Sleep Apnea and the Eye - 2008

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Ocular manifestations of sleep apnea. Updated and expanded for 2008

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  • Being a political year, let me first say: My name is Rick Trevino and I approve that message. SLEEP APNEA IS A NEWLY DISCOVERED DISEASE (1966) - Most prevalent disease discovered in the 20 th century – 20% of adult population in Western countries THE MOST COMMON “MEDICAL” SLEEP DISORDER - excluding shift-work and self-induced sleepiness (late night partying) IT IS NOT ONLY THE MOST COMMON SLEEP DISORDER, BUT ALSO THE MOST PHYSIOLOGICALLY DISRUPTIVE AND DANGEROUS SLEEP DISORDER - Life threatening disease: A recently published longitudinal study found pts with severe OSA had 3-4x the death rate of persons without OSA. - Wide spread effects throughout the body – As we shall see, not even the somewhat remote and esoteric world of eye care is immune from the influences of this devastating disease
  • Sleep Apnea and the Eye - 2008

    1. 1. Sleep Apnea & the Eye Rick Trevino, OD VA Outpatient Clinic Evansville, IN [email_address]
    2. 2. Sleep Apnea & the Eye <ul><li>Sleep Apnea </li></ul><ul><ul><li>Sleep physiology </li></ul></ul><ul><ul><li>Clinical consequences </li></ul></ul><ul><ul><li>Diagnosis </li></ul></ul><ul><ul><li>Treatment </li></ul></ul><ul><li>Ocular Manifestations </li></ul><ul><ul><li>Asthenopia </li></ul></ul><ul><ul><li>CPAP-assoc red eye </li></ul></ul><ul><ul><li>Floppy eyelid syndrome </li></ul></ul><ul><ul><li>NAION </li></ul></ul><ul><ul><li>Papilledema </li></ul></ul><ul><ul><li>Normal tension glaucoma </li></ul></ul>
    3. 3. Online Resources <ul><li>Lecture Notes </li></ul><ul><ul><li>http://richardtrevino.net/sleepapnea </li></ul></ul><ul><li>Powerpoint Slides </li></ul><ul><ul><li>http://www.slideshare.net/rhodopsin </li></ul></ul><ul><li>Free Texts </li></ul><ul><ul><li>http://jfponline.com (Aug 2008) </li></ul></ul><ul><ul><li>http://pubs.nrc-cnrc.gc.ca/cjo Can J Ophthalmol 2007;42(2):238-43 </li></ul></ul>
    4. 4. Sleep Cycle
    5. 5. Sleep Cycle <ul><li>Polysomnography </li></ul><ul><ul><li>EEG channels </li></ul></ul><ul><ul><li>EOG channels </li></ul></ul><ul><ul><li>EMG channel </li></ul></ul><ul><ul><li>Nasal air current channel </li></ul></ul><ul><ul><li>Thoracic motion channel </li></ul></ul><ul><ul><li>Abdominal motion channel </li></ul></ul><ul><ul><li>Oximeter channel </li></ul></ul><ul><ul><li>Leg movement channels </li></ul></ul><ul><ul><li>Microphone </li></ul></ul><ul><ul><li>Video recording </li></ul></ul>
    6. 6. Sleep Cycle Polysomnogram
    7. 7. Sleep Disorders <ul><li>Sleep apnea </li></ul><ul><li>Insomnia </li></ul><ul><li>Narcolepsy </li></ul><ul><li>Restless leg syndrome </li></ul><ul><li>Parasomnias </li></ul><ul><li>Circadian disorders </li></ul><ul><li>Drug side effects </li></ul><ul><li>Shift work </li></ul>OSA is the “most physiologically disruptive and dangerous of the sleep-related disorders.”
