be modulated by netarsudil or steroid treatment and to demonstrate the morphological changes that may be responsible for the changes of EFA. We analyzed EFA along the trabecular outflow pathway and found that elevated/reduced EFA correlated with increased outflow facility/IOP. Guided by EFA, we performed detailed morphological comparison between the active and inactive portions of aqueous humor filtration tissue to evaluate possible structural changes involved in EFA regulation. We found that increased EFA was associated with a loosened JCT structure and dilated episclearal veins, while decreased EFA was associated with a compacted JCT structure, increased deposition of curly collagen and/or fibrillary structure in the trabecular meshwork, and increased basement membrane continuity. Our data suggest that the netarsudil/steroid-induced morphological changes in the trabecular outflow pathway can result in either an increase or decrease in EFA, which in turn contributes to the regulation of outflow facility/IOP. / 2020-10-24T00:00:00Z

Primary open-angle glaucoma (POAG) is a leading cause of blindness in the world. A primary risk factor for POAG is elevated intraocular pressure (IOP), caused by increased aqueous humor outflow resistance. Currently, lowering the IOP is the only effective way of treating glaucoma; however, the cause of increased outflow resistance remains unclear. This thesis will present a series of studies which investigated structures of the trabecular outflow pathway, including Schlemm’s canal endothelium, juxtacanalicular tissue, and trabecular beams, and their roles in regulating aqueous outflow resistance. The studies were conducted in both human and animal models using ex vivo ocular perfusion as well as in vitro microfluidic systems. In the first study, we investigated the effects of Y27632, a derivative of Rho-kinase inhibitor that is being developed as next generation glaucoma drug with unclear IOP lowering mechanism, on aqueous humor outflow dynamics and associated morphological changes in normal human eyes and laser-induced ocular hypertensive monkey eyes. In the second study, we developed and validated a novel three-dimensional microfluidic system using lymphatic microvascular endothelial cells. The microfluidic system can be used to study Schlemm’s canal endothelial cell dynamics and aqueous humor transport mechanism in the future. In the last study, we characterized the morphological structure, distribution, and thickness of the endothelial glycocalyx in the aqueous humor outflow pathway of human and bovine eyes. Together these studies will help define new directions for therapy that will help control IOP and preserve vision throughout a normal life span.

BACKGROUND: Netarsudil, a Rho kinase and norepinephrine transport (NET) inhibitor, is a new FDA approved drug used for decreasing raised intraocular pressure (IOP) in ocular hypertensive and primary open-angle glaucoma (POAG) patients. Previous studies reported that netarsudil increased outflow facility and lowered IOP by increasing active outflow areas around the circumference of the eye and dilating the episcleral veins (ESV; Kiel and Kopczynski, 2015; Ren et al., 2016). However, the mechanisms by which netarsudil increases outflow facility have not yet been fully elucidated. Moreover, the effects of netarsudil on the inner wall (IW) endothelium I-pores and B-pores of the Schlemm’s canal (SC) have also not been investigated yet. AIM: The goal was to determine if netarsudil-treatment increased the effective filtration areas (EFA) by increasing pore density in both high- and non-flow type areas, compared to untreated control eyes. METHODS: In this study, the effects of netarsudil on the pore densities on IW of SC were investigated by serial block-face scanning electron microscopy (SBF-SEM). Two pairs of eyes were perfused with green fluorescent tracers in order to determine the outflow pattern prior to treatment. Then, one eye of each pair was perfused with netarsudil, while the fellow eye of each pair was perfused with vehicle solution. All eyes were then perfused with red fluorescent tracers in order to determine the outflow pattern once they were treated with netarsudil. Both pairs of eyes were perfused and fixed at 15 mmHg. Global imaging was performed for all eyes to visualize high- and non- flow areas in the trabecular meshwork (TM) and ESV’s. A SBF-SEM was used to image eight wedges of tissue including the IW of SC and TM (high- and non-flow areas from four eyes) for a total of 16,378 images. The study analyzed the percentage of pore-types (GV-associated I-pores, Non-GV associated I-pores, B-pores), the median pore spans, the GV-associated I-pore locations, and the pore densities (per IW nuclei and IW area) between the equivalent control and netarsudil-treated flow areas. RESULTS: In global images, an increase in high-flow areas were observed in netarsudil-treated eyes due to recruitment from low-flow and non-flow areas. A greater percentage of GV-associated I-pores, B-pores, and total pores were found in high-flow in contrast to non-flow areas in both control and netarsudil-treated eyes (all P ≤ 0.05). However, the percentage of GV-associated I-pores in non-flow areas were significantly greater in treated compared to control eyes (P ≤ 0.05). Qualitative observations from two pairs of eyes showed a trend of greater I-pore, B-pore, and total pore density/per IW nucleus and density/per IW surface area in high-flow in contrast to non-flow areas for both treated and control eyes. No difference in I-pore, B-pore, and total pore density/per IW nucleus and density /per IW surface area were observed in equivalent flow-type areas when comparing control and netarsudil-treated eyes. In addition, there was a significant greater percentage of I-pores located on the side of GVs than the top of GVs in all cases (P ≤ 0.05). CONCLUSIONS: Netarsudil increased high-flow areas. A greater pore density was found in high-flow in contrast to non-flow areas. Netarsudil also significantly increased the proportion of GV-associated I-pores in non-flow areas when compared to control eyes. Our results suggests that one mechanism of netarsudil increasing outflow facility is acting through recruiting the high-flow areas around the circumference of the eye, which is associated with higher pore density and increasing the proportion of GV-associated I-pores in non-flow areas.