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Ocular manifestations of sleep apnea, updated for 2011
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Sleep Apnea Sleep Apnea & the Eye& the Eye
Rick Trevino, ODRick Trevino, ODRosenberg School of OptometryRosenberg School of OptometryUniversity of the Incarnate WordUniversity of the Incarnate Word
[email protected]@uiwtx.edu
Sleep Apnea & the EyeSleep Apnea & the Eye Sleep ApneaSleep Apnea
Clinical consequencesClinical consequences DiagnosisDiagnosis TreatmentTreatment
Ocular Ocular ManifestationsManifestations AsthenopiaAsthenopia CPAP-assoc red eyeCPAP-assoc red eye Floppy eyelid Floppy eyelid
syndromesyndrome Diabetic retinopathyDiabetic retinopathy NAIONNAION PapilledemaPapilledema Normal tension Normal tension
glaucomaglaucoma
Online ResourcesOnline Resources
Lecture NotesLecture Notes http://richardtrevino.net/http://richardtrevino.net/
sleepapneasleepapnea
Powerpoint SlidesPowerpoint Slides http://slideshare.net/rhodopsinhttp://slideshare.net/rhodopsin
Free TextsFree Texts http://jfponline.com (Aug 2008)http://jfponline.com (Aug 2008) http://www.eyesite.cahttp://www.eyesite.ca
Can J Ophthalmol (April 2007)Can J Ophthalmol (April 2007)2007;42(2):238-432007;42(2):238-43
Source: J Am Board Fam Med. 2007;20:392-398
Sleep DisordersSleep Disorders
Sleep apnea Sleep apnea InsomniaInsomnia NarcolepsyNarcolepsy Restless leg Restless leg
syndromesyndrome ParasomniasParasomnias Circadian disordersCircadian disorders Drug side effectsDrug side effects Shift workShift work
OSA is the “most physiologically disruptive and dangerous of the sleep-related disorders.”
Sleep ArchitectureSleep Architecture
Source: Thorax 2004;59:73-78
Obstructive Sleep ApneaObstructive Sleep ApneaAny Condition that Any Condition that
Causes or Contributes Causes or Contributes to Upper Airway to Upper Airway
Narrowing is a Risk Narrowing is a Risk Factor for OSAFactor for OSA
ObesityObesity
Enlarged TonsilsEnlarged Tonsils
Anatomical MalformationsAnatomical Malformations
NeoplasmsNeoplasms
Edema of the pharynxEdema of the pharynx
Lymphoid HypertrophyLymphoid Hypertrophy
Pharyngeal Muscle Pharyngeal Muscle WeaknessWeakness
Dyscoordination of Dyscoordination of Respiratory MusclesRespiratory Muscles
Obstructive Sleep ApneaObstructive Sleep ApneaPolysomnography (PSG)Polysomnography (PSG)
Source: eMedicine (http://www.emedicine.com/med/topic163.htm)
Obstructive Sleep ApneaObstructive Sleep Apnea
Excessive daytime Excessive daytime sleepinesssleepiness
Most common symptomMost common symptom
Disruptive snoringDisruptive snoring Also gasping/snorting during Also gasping/snorting during
arousalsarousals
Apneic events Apneic events witnessed by bed witnessed by bed partnerpartner
Disruptive snoring + witnessed Disruptive snoring + witnessed apneas: 94% specificityapneas: 94% specificity
ObesityObesity 30% of pts with a BMI > 30 have 30% of pts with a BMI > 30 have
OSA, and 50% of pts with a BMI OSA, and 50% of pts with a BMI > 40 have OSA.> 40 have OSA.
Neck Neck circumferencecircumference
≥≥40 cm had a sensitivity of 61% 40 cm had a sensitivity of 61% and a specificity of 93% for OSAand a specificity of 93% for OSA
Correlates better than BMICorrelates better than BMI
MaleMale 2-3x more common than female2-3x more common than female
Family history of Family history of OSAOSA
Relatives have 2-4 fold Relatives have 2-4 fold risk risk
Clinical CharacteristicsClinical Characteristics
Source: Postgrad Med 2002;111(3):70-6.