    8. 8. Obstructive Sleep Apnea
    9. 9. Obstructive Sleep Apnea Any Condition that Causes or Contributes to Upper Airway Narrowing is a Risk Factor for OSA Obesity Enlarged Tonsils Anatomical Malformations Neoplasms Edema of the pharynx Lymphoid Hypertrophy Pharyngeal Muscle Weakness Dyscoordination of Respiratory Muscles
    10. 10. Obstructive Sleep Apnea <ul><ul><li>Excessive daytime sleepiness </li></ul></ul><ul><ul><ul><li>Most common symptom </li></ul></ul></ul><ul><ul><li>Disruptive snoring </li></ul></ul><ul><ul><ul><li>Also gasping/snorting during arousals </li></ul></ul></ul><ul><ul><li>Apneic events witnessed by bed partner </li></ul></ul><ul><ul><ul><li>Disruptive snoring + witnessed apneas: 94% specificity </li></ul></ul></ul><ul><ul><li>Obesity </li></ul></ul><ul><ul><ul><li>30% of pts with a BMI > 30 have OSA, and 50% of pts with a BMI > 40 have OSA. </li></ul></ul></ul><ul><ul><li>Neck circumference </li></ul></ul><ul><ul><ul><li>≥ 40 cm had a sensitivity of 61% and a specificity of 93% for OSA </li></ul></ul></ul><ul><ul><ul><li>Correlates better than BMI </li></ul></ul></ul><ul><ul><li>Male </li></ul></ul><ul><ul><ul><li>2-3x more common than female </li></ul></ul></ul><ul><ul><li>Family history of OSA </li></ul></ul><ul><ul><ul><li>Relatives have 2-4 fold  risk </li></ul></ul></ul>Clinical Characteristics
    11. 11. Obstructive Sleep Apnea <ul><li>Pickwickian Syndrome </li></ul><ul><ul><li>Obesity, daytime somnolence, loud snoring </li></ul></ul><ul><ul><li>Charles Dicken’s “Pickwick Papers” (1837) </li></ul></ul><ul><li>Prevalence increasing in parallel with prevalence of obesity </li></ul><ul><ul><li>30-60yo: 9%F, 24%M </li></ul></ul><ul><ul><li>Under-diagnosed </li></ul></ul>
    12. 12. Obstructive Sleep Apnea <ul><li>Cardiovascular Disease </li></ul><ul><ul><li>HTN, CAD/MI, CHF, Arrhythmia </li></ul></ul><ul><li>Stroke </li></ul><ul><li>Obesity </li></ul><ul><li>Metabolic Syndrome </li></ul><ul><li>Other Diseases </li></ul><ul><ul><li>Morning headache, Eye , Liver, Kidney, others </li></ul></ul><ul><li>Cognitive and Emotional </li></ul><ul><ul><li>Impaired mental functioning </li></ul></ul><ul><ul><li>Depression </li></ul></ul><ul><ul><li>Mood alteration </li></ul></ul><ul><li>Effects on bed partners </li></ul><ul><ul><li>Disruptive snoring </li></ul></ul><ul><li>Accidents </li></ul><ul><ul><li>Drowsy driving </li></ul></ul><ul><ul><li>Workplace </li></ul></ul>Clinical Consequences
    13. 13. Obstructive Sleep Apnea
    14. 14. Obstructive Sleep Apnea <ul><li>History </li></ul><ul><ul><li>Sleepiness assessment </li></ul></ul><ul><ul><li>Disruptive snoring </li></ul></ul><ul><ul><li>Witnessed apneas </li></ul></ul><ul><li>Physical </li></ul><ul><ul><li>Obesity </li></ul></ul><ul><ul><li>Neck circumference </li></ul></ul><ul><ul><li>Throat/Mouth exam </li></ul></ul><ul><li>PSG </li></ul><ul><ul><li>Gold Standard </li></ul></ul><ul><ul><li>Respiratory Disturbance Index </li></ul></ul>Clinical Evaluation
    15. 15. Obstructive Sleep Apnea <ul><li>Epworth Sleepiness Scale </li></ul>How likely are you to doze off or fall asleep in the following situations? 0 = No chance, 1 = Slight chance, 2 = Moderate chance, 3 = High Chance 1. Sitting and reading 2. Watching TV 3. Sitting inactive in a public place (theater, meeting) 4. As a passenger in a car for an hour without a break 5. Lying down to rest in the afternoon when circumstances permit 6. Sitting and talking to someone 7. Sitting quietly after a lunch without alcohol 8. In a car, while stopped for a few minutes in traffic
