A Review of Aqueous Outflow Resistance and its Relevance to Micro-invasive Glaucoma Surgery.

Primary open-angle glaucoma is the leading cause of irreversible blindness worldwide, and intraocular pressure (IOP) reduction remains the only proven treatment strategy. Elevated IOP occurs as the result of impaired aqueous humor outflow. Both a passive model and a dynamic model have been used to explain trabecular outflow resistance. The passive model posits that the trabecular meshwork acts as a static filter that exerts stable and passive resistance to outflow. In contrast, the dynamic model involves a 'biomechanical pump.' In recent years, the range of surgical management options for glaucoma has dramatically expanded, particularly the class of procedures known as micro-invasive glaucoma surgery (MIGS). These procedures typically target and enhance specific outflow routes. Optimal patient outcomes with MIGS require a clear understanding of aqueous outflow and a surgical approach that is targeted to overcome the site of abnormal resistance in the individual. We review the anatomy and physiology of trabecular and suprachoroidal outflow that is of relevance to MIGS surgeons.