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Ocular Accommodation, Intraocular Pressure, Development of Myopia, and Glaucoma: Role of Ciliary Muscle, Choroid, and Metabolism

Karan R Gregg Aggarwala


Ocular accommodation is not just a mechanism for altering curvature of the crystalline lens of the eye, it also enables aqueous humor outflow through the trabecular meshwork, influencing intraocular pressure (IOP). Long term stress on the ciliary muscle from sustained near focusing may initiate myopic eye growth in children and primary open angle glaucoma in presbyopic adults. Multi-factorial studies of ocular accommodation that include measures of IOP, ciliary muscle morphology, anterior chamber depth, and assessment of nutritional intake and metabolic markers may elucidate etiology and novel strategies for management of both myopia and chronic glaucoma. Anatomy of the ciliary fibers from anterior insertion in the fluid drainage pathway to their posterior consanguinity with the vascular choroid, alters ocular parameters such as micro-fluctuations of accommodation and pulsatile ocular blood flow that are driven by cardiac contractions conveyed by carotid arteries. Stretching of the choroid has consequences for thinning of the peripheral retina, sclera and lamina cribrosa—with potential to induce retinal tears and optic nerve cupping. It is hoped that the present synthesis of relevant literature and evidence based speculations, may stimulate additional research conducted clinically oriented scientists, supported by their host institutions. Early metabolic interventions may lead to prevention or reduced severity of myopia and glaucoma. It is hoped that improved quality of life for patients and informed consumers, and reduced disability from visual impairment and blindness may result.


Whitacre MM, Stein R. Sources of error with use of Goldmann-type tonometers. Survey of Ophthalmology. 1993;38(1):1-30. doi: 10.1016/0039-6257(93)90053-a

Armaly MF, Burian HM. Changes in the tonogram during accommodation. AMA Arch Ophthalmol. 1958;60(1):60-9. doi: 10.1001/archopht.1958.00940080074010 pmid: 13544666

Armaly MF, Jepson NC. Accommodation and the dynamics of the steady-state intraocular pressure. Invest Ophthalmol. 1962;1:480-3. pmid: 13862325

Gupta D, Chen PP. Glaucoma. Am Fam Physician. 2016;93(8):668-74. pmid: 27175839

Read SA, Collins MJ, Becker H, Cutting J, Ross D, Savill AK, et al. Changes in intraocular pressure and ocular pulse amplitude with accommodation. Br J Ophthalmol. 2010; 94(3):332-5. doi: 10.1136/bjo.2009.166355 pmid: 19822912

Yan L, Huibin L, Xuemin L. Accommodation-induced intraocular pressure changes in progressing myopes and emmetropes. Eye (Lond). 2014;28(11):1334-40. doi: 10. 1038/eye.2014.208 pmid: 25190534

Tomlinson A, Phillips CI. Applanation tension and axial length of the eyeball. Br J Ophthalmol. 1970;54(8):548-53. doi: 10.1136/bjo.54.8.548 pmid: 5458678

Jensen H. Myopia progression in young school children and intraocular pressure. Doc Ophthalmol. 1992;82(3):249-55. doi: 10.1007/bf00160772 pmid: 1303861

Fisher RF. The force of contraction of the human ciliary muscle during accommodation. J Physiol. 1977;270(1):51-74. doi: 10.1113/jphysiol.1977.sp011938 pmid: 915798

Swegmark G. Studies with impedance cyclography on human ocular accommodation at different ages. Acta Ophthalmol (Copenh). 1969;47(5):1186-206. doi: 10.1111/j. 1755-3768.1969.tb02519.x pmid: 5395863

Petrash JM. Aging and age-related diseases of the ocular lens and vitreous body. Invest Ophthalmol Vis Sci. 2013;54 (14):ORSF54-9. doi: 10.1167/iovs.13-12940 pmid: 24335070

Strenk SA, Strenk LM, Koretz JF. The mechanism of presbyopia. Prog Retin Eye Res. 2005;24(3):379-93. doi: 10. 1016/j.preteyeres.2004.11.001 pmid: 15708834

Schiefer U, Kraus C, Baumbach P, Ungewiss J, Michels R. Refractive errors. Dtsch Arztebl Int. 2016;113(41):693-702. doi: 10.3238/arztebl.2016.0693 pmid: 27839543

Chattopadhyay DN, Seal GN. Amplitude of accommodation in different age groups and age of on set of presbyopia in Bengalee population. Indian J Ophthalmol. 1984;32(2):85-7. pmid: 6526471

Aggarwala K, Premila C. Master's Thesis of Caroline Premila. Mumbai

Nesterov A. The future for surgery in the glaucomas by increasing uveoscleral outflow. In: Cairns J, editor. Glaucoma: Grune & Stratton; 1986. p. 257-73.