    16. 16. Obstructive Sleep Apnea <ul><li>Treatment Options </li></ul><ul><ul><li>Behavioral: Weight loss, EtOH avoidance, nonsupine position </li></ul></ul><ul><ul><li>Positive Airway Pressure: CPAP, others </li></ul></ul><ul><ul><li>Mandibular advancement device </li></ul></ul><ul><ul><li>Surgery: UPPP, Tonsillectomy, Tracheostomy </li></ul></ul>
    17. 18. OSA & the Eye <ul><li>Obese middle-aged men </li></ul><ul><li>Excessive sleepiness Disruptive snoring Witnessed apneas </li></ul><ul><li>Ocular Manifestations </li></ul><ul><ul><li>Asthenopia </li></ul></ul><ul><ul><li>CPAP-associated red eye </li></ul></ul><ul><ul><li>Floppy Eyelid Syndrome </li></ul></ul><ul><ul><li>NAION </li></ul></ul><ul><ul><li>Papilledema </li></ul></ul><ul><ul><li>Normal Tension Glaucoma </li></ul></ul>
    18. 19. Asthenopia <ul><li>Common OSA Symptoms Include: </li></ul><ul><ul><li>“Tiredness” </li></ul></ul><ul><ul><li>“Fatigue” </li></ul></ul><ul><ul><li>“Lack of energy” </li></ul></ul><ul><ul><li>Morning headache </li></ul></ul><ul><li>These OSA symptoms may be misinterpreted as “eye strain” </li></ul>
    19. 20. Asthenopia <ul><li>Common OSA-associated asthenopic symptoms </li></ul><ul><ul><li>Unexplained symptoms of blur </li></ul></ul><ul><ul><ul><li>Vision is 20/20 but the patient is c/o blur </li></ul></ul></ul><ul><ul><li>Misinterpreting what is seen </li></ul></ul><ul><ul><ul><li>Incorrect recording or copying </li></ul></ul></ul><ul><ul><li>Eye strain and/or fatigue </li></ul></ul><ul><ul><li>Headaches </li></ul></ul><ul><ul><ul><li>Worse in the morning </li></ul></ul></ul>
    20. 21. Asthenopia <ul><li>42yo WM presents with c/o eye fatigue at near. </li></ul><ul><li>LEE: <1yr with current eyeglasses </li></ul><ul><li>MH: 1. OSA (noncompliant with CPAP) </li></ul><ul><li>2. Frequent HA </li></ul><ul><li>3. Overweight </li></ul><ul><li>4. Hyperlipidemia </li></ul><ul><li>5. GERD </li></ul><ul><li>6. Smokes 1PPD </li></ul><ul><li>Optometric Exam: Unremarkable </li></ul><ul><li>Plan: 1. OSA management </li></ul><ul><li>2. Visual hygiene </li></ul><ul><li>3. Smoking cessation </li></ul>
    21. 22. Asthenopia <ul><li>OSA Supportive Management </li></ul><ul><ul><li>Encourage compliance with CPAP </li></ul></ul><ul><ul><ul><li>50% compliance rate, high drop-out rate </li></ul></ul></ul><ul><ul><li>Quit smoking </li></ul></ul><ul><ul><ul><li>Smokers 3 times more likely to have OSA </li></ul></ul></ul><ul><ul><ul><li>Reversible with smoking cessation </li></ul></ul></ul><ul><ul><li>Weight reduction </li></ul></ul><ul><ul><ul><li>10% increase in weight results in 6x greater risk of developing OSA </li></ul></ul></ul><ul><ul><ul><li>Weight loss decreases OSA severity </li></ul></ul></ul><ul><ul><li>Avoid sleeping on back </li></ul></ul><ul><ul><ul><li>Sew golf ball into pocket on back of shirt </li></ul></ul></ul><ul><ul><li>Avoid alcohol within 4 hours of bedtime </li></ul></ul><ul><ul><li>Avoid sleeping pills </li></ul></ul>
    22. 23. OSA & the Eye <ul><li>Obese middle-aged men </li></ul><ul><li>Excessive sleepiness Disruptive snoring Witnessed apneas </li></ul><ul><li>Ocular Manifestations </li></ul><ul><ul><li>Asthenopia </li></ul></ul><ul><ul><li>CPAP-associated red eye </li></ul></ul><ul><ul><li>Floppy Eyelid Syndrome </li></ul></ul><ul><ul><li>NAION </li></ul></ul><ul><ul><li>Papilledema </li></ul></ul><ul><ul><li>Normal Tension Glaucoma </li></ul></ul>