Obstructive Sleep ApneaObstructive Sleep Apnea Pickwickian SyndromePickwickian Syndrome
Obesity, daytime Obesity, daytime somnolence, loud somnolence, loud snoringsnoring
Charles Dicken’s Charles Dicken’s “Pickwick Papers” “Pickwick Papers” (1837)(1837)
Prevalence increasing Prevalence increasing in parallel with in parallel with prevalence of obesityprevalence of obesity 30-60yo: 9%F, 24%M30-60yo: 9%F, 24%M Under-diagnosedUnder-diagnosed
Source: How Stuff Works (http://healthguide.howstuffworks.com/sleep-apnea-in-depth.htm)
Obstructive Sleep ApneaObstructive Sleep Apnea
Cardiovascular Cardiovascular DiseaseDisease HTN, CAD/MI, CHF, HTN, CAD/MI, CHF,
ArrhythmiaArrhythmia StrokeStroke ObesityObesity Metabolic SyndromeMetabolic Syndrome Other DiseasesOther Diseases
Morning headache, Morning headache, EyeEye, Liver, Kidney, , Liver, Kidney, othersothers
Cognitive and Cognitive and EmotionalEmotional Impaired mental Impaired mental
functioningfunctioning DepressionDepression Mood alterationMood alteration
Effects on bed Effects on bed partnerspartners Disruptive snoringDisruptive snoring
AccidentsAccidents Drowsy drivingDrowsy driving WorkplaceWorkplace
ClinicalClinical ConsequencesConsequences
Source: J Fam Prac. 2008;57(8) Suppl (http://www.jfponline.com)
Obstructive Sleep ApneaObstructive Sleep Apnea
HistoryHistory Sleepiness assessmentSleepiness assessment Disruptive snoringDisruptive snoring Witnessed apneasWitnessed apneas
PhysicalPhysical ObesityObesity Neck circumferenceNeck circumference Throat/Mouth examThroat/Mouth exam
PSGPSG Gold StandardGold Standard Respiratory Disturbance Index; Apnea/Hypopnea Respiratory Disturbance Index; Apnea/Hypopnea
IndexIndex<15 = mild, 15-30 = Moderate, >30 = severe<15 = mild, 15-30 = Moderate, >30 = severe
Clinical Evaluation
Source: Sleep 1994;17:160–167
Obstructive Sleep ApneaObstructive Sleep ApneaEpworth Sleepiness ScaleEpworth Sleepiness Scale
How likely are you to doze off or fall asleep in the How likely are you to doze off or fall asleep in the following situations?following situations?
0 = No chance, 1 = Slight chance, 2 = Moderate chance, 3 = 0 = No chance, 1 = Slight chance, 2 = Moderate chance, 3 = High ChanceHigh Chance
1. Sitting and reading1. Sitting and reading
2. Watching TV2. Watching TV
3. Sitting inactive in a public place (theater, meeting)3. Sitting inactive in a public place (theater, meeting)
4. As a passenger in a car for an hour without a break4. As a passenger in a car for an hour without a break
5. Lying down to rest in the afternoon when 5. Lying down to rest in the afternoon when circumstances permitcircumstances permit
6. Sitting and talking to someone6. Sitting and talking to someone
7. Sitting quietly after a lunch without alcohol7. Sitting quietly after a lunch without alcohol
8. In a car, while stopped for a few minutes in traffic8. In a car, while stopped for a few minutes in traffic
Source: J Fam Prac. 2008;57(8) Suppl (http://www.jfponline.com)
Obstructive Sleep ApneaObstructive Sleep Apnea Treatment OptionsTreatment Options
Behavioral: Weight loss, EtOH avoidance, Behavioral: Weight loss, EtOH avoidance, nonsupine positionnonsupine position
Positive Airway Pressure: CPAP, Provent, Positive Airway Pressure: CPAP, Provent, othersothers
Mandibular advancement deviceMandibular advancement device
Surgery: UPPP, Tonsillectomy,Surgery: UPPP, Tonsillectomy,TracheostomyTracheostomy
ProventProvent Provent is a relatively new FDA approved Provent is a relatively new FDA approved
proprietary device for treating OSA. proprietary device for treating OSA. It is a 'one-way It is a 'one-way
valve' that is taped valve' that is taped into the nostrils, into the nostrils, so that the seal is so that the seal is airtight. airtight.