Johnson M, McLaren JW, Overby DR. Unconventional aqueous humor outflow: A review. Exp Eye Res. 2017;158: 94-111. doi: 10.1016/j.exer.2016.01.017 pmid: 26850315

Nilsson SF. The uveoscleral outflow routes. Eye (Lond). 1997;11 ( Pt 2):149-54. doi: 10.1038/eye.1997.43 pmid: 9349404

Alm A, Nilsson SF. Uveoscleral outflow--a review. Exp Eye Res. 2009; 88(4):760-8. doi: 10.1016/j.exer.2008.12.012 pmid: 19150349

Crawford K, Kaufman PL. Pilocarpine antagonizes prostaglandin F2 alpha-induced ocular hypotension in monkeys. Evidence for enhancement of Uveoscleral outflow by prostaglandin F2 alpha. Arch Ophthalmol. 1987;105 (8):1112-6. doi: 10.1001/archopht.1987. 01060080114039 pmid: 3477218

Selbach JM, Gottanka J, Wittmann M, Lutjen-Drecoll E. Efferent and afferent innervation of primate trabecular meshwork and scleral spur. Invest Ophthalmol Vis Sci. 2000;41(8):2184-91. pmid: 10892861

Sagara T, Gaton DD, Lindsey JD, Gabelt BT, Kaufman PL, Weinreb RN. Reduction of collagen type I in the ciliary muscle of inflamed monkey eyes. Invest Ophthalmol Vis Sci. 1999;40(11):2568-76. pmid: 10509651

Overby DR, Bertrand J, Schicht M, Paulsen F, Stamer WD, Lutjen-Drecoll E. The structure of the trabecular meshwork, its connections to the ciliary muscle, and the effect of pilocarpine on outflow facility in mice. Invest Ophthalmol Vis Sci. 2014;55(6):3727-36. doi: 10.1167/iovs.13-13699 pmid: 24833737

Croft MA, Oyen MJ, Gange SJ, Fisher MR, Kaufman PL. Aging effects on accommodation and outflow facility responses to pilocarpine in humans. Arch Ophthalmol. 1996;114(5):586-92. doi: 10.1001/archopht.1996.01100130578015 pmid: 8619770

Oliveira C, Tello C, Liebmann JM, Ritch R. Ciliary body thickness increases with increasing axial myopia. Am J Ophthalmol. 2005;140(2):324-5. doi: 10.1016/j.ajo.2005.01. 047 pmid: 16086961

Lane BC. Elevation of Intraocular Pressure with Daily Sustained Closework Stimulus to Accommodation Lowered Tissue Chromium and Dietary Deficiency of Ascorbic Acid (Vitamin C). Third International Conference on Myopia Copenhagen, August 24–27, 1980. Documenta Ophthalmologica Proceedings Series1981. p. 149-55.

Kaufman PL. Enhancing trabecular outflow by disrupting the actin cytoskeleton, increasing uveoscleral outflow with prostaglandins, and understanding the pathophysiology of presbyopia interrogating Mother Nature: asking why, asking how, recognizing the signs, following the trail. Exp Eye Res. 2008;86(1):3-17. doi: 10.1016/j.exer.2007.10.007 pmid: 18053986

Bailey MD, Sinnott LT, Mutti DO. Ciliary body thickness and refractive error in children. Invest Ophthalmol Vis Sci. 2008; 49(10):4353-60. doi: 10.1167/iovs.08-2008 pmid: 18566470

Tamm S, Tamm E, Rohen JW. Age-related changes of the human ciliary muscle. A quantitative morphometric study. Mechanisms of Ageing and Development. 1992;62(2):209-21. doi: 10.1016/0047-6374(92)90057-k

Bito L, Miranda O. Accommodation and presbyopia. Ophthalmol Annu. 1989;103.

Glasser A. Accommodation. Adler's Physiology of the Eye2011. p. 40-70.