    23. 24. CPAP-associated Red Eye <ul><li>Clinical Problems </li></ul><ul><ul><li>Dry eye </li></ul></ul><ul><ul><li>EXW CL intolerance </li></ul></ul><ul><ul><li>Conjunctivitis </li></ul></ul><ul><ul><li>Reactivation of RCE </li></ul></ul><ul><li>Causes </li></ul><ul><ul><li>Air leaks </li></ul></ul><ul><ul><li>Retrograde air flow thru nasolacrimal apparatus </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>CPAP refitting: adjust headgear and pressure </li></ul></ul><ul><ul><li>Ointments HS, punctal plugs </li></ul></ul>
    24. 25. OSA & the Eye <ul><li>Obese middle-aged men </li></ul><ul><li>Excessive sleepiness, disruptive snoring, witnessed apneas </li></ul><ul><li>Ocular Manifestations </li></ul><ul><ul><li>Asthenopia </li></ul></ul><ul><ul><li>CPAP-associated red eye </li></ul></ul><ul><ul><li>Floppy Eyelid Syndrome </li></ul></ul><ul><ul><li>NAION </li></ul></ul><ul><ul><li>Papilledema </li></ul></ul><ul><ul><li>Normal Tension Glaucoma </li></ul></ul>
    25. 26. Floppy Eyelid Syndrome <ul><li>Clinical Characteristics </li></ul><ul><ul><li>Eyelid hyperlaxity </li></ul></ul><ul><ul><li>Rubbery, easily everted upper eyelids </li></ul></ul><ul><ul><li>Eyelash ptosis with loss of parallelism </li></ul></ul><ul><ul><li>Papillary conjunctivitis </li></ul></ul><ul><ul><li>Chronic ocular irritation, worse upon waking </li></ul></ul><ul><ul><li>SPK, mucoid discharge common </li></ul></ul><ul><ul><li>Rubbing on pillow case </li></ul></ul><ul><ul><li>Should be suspected in any obese pt with a chronic red eye </li></ul></ul>
    26. 27. Floppy Eyelid Syndrome <ul><li>Eyelash ptosis </li></ul><ul><ul><li>Downward displacement of eyelashes </li></ul></ul><ul><ul><li>Lashes may curl toward the globe </li></ul></ul><ul><ul><li>Lashes may point in various directions - loss of parallelism </li></ul></ul><ul><ul><li>Pts may trim with scissors </li></ul></ul>
    27. 28. Floppy Eyelid Syndrome
    28. 29. Floppy Eyelid Syndrome <ul><li>Pathophysiology </li></ul><ul><ul><li>Loss of elastic fibers in tarsus and skin of lid </li></ul></ul><ul><ul><li>Upregulation of elastin-degrading enzymes (matrix metalloproteinases) </li></ul></ul><ul><ul><li>Caused by repeated mechanical trauma, possibly eye rubbing or sleeping with the face buried in the pillow </li></ul></ul>
    29. 30. Floppy Eyelid Syndrome <ul><li>Treatment </li></ul><ul><ul><li>Lubrication therapy </li></ul></ul><ul><ul><ul><li>Poor lid-eye contact </li></ul></ul></ul><ul><ul><ul><li>Inadequate tear distribution </li></ul></ul></ul><ul><ul><li>Protect eye during sleep </li></ul></ul><ul><ul><ul><li>Ointments HS </li></ul></ul></ul><ul><ul><ul><li>Fox shield, patching, taping </li></ul></ul></ul><ul><ul><li>May improve or resolve with CPAP </li></ul></ul><ul><ul><li>Surgical therapy deferred until OSA treated </li></ul></ul><ul><ul><ul><li>Horizontal lid shortening </li></ul></ul></ul>
    30. 31. Floppy Eyelid Syndrome <ul><li>Relation to OSA </li></ul><ul><ul><li>Pts with FES are a subset of all OSA pts </li></ul></ul><ul><ul><ul><li>96% pts with FES have OSA (almost 100%!) </li></ul></ul></ul><ul><ul><ul><li>5-15% pts with OSA have FES </li></ul></ul></ul><ul><ul><li>OSA tends to be more severe in pts with FES </li></ul></ul>