By inhibiting the By inhibiting the outflow of air, outflow of air, positive pressure positive pressure in the airway is in the airway is achievedachieved
OSA & the EyeOSA & the Eye Ocular Ocular
Manifestations of Manifestations of Sleep ApneaSleep Apnea AsthenopiaAsthenopia CPAP-associated Red CPAP-associated Red
EyeEye Floppy Eyelid SyndromeFloppy Eyelid Syndrome Diabetic RetinopathyDiabetic Retinopathy NAIONNAION Normal Tension Normal Tension
GlaucomaGlaucoma
AsthenopiaAsthenopia
Common OSA-associated asthenopic Common OSA-associated asthenopic symptomssymptoms Unexplained symptoms of blurUnexplained symptoms of blur
Trouble “focusing eyes”Trouble “focusing eyes” Vision is 20/20 but the Vision is 20/20 but the
patient is c/o blurpatient is c/o blur
Misinterpreting what is seenMisinterpreting what is seen Incorrect recording or copyingIncorrect recording or copying Work-related errorsWork-related errors
Eye strain and/or fatigueEye strain and/or fatigue HeadachesHeadaches
Worse in the morningWorse in the morning
AsthenopiaAsthenopia If OSA is in the medical historyIf OSA is in the medical history
Be on the lookout for sxs of fatigueBe on the lookout for sxs of fatigue Possibly due to poor compliance or residual Possibly due to poor compliance or residual
fatiguefatigue Offer supportive management (eg. CPAP Offer supportive management (eg. CPAP
compliance)compliance)
If OSA is not in the medical historyIf OSA is not in the medical history High index of suspicion whenever the chief High index of suspicion whenever the chief
complaint is fatigue or asthenopiacomplaint is fatigue or asthenopia Especially if habitus is PickwickianEspecially if habitus is Pickwickian Be prepared to Be prepared to screen for sleepinessscreen for sleepiness
Source: Optometry. 2007;78:352-355
CPAP-associated Red EyeCPAP-associated Red Eye Clinical ProblemsClinical Problems
Dry eye syndromeDry eye syndrome EXW CL intoleranceEXW CL intolerance
Recurrent Corneal Recurrent Corneal ErosionErosion
Infectious conjunctivitisInfectious conjunctivitis
CausesCauses Air leaksAir leaks Retrograde air flow Retrograde air flow
thru nasolacrimal apparatusthru nasolacrimal apparatus
TreatmentTreatment Lubricating ointments HS, punctal plugsLubricating ointments HS, punctal plugs CPAP refitting: adjust headgear and pressureCPAP refitting: adjust headgear and pressure
CPAP-associated Red EyeCPAP-associated Red Eye
Persons with OSA generally have greater ocular discomfort than controls, Persons with OSA generally have greater ocular discomfort than controls, but is greatest among persons that are noncompliant with CPAPbut is greatest among persons that are noncompliant with CPAP
Source: Eye 2010;24:843–850
Source: Clin Exp Ophthalmol 2005;33:117-125.
