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Sleep Apnea and the Eye - 2008

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Ocular manifestations of sleep apnea. Updated and expanded for 2008

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
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    • 1. Sleep Apnea & the Eye Rick Trevino, OD VA Outpatient Clinic Evansville, IN [email_address]
    • 2. Sleep Apnea & the Eye
      • Sleep Apnea
        • Sleep physiology
        • Clinical consequences
        • Diagnosis
        • Treatment
      • Ocular Manifestations
        • Asthenopia
        • CPAP-assoc red eye
        • Floppy eyelid syndrome
        • NAION
        • Papilledema
        • Normal tension glaucoma
    • 3. Online Resources
      • Lecture Notes
        • http://richardtrevino.net/sleepapnea
      • Powerpoint Slides
        • http://www.slideshare.net/rhodopsin
      • Free Texts
        • http://jfponline.com (Aug 2008)
        • http://pubs.nrc-cnrc.gc.ca/cjo Can J Ophthalmol 2007;42(2):238-43
    • 4. Sleep Cycle
    • 5. Sleep Cycle
      • Polysomnography
        • EEG channels
        • EOG channels
        • EMG channel
        • Nasal air current channel
        • Thoracic motion channel
        • Abdominal motion channel
        • Oximeter channel
        • Leg movement channels
        • Microphone
        • Video recording
    • 6. Sleep Cycle Polysomnogram
    • 7. Sleep Disorders
      • Sleep apnea
      • Insomnia
      • Narcolepsy
      • Restless leg syndrome
      • Parasomnias
      • Circadian disorders
      • Drug side effects
      • Shift work
      OSA is the “most physiologically disruptive and dangerous of the sleep-related disorders.”
    • 8. Obstructive Sleep Apnea
    • 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. Obstructive Sleep Apnea
        • Excessive daytime sleepiness
          • Most common symptom
        • Disruptive snoring
          • Also gasping/snorting during arousals
        • Apneic events witnessed by bed partner
          • Disruptive snoring + witnessed apneas: 94% specificity
        • Obesity
          • 30% of pts with a BMI > 30 have OSA, and 50% of pts with a BMI > 40 have OSA.
        • Neck circumference
          • ≥ 40 cm had a sensitivity of 61% and a specificity of 93% for OSA
          • Correlates better than BMI
        • Male
          • 2-3x more common than female
        • Family history of OSA
          • Relatives have 2-4 fold  risk
      Clinical Characteristics
    • 11. Obstructive Sleep Apnea
      • Pickwickian Syndrome
        • Obesity, daytime somnolence, loud snoring
        • Charles Dicken’s “Pickwick Papers” (1837)
      • Prevalence increasing in parallel with prevalence of obesity
        • 30-60yo: 9%F, 24%M
        • Under-diagnosed
    • 12. Obstructive Sleep Apnea
      • Cardiovascular Disease
        • HTN, CAD/MI, CHF, Arrhythmia
      • Stroke
      • Obesity
      • Metabolic Syndrome
      • Other Diseases
        • Morning headache, Eye , Liver, Kidney, others
      • Cognitive and Emotional
        • Impaired mental functioning
        • Depression
        • Mood alteration
      • Effects on bed partners
        • Disruptive snoring
      • Accidents
        • Drowsy driving
        • Workplace
      Clinical Consequences
    • 13. Obstructive Sleep Apnea
    • 14. Obstructive Sleep Apnea
      • History
        • Sleepiness assessment
        • Disruptive snoring
        • Witnessed apneas
      • Physical
        • Obesity
        • Neck circumference
        • Throat/Mouth exam
      • PSG
        • Gold Standard
        • Respiratory Disturbance Index
      Clinical Evaluation
    • 15. Obstructive Sleep Apnea
      • Epworth Sleepiness Scale
      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. Obstructive Sleep Apnea
      • Treatment Options
        • Behavioral: Weight loss, EtOH avoidance, nonsupine position
        • Positive Airway Pressure: CPAP, others
        • Mandibular advancement device
        • Surgery: UPPP, Tonsillectomy, Tracheostomy
    • 17.  
    • 18. OSA & the Eye
      • Obese middle-aged men
      • Excessive sleepiness Disruptive snoring Witnessed apneas
      • Ocular Manifestations
        • Asthenopia
        • CPAP-associated red eye
        • Floppy Eyelid Syndrome
        • NAION
        • Papilledema
        • Normal Tension Glaucoma
    • 19. Asthenopia
      • Common OSA Symptoms Include:
        • “Tiredness”
        • “Fatigue”
        • “Lack of energy”
        • Morning headache
      • These OSA symptoms may be misinterpreted as “eye strain”
    • 20. Asthenopia
      • Common OSA-associated asthenopic symptoms
        • Unexplained symptoms of blur
          • Vision is 20/20 but the patient is c/o blur
        • Misinterpreting what is seen
          • Incorrect recording or copying
        • Eye strain and/or fatigue
        • Headaches
          • Worse in the morning
    • 21. Asthenopia
      • 42yo WM presents with c/o eye fatigue at near.