    31. 32. OSA & the Eye <ul><li>Obese middle-aged men </li></ul><ul><li>Excessive sleepiness Disruptive snoring Witnessed apneas </li></ul><ul><li>Ocular Manifestations </li></ul><ul><ul><li>Asthenopia </li></ul></ul><ul><ul><li>CPAP-associated red eye </li></ul></ul><ul><ul><li>Floppy Eyelid Syndrome </li></ul></ul><ul><ul><li>NAION </li></ul></ul><ul><ul><li>Papilledema </li></ul></ul><ul><ul><li>Normal Tension Glaucoma </li></ul></ul>
    32. 33. NAION <ul><li>Clinical Characteristics </li></ul><ul><ul><li>Most common acute optic neuropathy in pts >50yo </li></ul></ul><ul><ul><li>Sudden painless visual loss, usually upon awaking </li></ul></ul><ul><ul><li>Nerve fiber bundle VF defects </li></ul></ul><ul><ul><li>Diffuse or sectoral disc edema </li></ul></ul><ul><ul><li>Disc at risk: small, crowded </li></ul></ul><ul><ul><ul><li>Mean C/D = 0.2 </li></ul></ul></ul><ul><ul><ul><li>All ≤ 0.4 </li></ul></ul></ul>
    33. 34. NAION <ul><li>Pathophysiology </li></ul><ul><ul><li>Idiopathic ischemic process </li></ul></ul><ul><ul><ul><li>Disorder of posterior ciliary artery circulation </li></ul></ul></ul><ul><ul><ul><li>Transient poor circulation in the ONH </li></ul></ul></ul><ul><ul><ul><li>Trigger Event : Fall in blood pressure below a critical level? </li></ul></ul></ul><ul><ul><ul><li>There is no actual blockage of the posterior ciliary arteries </li></ul></ul></ul><ul><ul><li>Cascade Effect </li></ul></ul><ul><ul><ul><li>Mechanical crowding caused by small crowded disc </li></ul></ul></ul><ul><ul><ul><li>Ischemia  Swelling  Compression  Ischemia </li></ul></ul></ul>
    34. 35. <ul><li>Diagnosis: Must exclude GCA in every case </li></ul><ul><ul><li>ESR </li></ul></ul><ul><ul><li>C-Reactive Protein </li></ul></ul><ul><ul><ul><li>Positive acute-phase protein </li></ul></ul></ul><ul><ul><ul><li>Levels increase in presence of inflammation </li></ul></ul></ul><ul><ul><ul><li>Upper limit normal does not rise with age </li></ul></ul></ul><ul><ul><li>Platelets </li></ul></ul><ul><ul><ul><li>Secondary thrombocytosis due to chronic inflammation </li></ul></ul></ul>NAION
    35. 36. NAION <ul><li>Treatment </li></ul><ul><ul><li>Aspirin </li></ul></ul><ul><ul><ul><li>Decreases incidence in fellow eye at 2 years, but not at 5 years </li></ul></ul></ul><ul><ul><li>Surgical decompression </li></ul></ul><ul><ul><ul><li>No benefit (Ischemic Optic Neuropathy Decompression Trial) </li></ul></ul></ul><ul><ul><li>Control of predisposing systemic disease </li></ul></ul><ul><ul><ul><li>May slow progression or reduce incidence in fellow eye </li></ul></ul></ul><ul><ul><ul><li>Hypertension, Diabetes, Hyperlipidemia </li></ul></ul></ul><ul><ul><li>Avoid phosphodiesterase 5 inhibitors (Viagra, Levitra, Cialis) </li></ul></ul><ul><ul><ul><li>May increase risk of NAION in fellow eye </li></ul></ul></ul>
    36. 37. NAION <ul><li>Medicolegal obligation to inform pts of risk to fellow eye </li></ul>
    37. 38. NAION <ul><li>Relation to OSA </li></ul><ul><ul><li>Mojon (2002) </li></ul></ul><ul><ul><li>Behbehani (2005) </li></ul></ul><ul><ul><li>Palombi (2006) </li></ul></ul><ul><ul><li>Li (2007) </li></ul></ul>
    38. 39. NAION <ul><li>Mojon (2002) </li></ul><ul><ul><li>Matched case-control study with 17 NAION cases and 17 controls </li></ul></ul><ul><ul><li>71% of patients with NAION have OSA compared with 18% of controls </li></ul></ul><ul><ul><li>Can CPAP prevent NAION in predisposed individuals with OSA? </li></ul></ul>
    39. 40. NAION <ul><li>Behbehani (2005) </li></ul><ul><ul><li>Report of 3 patients that developed NAION while using CPAP for OSA </li></ul></ul><ul><ul><li>Concluded that CPAP does not prevent NAION in patients with OSA </li></ul></ul><ul><ul><li>Questions role of OSA in development of NAION </li></ul></ul>