Floppy Eyelid SyndromeFloppy Eyelid Syndrome
Clinical Clinical CharacteristicsCharacteristicsEyelid hyperlaxityEyelid hyperlaxity Rubbery, easily everted upper Rubbery, easily everted upper
eyelidseyelids Eyelash ptosis with loss of Eyelash ptosis with loss of
parallelismparallelism
Papillary conjunctivitisPapillary conjunctivitis Chronic ocular irritation, Chronic ocular irritation,
worse upon waking worse upon waking SPK, mucoid discharge SPK, mucoid discharge
commoncommon Rubbing on pillow caseRubbing on pillow case
Source: Ophthalmology 1998;105:165-169
Floppy Eyelid SyndromeFloppy Eyelid Syndrome
Eyelash ptosisEyelash ptosis Downward Downward
displacement of displacement of eyelasheseyelashes
Lashes may point Lashes may point in various in various directions directions
Loss of parallelismLoss of parallelism Pts may trim with Pts may trim with
scissorsscissors
Floppy Eyelid SyndromeFloppy Eyelid Syndrome
Source: Surv Ophthalmol 2010;55:35-46
Floppy Eyelid SyndromeFloppy Eyelid SyndromeEtiopathogenesisEtiopathogenesis
Loss of elastic fibers in tarsus Loss of elastic fibers in tarsus and upregulation of elastase and upregulation of elastase MMPMMP
Likely caused by repeated Likely caused by repeated mechanical trauma, possibly eye mechanical trauma, possibly eye rubbing or sleeping with the face rubbing or sleeping with the face buried in the pillowburied in the pillow
May represent an adaptive May represent an adaptive response that allows tensional response that allows tensional homeostasis to be maintained at homeostasis to be maintained at the high levels of tissue stress the high levels of tissue stress experienced in FESexperienced in FES
FES strongly associated with FES strongly associated with keratoconuskeratoconus, reinforcing , reinforcing suspected role of mechanical suspected role of mechanical traumatrauma
Source: Ophthalmol. 2010;117:839-846
Floppy Eyelid SyndromeFloppy Eyelid Syndrome
TreatmentTreatment CPAP therapyCPAP therapy
Treatment of OSA can improve Treatment of OSA can improve symptoms of FESsymptoms of FES
Protect eye during sleepProtect eye during sleep Ointments HSOintments HS Patching, taping, sleep maskPatching, taping, sleep mask
Surgical therapy is considered Surgical therapy is considered the definitive treatmentthe definitive treatment
Greatest success with medial canthus/lateral canthus Greatest success with medial canthus/lateral canthus plication and upper lid lateral tarsal strip proceduresplication and upper lid lateral tarsal strip procedures
25-50% failure rate within 2yrs25-50% failure rate within 2yrs
Source: Surv Ophthalmol 2010;55:35-46
Floppy Eyelid SyndromeFloppy Eyelid Syndrome
Relation to OSARelation to OSA 5-15% pts with OSA 5-15% pts with OSA
have FEShave FES 96% pts with FES 96% pts with FES
have OSAhave OSA OSA tends to be more OSA tends to be more
severe in pts with FESsevere in pts with FES FES strongly FES strongly
associated with OSA associated with OSA even after adjusting even after adjusting for weightfor weight
OSA & the EyeOSA & the Eye Ocular Ocular
Manifestations of Manifestations of Sleep ApneaSleep Apnea AsthenopiaAsthenopia CPAP-associated red CPAP-associated red
eyeeye Floppy Eyelid SyndromeFloppy Eyelid Syndrome Diabetic RetinopathyDiabetic Retinopathy NAIONNAION Normal Tension Normal Tension
GlaucomaGlaucoma
Source: Am J Ophthalmol. 2010;149:959–963
Diabetic RetinopathyDiabetic Retinopathy
OSA associated with higher OSA associated with higher risk of PDR, independent risk of PDR, independent of other risk factorsof other risk factors
