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  • Title: Lymphatic vessels of the eye - old questions - new insights.
    Author: Grüntzig J, Hollmann F.
    Journal: Ann Anat; 2019 Jan; 221():1-16. PubMed ID: 30240907.
    Abstract:
    Due to its accessible position and tissue heterogeneity, the eye is ideally suited for studying the lymphatic system. As early as the 19th century, questions about the origin and function of this system were discussed. For example, whether Schlemm's canal, which is of particular importance in the pathogenesis of glaucoma, is a lymphatic vessel, or does this vascular system begin with finger-shaped protuberances? Despite the discovery of lymphatic endothelial molecules and the use of molecular imaging technologies, these questions are still discussed controversially today. Leber demonstrated in 1873 with a solution consisting of two dyes of different particle size that only the smaller particles from the anterior chamber of the eye filled the episcleral and conjunctival veins around the corneal margin. He believed to have proven - to be read in the historical review of our article - that the Canalis Schlemmii in humans is a venous circular vessel and not a lymphatic vessel. In our own investigations, we reduced the rather contradictory and complex question of whether there are lymphatic vessels in the eye to the question of whether there are drainage connections between the different sections of the eye and the lymphatic system or not. With different radioactive tracers and combined with unilateral ligation of cervical lymph vessels, we observed outflow from the subconjunctival and retrobulbar space, from the anterior chamber and the vitreous body. The rate of discharge of the radioactive tracer was determined by the radiopharmaceutical and injection site. In analogy to the lymphatic drainage of the head we found a segmental drainage of lymphatic substances on the eye. Vitreous humour and retrobulbar space were drained by lymphatic vessels, predominantly to the deep cervical lymph nodes, while anterior chamber and subconjunctival space drains predominated over the superficial cervical lymph nodes. Eyeball tattoos - as loved by some fan communities - should therefore cause a coloured staining of the superficial cervical lymph nodes. The boundary of the drained segments would be in the area of the eyeball's equator. According to the textbooks, the lymph is actively removed from finger-shaped initial segments via pre-collectors and collectors with properly functioning intraluminal valves and smooth muscle cells in the vessels' media. In patients with spontaneous conjunctival bleeding, however, we observed phenomena in the conjunctival lymph vessels, which ca not be explained with old familiar ideas. At nozzle-shaped vessel constrictions separation of blood components occurred. The erythrocytes formed partially a so-called fluidic "resting bulk layer". Parallel vessel parts caused a retrograde filling of already emptied segments. These observations led our experimental investigations. In the literature, there are different scanning electron microscopy (SEM) images of lymphatic endothelial surfaces; nevertheless they are unassigned to a particular vessel segment. In the conjunctiva, we studied the question whether there is a dependence between vessel diameter and the surface characteristics of endothelial cells (after unfolding by lymphography). A constantly applied photo-mathematical procedure for all specimens allowed determining the size of the cross sections. The specimens were randomized into seven groups with diameters of 0.1-1.0mm and above and examined by SEM. In the smallest vessels (diameter=0.11mm), the impressions of the occasionally occurring nuclei in the lumen were clearly impressive. With increasing diameter, these impressions were lost and the individual endothelial nuclei could no longer be identified. Rather, one recognized only wall-like structures. In vessels of intermediate diameter (0.3-0.4mm), structures could be seen on the surface similar to reticular fibres. With increasing diameters, their prominent character weakened. In the group with diameters above 0.5mm, wavy surface structures were shown. Finally, in vessels of diameters over 1.0mm, a uniform, flat surface was observed. Regardless of the collection site of the specimens, we found certain surface characteristics related to the vessels' calibre. In further investigations by means of interstitial dye lymphography, we were able to demonstrate in the conjunctiva that under increasing injection pressure, additional vessels stained from finger-shaped processes. At least in the conjunctiva, the existence of so-called "blind-ending initial segments" seems doubtful (despite the fact that initial segments or "initial lymphatics" would begin in periphery, not end). Rather, these are likely to be temporary filling states. SEM investigations were carried out on the internal structure of these dome-shaped vessel parts by means of a specially developed preparation technique. Despite numerous variants in the lymphographic design of the blind bags - in the form of finger, balloon, dome, piston, pyramidal, double-humped and spearhead-like endings - slot-shaped, lip-shaped and saw blade-like structures were repeatedly found, similar to a zipper. These findings suggest preformed connections to the next segment and may control lymphatic flow. To clarify the retrograde fluid movements, we examined the lymph vessels' valves or those structures that were previously interpreted as valves. The different structures found could be subdivided into three groups. The lack of common bicuspid structures provides an explanation for retrograde fluid movement. That nevertheless a directional flow is possible, is explained by the flow model developed by Gerhart Liebau. Conjunctival lymphatics show intraluminal structures by double contrast injection, which we divided into four groups due to anatomical differences: An accurate statement about the occurrence of certain intraluminal vascular structures in certain vascular calibres was possible only conditionally. However, complex and extended structures (group d) were found almost exclusively in larger vessel calibres (diameter>0.9mm). The structures are reminiscent of published findings in the "collector channel orifices of Schlemm's canal". They should play an important role in the regulation of the intraocular pressure, or the balance between production and outflow of the aqueous humour. The influence of such structures on the function of the lymphatic vessels is not yet known. As an approach models could be used, which for instance are applied in the water industry for the drainage, the degradation of introduced substances, or the detention pond. The latter serves for the retention and purification of drainage water (storage, treatment and reuse of drainage water). Dead zones, barriers, short-circuit currents and swirling are further hydraulic terms. Can intraluminal vascular structures, for example, affect the lymphatic flow and thus the mechano-sensitivity of lymphatic endothelial cells? Whatever interpretation model we use, the warning of the Swiss anatomist His from 1862 is still true today that all theories about the formation and movement of lymph should be based on precise anatomical basics. This review article therefore tries to make a contribution therefore. Despite knowing of lymphatic endothelial molecules, despite the discovery of the role of lymphangiogenic growth factors in diseases and the use of molecular imaging technologies, we still know too little about the anatomy and function of the lymphatic system.
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