    40. 41. NAION <ul><li>Palombi (2006) </li></ul><ul><ul><li>24 of 27 (89%) NAION patients had OSA </li></ul></ul><ul><ul><li>OSA was the most frequent disorder associated with NAION </li></ul></ul><ul><ul><ul><li>HTN: 59% </li></ul></ul></ul><ul><ul><ul><li>DM: 37% </li></ul></ul></ul><ul><ul><li>Recommend all NAION pts be screened for OSA </li></ul></ul><ul><ul><ul><li>Daytime sleepiness, noisy sleep, witnessed apneas </li></ul></ul></ul><ul><ul><ul><li>Pickwickian habitus (obese middle-aged men) </li></ul></ul></ul>
    41. 42. NAION <ul><li>Li (2007) </li></ul><ul><ul><li>Matched case-control study of 73 NAION cases and 73 controls </li></ul></ul><ul><ul><li>Administered questionnaire that included the SA-SDQ </li></ul></ul><ul><ul><li>22 (30.1%) cases and 13 (17.8%) controls had scores consistent with OSA </li></ul></ul><ul><ul><li>Conclude that patients with OSA are at increased risk of NAION </li></ul></ul>
    42. 43. OSA & the Eye <ul><li>Obese middle-aged men </li></ul><ul><li>Excessive sleepiness Disruptive snoring Witnessed apneas </li></ul><ul><li>Ocular Manifestations </li></ul><ul><ul><li>Asthenopia </li></ul></ul><ul><ul><li>CPAP-associated red eye </li></ul></ul><ul><ul><li>Floppy Eyelid Syndrome </li></ul></ul><ul><ul><li>NAION </li></ul></ul><ul><ul><li>Papilledema </li></ul></ul><ul><ul><li>Normal Tension Glaucoma </li></ul></ul>
    43. 44. Papilledema <ul><li>Clinical Characteristics </li></ul><ul><ul><li>Disc swelling associated with increased ICP </li></ul></ul><ul><ul><li>Symptoms of elevated ICP: Headache, tinnitus, TOV </li></ul></ul><ul><ul><li>Chronic papilledema (months) may lead to optic atrophy and vision loss </li></ul></ul>
    44. 45. Papilledema <ul><li>Work-up </li></ul><ul><ul><li>Urgent MRI or CT scan </li></ul></ul><ul><ul><li>Lumbar puncture if imaging normal </li></ul></ul><ul><li>Idiopathic Intracranial Hypertension </li></ul><ul><ul><li>“ Pseudotumor cerebri” </li></ul></ul><ul><ul><li>Syndrome of elevated ICP, papilledema, normal MRI/CT, normal CSF </li></ul></ul><ul><ul><li>Secondary pseudotumor cerebri syndromes </li></ul></ul><ul><ul><ul><li>Venous sinus thrombosis, vitamin A toxicity, COPD, OSA </li></ul></ul></ul><ul><ul><li>Tx: Diamox 250mg po QID , Underlying cause if known </li></ul></ul>
    45. 46. Papilledema <ul><li>Relation to OSA </li></ul><ul><ul><li>4 pts with vision loss, unexplained disc edema and OSA </li></ul></ul><ul><ul><li>ICP is normal during the day but elevated at night </li></ul></ul><ul><ul><ul><li>Apneas were occurring despite CPAP – require surgical tx </li></ul></ul></ul><ul><ul><li>Hypercapnia-induced cerebral vasodilatation elevates ICP </li></ul></ul><ul><ul><ul><li>Intermittent ↑ ICP can cause sustained papilledema </li></ul></ul></ul><ul><ul><li>Papilledema resolved with successful tx of OSA </li></ul></ul>
    46. 47. OSA & the Eye <ul><li>Obese middle-aged men </li></ul><ul><li>Excessive sleepiness Disruptive snoring Witnessed apneas </li></ul><ul><li>Ocular Manifestations </li></ul><ul><ul><li>Asthenopia </li></ul></ul><ul><ul><li>CPAP-associated red eye </li></ul></ul><ul><ul><li>Floppy Eyelid Syndrome </li></ul></ul><ul><ul><li>NAION </li></ul></ul><ul><ul><li>Papilledema </li></ul></ul><ul><ul><li>Normal Tension Glaucoma </li></ul></ul>