Risk of progression associatedRisk of progression associatedwith severity of OSAwith severity of OSA
OSA increases risk of NVGOSA increases risk of NVGin patients with PDRin patients with PDR
CPAP may prevent progression CPAP may prevent progression of diabetic retinopathy by minimizing nocturnal of diabetic retinopathy by minimizing nocturnal hypoxiahypoxia
Diabetics with OSA should be screened for retinopathy Diabetics with OSA should be screened for retinopathy and encouraged to be compliant with CPAPand encouraged to be compliant with CPAP
OSA increases risk of progression of retinopathyOSA increases risk of progression of retinopathy
Source: Rev Ophthalmol (http://www.revophth.com/index.asp?page=1_13156.htm)
NAIONNAION
Clinical Clinical CharacteristicsCharacteristics Most common acute optic Most common acute optic
neuropathy in pts >50yoneuropathy in pts >50yo Sudden painless visual loss, Sudden painless visual loss,
usually upon awakingusually upon awaking Nerve fiber bundle VF Nerve fiber bundle VF
defectsdefects Diffuse or sectoral disc Diffuse or sectoral disc
edemaedema Disc at risk:Disc at risk: small, crowded small, crowded
Mean C/D = 0.2Mean C/D = 0.2 All ≤ 0.4All ≤ 0.4
Source: http://webeye.ophth.uiowa.edu/dept/AION/Index.htm
NAIONNAION
PathophysiologyPathophysiology Idiopathic ischemic process Idiopathic ischemic process
Disorder of posterior ciliary artery circulationDisorder of posterior ciliary artery circulation Transient poor circulation in the ONHTransient poor circulation in the ONH Trigger EventTrigger Event: Fall in blood pressure below a : Fall in blood pressure below a
critical level?critical level? There is no actual blockage of the posterior ciliary There is no actual blockage of the posterior ciliary
arteriesarteries
Cascade EffectCascade Effect Mechanical crowding caused by small crowded Mechanical crowding caused by small crowded
discdisc Ischemia Ischemia Swelling Swelling Compression Compression Ischemia Ischemia
Diagnosis: Must exclude GCA in Diagnosis: Must exclude GCA in every caseevery case ESRESR C-Reactive ProteinC-Reactive Protein
Positive acute-phase proteinPositive acute-phase protein Levels increase in presence of Levels increase in presence of
inflammation inflammation Upper limit normal does not Upper limit normal does not
rise with age rise with age PlateletsPlatelets
Secondary thrombocytosis Secondary thrombocytosis due to chronic inflammationdue to chronic inflammation
NAIONNAION
NAIONNAION
TreatmentTreatment AspirinAspirin
Decreases incidence in fellow eye at 2 years, but not at 5 Decreases incidence in fellow eye at 2 years, but not at 5 yearsyears
Surgical decompressionSurgical decompression No benefit (Ischemic Optic Neuropathy Decompression No benefit (Ischemic Optic Neuropathy Decompression
Trial)Trial)
Control of predisposing systemic diseaseControl of predisposing systemic disease May slow progression or reduce incidence in fellow eyeMay slow progression or reduce incidence in fellow eye Hypertension, Diabetes, Hyperlipidemia, OSAHypertension, Diabetes, Hyperlipidemia, OSA
Avoid Avoid phosphodiesterase 5 inhibitors (Viagra, Levitra, Cialis)
May increase risk of NAION in fellow eye
NAIONNAION
Medicolegal obligation to inform pts of risk to Medicolegal obligation to inform pts of risk to fellow eyefellow eye
NAIONNAION
Relation to OSARelation to OSA
ConclusionsConclusions OSA may play an important role in pathogenesis of OSA may play an important role in pathogenesis of
NAIONNAION OSA may be the systemic disorder most frequently OSA may be the systemic disorder most frequently