Schultz KE, Sinnott LT, Mutti DO, Bailey MD. Accommodative fluctuations, lens tension, and ciliary body thickness in children. Optom Vis Sci. 2009;86(6):677-84. doi: 10.1097/OPX.0b013e3181a7b3ce pmid: 19417700

Schmetterer L, Dallinger S, Findl O, Eichler HG, Wolzt M. A comparison between laser interferometric measurement of fundus pulsation and pneumotonometric measurement of pulsatile ocular blood flow. 1. Baseline considerations. Eye (Lond). 2000;14 ( Pt 1):39-45. doi: 10.1038/eye.2000.9 pmid: 10755098

Kaufman PL, Lutjen Drecoll E, Croft MA. Presbyopia and Glaucoma: Two Diseases, One Pathophysiology? The 2017 Friedenwald Lecture. Invest Ophthalmol Vis Sci. 2019; 60(5):1801-12. doi: 10.1167/iovs.19-26899 pmid: 31038661

Loyo-Berrios NI, Blustein JN. Primary-open glaucoma and myopia: a narrative review. WMJ. 2007;106(2):85-9, 95. pmid: 17479825

Black I. Trophic Interactions and Brain Plasticity. In: Michael S, Gazzaniga, editors. The Cognitive Neurosciences. Cambridge: MIT Press; 1995.

Sendtner M, Carroll P, Holtmann B, Hughes RA, Thoenen H. Ciliary neurotrophic factor. J Neurobiol. 1994;25(11):1436-53. doi: 10.1002/neu.480251110 pmid: 7852996

Wentzek LA, Bowers CW, Khairallah L, Pilar G. Choroid tissue supports the survival of ciliary ganglion neurons in vitro. J Neurosci. 1993;13(7):3143-54. pmid: 8331391

Shen L, Melles RB, Metlapally R, Barcellos L, Schaefer C, Risch N, et al. The Association of Refractive Error with Glaucoma in a Multiethnic Population. Ophthalmology. 2016;123(1):92-101. doi: 10.1016/j.ophtha.2015.07.002 pmid: 26260281

Aggarwala K, Richer S. Influencing Myopia: Science and Clinical Practice. Review of Optometry. 2019.

Croft MA, Lutjen-Drecoll E, Kaufman PL. Age-related posterior ciliary muscle restriction - A link between trabecular meshwork and optic nerve head pathophysiology. Exp Eye Res. 2017;158:187-9. doi: 10. 1016/j.exer.2016.07.007 pmid: 27453343

Arciniegas A, Amaya LE. Mechanical behavior of the sclera. Ophthalmologica. 1986;193(1-2):45-55. doi: 10.1159/ 000309678 pmid: 3822394

Lane B. Nutrition and vision. In: Bland J, editor. Yearbook of Nutritional Medicine. New Canaan: Keats Publishing, Inc; 1984. p. 239-81.

Van Alphen GWHM. Choroidal stress and emmetropization. Vision Research. 1986;26(5):723-34. doi: 10.1016/0042-6989(86)90086-6

Summers JA. The choroid as a sclera growth regulator. Exp Eye Res. 2013;114:120-7. doi: 10.1016/j.exer.2013.03.008 pmid: 23528534

Lane B, editor Elevation of intraocular pressure (IOP) with sustained stimulus to accommodation, lowered tissue chromium,* and dietary deficiency of ascorbic acid. American Association for the Advancement of Science: Abstracts of papers of the 147th national meeting, 3-8 January 1981, Toronto, Ontario, Canada; 1981.

Tasca JR. The importance of nutrition in eye development and vision function. Viktoras Kulvinskas: Life in the 21st Century. Woodstock Valley: Omangod Press; 1981. p. 236-41, 388-9.

Rondeau M, Aggarwala K, Silverman R, Aslanides I, Lloyd H, Lizzi F, et al., editors. Accommodative hysteresis and ciliary muscle function: an ultrasound backscatter study. Investigative ophthalmology & visual science; 1996: lippincott-raven publ 227 east washington sq, philadelphia, pa 19106.

Aggarwala K, Silverman R, Rondeau M, Aslanides I, Coleman D, editors. Depth of the anterior chamber changes progressively with accommodation. INVESTIGATIVE Ophthalmology & Visual Science; 1996: Lippincott-Raven Publ 227 East Washington Sq, Philadelphia, Pa 19106.

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