    47. 48. Normal Tension Glaucoma <ul><li>Clinical Characteristics </li></ul><ul><ul><li>Probably a variant of COAG </li></ul></ul><ul><ul><li>IOP is never documented above 21 mmHg </li></ul></ul><ul><ul><li>Peripapillary hemorrhages may be more frequent </li></ul></ul><ul><ul><li>Peripapillary atrophy may be more marked </li></ul></ul><ul><ul><li>VF defects tend to be deeper and more localized </li></ul></ul>
    48. 49. Normal Tension Glaucoma <ul><li>Pathophysiology </li></ul><ul><ul><li>NTG differs from NAION only in that the latter is a more acute process. (Hayreh, 1975) </li></ul></ul><ul><ul><li>Role of IOP unclear </li></ul></ul><ul><ul><ul><li>Proven value of aggressive IOP lowering (CNTGS, 1998) </li></ul></ul></ul><ul><ul><ul><li>Pressure-independent component also exists (LoGTS, 2007) </li></ul></ul></ul>
    49. 50. Normal Tension Glaucoma <ul><li>Diagnosis </li></ul><ul><ul><li>R/O other glaucomas </li></ul></ul><ul><ul><ul><li>Diurnal IOP fluctuation </li></ul></ul></ul><ul><ul><ul><li>IOP normalization (Burnt-out glaucoma, pseudophakia, steroids) </li></ul></ul></ul><ul><ul><li>R/O other optic neuropathies </li></ul></ul><ul><ul><ul><li>NAION, space-occupying lesions, congenital anomalies </li></ul></ul></ul><ul><ul><ul><li>When to order neuroimaging : </li></ul></ul></ul><ul><ul><ul><ul><li>Younger age (<50 yrs) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Reduced VA (< 20/40) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Vertically aligned VF defects </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Neuroretinal rim pallor </li></ul></ul></ul></ul>
    50. 51. Normal Tension Glaucoma <ul><li>Relation to OSA </li></ul>10% (NTG), 3% (POAG) Karakuck (2008) 27% Bendel (2007) 6% (NTG) Sergi (2007) 2% Geyer (2003) Mojon (1999) Mojon (2002) Marcus (2001) Mojon (2000) 7% OSA Patients with Glaucoma (5-10% OSA pts have NTG) 50-60% (NTG, varies with age) 57% (NTG) 20% (POAG) Glaucoma Patients with OSA (50-60% NTG pts have OSA)
    51. 52. Normal Tension Glaucoma <ul><li>OSA May Cause VF Loss Without Glaucoma </li></ul><ul><li>VF loss may occur due to optic nerve damage caused by cerebral ischemia and intermittent ICP elevation </li></ul><ul><li>Batisse (2004) </li></ul><ul><ul><li>Eye exam on 35 consecutive patients undergoing PSG </li></ul></ul><ul><ul><li>VF mean deviation correlated with RDI </li></ul></ul><ul><li>Tsang (2006) </li></ul><ul><ul><li>Compared VF and ONH changes between 41 pts with moderate-severe OSA with 35 age-matched controls </li></ul></ul><ul><ul><li>In OSA pts the VF indices were significantly subnormal </li></ul></ul><ul><li>Karakucuk (2008) </li></ul><ul><ul><li>Eye exams and orbital blood flow studies on 31 pts with OSA and 25 normal control subjects </li></ul></ul><ul><ul><li>VF defects were detected in 10 pts despite normal eye exam. </li></ul></ul>
    52. 53. Normal Tension Glaucoma <ul><li>CPAP Increases IOP </li></ul><ul><li>Kiekens (2008) </li></ul><ul><ul><li>Diurnal IOP in 21 OSA pts with and without CPAP </li></ul></ul><ul><ul><li>Average IOP and diurnal fluctuation higher with CPAP </li></ul></ul><ul><ul><li>30 min after CPAP cessation a significant decrease in IOP was recorded </li></ul></ul><ul><ul><li>Speculate that CPAP elevates intrathoracic pressure, leading to higher central venous pressure, and ultimately higher IOP </li></ul></ul><ul><ul><li>Recommend regular screening of VF and the optic disc for all patients with OSA , especially those treated with CPAP </li></ul></ul>
    53. 55. Thank You!
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