associated with NAIONassociated with NAION Patients with NAION should be screened for OSAPatients with NAION should be screened for OSA
NAION Patients with OSAMojon (2002)Mojon (2002) 71% 71% (Controls: 18%)
Palombi (2006)Palombi (2006) 89% 89% (HTN: 59%, DM: (HTN: 59%, DM: 37%)37%)
Li (2007)Li (2007) 30% 30% (Controls: 18%)
PapilledemaPapilledema
Clinical Clinical CharacteristicsCharacteristics Disc swelling associated Disc swelling associated
with increased ICPwith increased ICP
Symptoms of elevated Symptoms of elevated ICP: Headache, tinnitus, ICP: Headache, tinnitus, TOV TOV
Chronic papilledema Chronic papilledema (months) may lead to (months) may lead to optic atrophy and vision optic atrophy and vision loss loss
Source: Arch Ophthalmol 2000;118:1626-1630
PapilledemaPapilledema Work-upWork-up
Urgent MRI or CT scanUrgent MRI or CT scan Lumbar puncture if imaging normalLumbar puncture if imaging normal
Idiopathic Intracranial Idiopathic Intracranial HypertensionHypertension ““Pseudotumor cerebri”Pseudotumor cerebri” Syndrome of elevated ICP, Syndrome of elevated ICP,
papilledema, normal MRI/CT, papilledema, normal MRI/CT, normal CSFnormal CSF
Secondary pseudotumor cerebri Secondary pseudotumor cerebri syndromes syndromes
Venous sinus thrombosis, Venous sinus thrombosis, vitamin A toxicity, COPD, vitamin A toxicity, COPD, OSAOSA
Tx: Diamox 250mg po QID , Underlying cause if knownTx: Diamox 250mg po QID , Underlying cause if known
PapilledemaPapilledema
Relation to OSARelation to OSA Stein (2011) Stein (2011)
Reviewed 2.3 million insurance Reviewed 2.3 million insurance company billing records company billing records
Persons with OSA have 30% Persons with OSA have 30% to 100% increased risk of to 100% increased risk of developing papilledemadeveloping papilledema
Parvin (2000)Parvin (2000) 4 pts with unexplained papilledema that resolved with 4 pts with unexplained papilledema that resolved with
successful tx of OSAsuccessful tx of OSA ICP is normal during the day but elevated at nightICP is normal during the day but elevated at night
Intermittent ↑ ICP can cause sustained papilledemaIntermittent ↑ ICP can cause sustained papilledema Hypercapnia-induced cerebral vasodilatation elevates ICPHypercapnia-induced cerebral vasodilatation elevates ICP
OSA & the EyeOSA & the Eye Ocular Ocular
Manifestations of Manifestations of Sleep ApneaSleep Apnea AsthenopiaAsthenopia CPAP-associated red CPAP-associated red
eyeeye Floppy Eyelid SyndromeFloppy Eyelid Syndrome Diabetic RetinopathyDiabetic Retinopathy NAIONNAION Normal Tension Normal Tension
GlaucomaGlaucoma
Source: Shield's Textbook of Glaucoma, 2005
Normal Tension Normal Tension GlaucomaGlaucoma
Clinical CharacteristicsClinical Characteristics Probably a variant of POAGProbably a variant of POAG IOP is never documented IOP is never documented
above 21 mmHg above 21 mmHg Peripapillary hemorrhages Peripapillary hemorrhages
may be more frequentmay be more frequent Peripapillary atrophy may Peripapillary atrophy may
be more marked be more marked VF defects tend to be VF defects tend to be
deeper and more localized deeper and more localized
Normal Tension Normal Tension GlaucomaGlaucoma
PathophysiologyPathophysiology IOP-independent factors predominateIOP-independent factors predominate
Vascular insufficiency: CVD, HTNVascular insufficiency: CVD, HTN Vasospasm: migraine, Raynaud's Vasospasm: migraine, Raynaud's
phenomenon phenomenon Translaminar pressure difference: low ICPTranslaminar pressure difference: low ICP
Source: Ophthalmology 1998;105:1866-1874
Normal Tension Normal Tension GlaucomaGlaucoma
DiagnosisDiagnosis R/O other glaucomasR/O other glaucomas
Diurnal IOP fluctuationDiurnal IOP fluctuation IOP normalization (Burnt-out IOP normalization (Burnt-out
glaucoma, pseudophakia, glaucoma, pseudophakia, steroids)steroids)
R/O other optic R/O other optic neuropathiesneuropathies
NAION, space-occupying NAION, space-occupying lesions, congenital anomalieslesions, congenital anomalies
When to order neuroimagingWhen to order neuroimaging: : Younger age (<50 yrs)Younger age (<50 yrs) Reduced VA (< 20/40)Reduced VA (< 20/40) Vertically aligned VF defectsVertically aligned VF defects Neuroretinal rim pallorNeuroretinal rim pallor
Normal Tension Normal Tension GlaucomaGlaucoma
Relation to OSARelation to OSA Glaucoma Patients with OSA (50-60% NTG pts have OSA)
Mojon (2000)Mojon (2000) 20%20% (POAG) (POAG)
Marcus (2001)Marcus (2001) 57%57% (NTG) (NTG)
Mojon (2002)Mojon (2002) 50-60%50-60% (NTG, varies with age) (NTG, varies with age)
Roberts (2009)Roberts (2009) 17%17% (POAG) (POAG)
OSA Patients with Glaucoma (6-10% OSA pts have NTG)
Mojon Mojon (1999)(1999)
7%7% Karakuck (2008)Karakuck (2008) 10%10% (NTG), (NTG), 3%3% (POAG)(POAG)
Geyer Geyer (2003)(2003)
2%2% Boonyaleephan Boonyaleephan (2008)(2008)
9%9% (NTG), (NTG), 5%5% (POAG)(POAG)
Sergi Sergi (2007)(2007)
6%6% (NTG)(NTG)
Lin (2010)Lin (2010) 6%6% (NTG) (NTG)
Bendel Bendel (2008)(2008)
27%27% Kadyan (2010) 2%2%
Same as general popGreater than general pop
Normal Tension Normal Tension GlaucomaGlaucoma
Relation to OSARelation to OSA 6%-10% of OSA 6%-10% of OSA
patients have NTGpatients have NTG (0.5% general pop)(0.5% general pop)
50% of NTG 50% of NTG patients have OSApatients have OSA
Treatment of OSA Treatment of OSA may help stabilize may help stabilize NTG (Kremmer, NTG (Kremmer, 2003) and improve 2003) and improve VF performance VF performance (Sebastian, 2006)(Sebastian, 2006)
Source: Invest Ophthalmol Vis Sci. 2008;49:934–940
Normal Tension Normal Tension GlaucomaGlaucoma
CPAP Increases IOPCPAP Increases IOP Kiekens (2008)Kiekens (2008)
Diurnal IOP in 21 OSA Diurnal IOP in 21 OSA pts with and without CPAPpts with and without CPAP
Average IOP and diurnal Average IOP and diurnal fluctuation higher with CPAP fluctuation higher with CPAP
30 min after CPAP cessation 30 min after CPAP cessation a significant decrease in IOP a significant decrease in IOP was recorded was recorded
Speculate that CPAP elevates intrathoracic pressure, leading to higher central venous pressure, and ultimately higher IOP
Recommend regular screening of VF and the optic disc for all patients with OSA, especially those treated with CPAP
Source:Arch Ophthalmol 2010;128:1257-1263
Normal Tension Normal Tension GlaucomaGlaucoma
CPAP Increases IOPCPAP Increases IOP Pepin (2010)Pepin (2010)
Diurnal IOP in 18 OSA Diurnal IOP in 18 OSA pts with and without CPAPpts with and without CPAP
CPAP caused a significant CPAP caused a significant increase in IOP during the increase in IOP during the nightnight
Speculate that some effects ofSpeculate that some effects ofuntreated OSA, such as untreated OSA, such as disruption of sleep cycles and disruption of sleep cycles and respiratory effort, may result inrespiratory effort, may result indecreased nocturnal IOP and these are normalized by decreased nocturnal IOP and these are normalized by use of CPAPuse of CPAP
Concludes that Concludes that IOP changes induced by CPAP are IOP changes induced by CPAP are explained by restoring normal IOP rhythm explained by restoring normal IOP rhythm rather than rather than by a deleterious effect of the deviceby a deleterious effect of the device
Normal Tension Normal Tension GlaucomaGlaucoma
OSA May Cause VF Loss Without GlaucomaOSA May Cause VF Loss Without Glaucoma VF loss may occur due to optic nerve damage VF loss may occur due to optic nerve damage
caused by cerebral ischemia and intermittent caused by cerebral ischemia and intermittent ICP elevationICP elevation
Batisse (2004)Batisse (2004) Eye exam on 35 consecutive patients undergoing PSG Eye exam on 35 consecutive patients undergoing PSG VF mean deviation correlated with RDIVF mean deviation correlated with RDI
Tsang (2006)Tsang (2006) Compared VF and ONH changes between 41 pts with Compared VF and ONH changes between 41 pts with
moderate-severe OSA with 35 age-matched controls moderate-severe OSA with 35 age-matched controls In OSA pts the VF indices were significantly subnormalIn OSA pts the VF indices were significantly subnormal
Karakucuk (2008) Karakucuk (2008) Eye exams and orbital blood flow studies on 31 pts with Eye exams and orbital blood flow studies on 31 pts with
OSA and 25 normal control subjects OSA and 25 normal control subjects VF defects were detected in 10 pts despite normal eye VF defects were detected in 10 pts despite normal eye
exam. exam.
Normal Tension Normal Tension GlaucomaGlaucoma
OSA May Cause NFL Loss Without OSA May Cause NFL Loss Without GlaucomaGlaucomaNFL thinning may place patients with OSA at increased NFL thinning may place patients with OSA at increased risk of glaucomarisk of glaucomaKargi (2005)Kargi (2005)
Compared NFL in 34 pts with OSA and 20 controls using GDxCompared NFL in 34 pts with OSA and 20 controls using GDx NFL thickness was reduced in patients with OSANFL thickness was reduced in patients with OSA Thinning was correlated to severity of OSA (AHI)Thinning was correlated to severity of OSA (AHI) Pts with VF defects were excluded from the studyPts with VF defects were excluded from the study
Lin (2010)Lin (2010) Compared NFL in 105 pts with OSA and 22 controls using OCTCompared NFL in 105 pts with OSA and 22 controls using OCT NFL thickness was reduced in patients with OSANFL thickness was reduced in patients with OSA Thinning was correlated to severity of OSA (lowest Thinning was correlated to severity of OSA (lowest
oxygenation saturation on PSG)oxygenation saturation on PSG) Pts with OSA did not have an increased prevalence of VF Pts with OSA did not have an increased prevalence of VF
defects (defects (“silent optic neuropathy”“silent optic neuropathy”))
Normal Tension Normal Tension GlaucomaGlaucoma
Conclusions & RecommendationsConclusions & Recommendations Persons with OSA should be screened for Persons with OSA should be screened for
glaucomaglaucoma Risk of glaucoma is correlated with severity of OSARisk of glaucoma is correlated with severity of OSA
Patients with NTG should be screened or at Patients with NTG should be screened or at least questioned about OSA to determine if that least questioned about OSA to determine if that is part of the explanation for their glaucomatous is part of the explanation for their glaucomatous damage at normal IOPsdamage at normal IOPs
Treatment of uncontrolled OSA may help stabilize Treatment of uncontrolled OSA may help stabilize glaucoma and improve VF performanceglaucoma and improve VF performance
Initiation of CPAP therapy may increase Initiation of CPAP therapy may increase nocturnal IOPnocturnal IOP
The clinical significance of this in unknownThe clinical significance of this in unknown
Source: Can J Ophthalmol 2007;42:238–243
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