      • LEE: <1yr with current eyeglasses
      • MH: 1. OSA (noncompliant with CPAP)
      • 2. Frequent HA
      • 3. Overweight
      • 4. Hyperlipidemia
      • 5. GERD
      • 6. Smokes 1PPD
      • Optometric Exam: Unremarkable
      • Plan: 1. OSA management
      • 2. Visual hygiene
      • 3. Smoking cessation
    • 22. Asthenopia
      • OSA Supportive Management
        • Encourage compliance with CPAP
          • 50% compliance rate, high drop-out rate
        • Quit smoking
          • Smokers 3 times more likely to have OSA
          • Reversible with smoking cessation
        • Weight reduction
          • 10% increase in weight results in 6x greater risk of developing OSA
          • Weight loss decreases OSA severity
        • Avoid sleeping on back
          • Sew golf ball into pocket on back of shirt
        • Avoid alcohol within 4 hours of bedtime
        • Avoid sleeping pills
    • 23. OSA & the Eye
      • Obese middle-aged men
      • Excessive sleepiness Disruptive snoring Witnessed apneas
      • Ocular Manifestations
        • Asthenopia
        • CPAP-associated red eye
        • Floppy Eyelid Syndrome
        • NAION
        • Papilledema
        • Normal Tension Glaucoma
    • 24. CPAP-associated Red Eye
      • Clinical Problems
        • Dry eye
        • EXW CL intolerance
        • Conjunctivitis
        • Reactivation of RCE
      • Causes
        • Air leaks
        • Retrograde air flow thru nasolacrimal apparatus
      • Treatment
        • CPAP refitting: adjust headgear and pressure
        • Ointments HS, punctal plugs
    • 25. OSA & the Eye
      • Obese middle-aged men
      • Excessive sleepiness, disruptive snoring, witnessed apneas
      • Ocular Manifestations
        • Asthenopia
        • CPAP-associated red eye
        • Floppy Eyelid Syndrome
        • NAION
        • Papilledema
        • Normal Tension Glaucoma
    • 26. Floppy Eyelid Syndrome
      • Clinical Characteristics
        • Eyelid hyperlaxity
        • Rubbery, easily everted upper eyelids
        • Eyelash ptosis with loss of parallelism
        • Papillary conjunctivitis
        • Chronic ocular irritation, worse upon waking
        • SPK, mucoid discharge common
        • Rubbing on pillow case
        • Should be suspected in any obese pt with a chronic red eye
    • 27. Floppy Eyelid Syndrome
      • Eyelash ptosis
        • Downward displacement of eyelashes
        • Lashes may curl toward the globe
        • Lashes may point in various directions - loss of parallelism
        • Pts may trim with scissors
    • 28. Floppy Eyelid Syndrome
    • 29. Floppy Eyelid Syndrome
      • Pathophysiology
        • Loss of elastic fibers in tarsus and skin of lid
        • Upregulation of elastin-degrading enzymes (matrix metalloproteinases)
        • Caused by repeated mechanical trauma, possibly eye rubbing or sleeping with the face buried in the pillow
    • 30. Floppy Eyelid Syndrome
      • Treatment
        • Lubrication therapy
          • Poor lid-eye contact
          • Inadequate tear distribution
        • Protect eye during sleep
          • Ointments HS
          • Fox shield, patching, taping
        • May improve or resolve with CPAP
        • Surgical therapy deferred until OSA treated
          • Horizontal lid shortening
    • 31. Floppy Eyelid Syndrome
      • Relation to OSA
        • Pts with FES are a subset of all OSA pts
          • 96% pts with FES have OSA (almost 100%!)
          • 5-15% pts with OSA have FES
        • OSA tends to be more severe in pts with FES
    • 32. OSA & the Eye
      • Obese middle-aged men
      • Excessive sleepiness Disruptive snoring Witnessed apneas
      • Ocular Manifestations
        • Asthenopia
        • CPAP-associated red eye
        • Floppy Eyelid Syndrome
        • NAION
        • Papilledema
        • Normal Tension Glaucoma
    • 33. NAION
      • Clinical Characteristics
        • Most common acute optic neuropathy in pts >50yo
        • Sudden painless visual loss, usually upon awaking
        • Nerve fiber bundle VF defects
        • Diffuse or sectoral disc edema
        • Disc at risk: small, crowded
          • Mean C/D = 0.2
          • All ≤ 0.4
    • 34. NAION
      • Pathophysiology
        • Idiopathic ischemic process
          • Disorder of posterior ciliary artery circulation
          • Transient poor circulation in the ONH
          • Trigger Event : Fall in blood pressure below a critical level?
          • There is no actual blockage of the posterior ciliary arteries
        • Cascade Effect
          • Mechanical crowding caused by small crowded disc
          • Ischemia  Swelling  Compression  Ischemia
    • 35.
      • Diagnosis: Must exclude GCA in every case
        • ESR
        • C-Reactive Protein
          • Positive acute-phase protein
          • Levels increase in presence of inflammation
          • Upper limit normal does not rise with age
        • Platelets
          • Secondary thrombocytosis due to chronic inflammation
      NAION
    • 36. NAION
      • Treatment
        • Aspirin
          • Decreases incidence in fellow eye at 2 years, but not at 5 years
        • Surgical decompression
          • No benefit (Ischemic Optic Neuropathy Decompression Trial)
        • Control of predisposing systemic disease
          • May slow progression or reduce incidence in fellow eye
          • Hypertension, Diabetes, Hyperlipidemia
        • Avoid phosphodiesterase 5 inhibitors (Viagra, Levitra, Cialis)
          • May increase risk of NAION in fellow eye
    • 37. NAION
      • Medicolegal obligation to inform pts of risk to fellow eye
    • 38. NAION
      • Relation to OSA
        • Mojon (2002)
        • Behbehani (2005)
        • Palombi (2006)
        • Li (2007)
    • 39. NAION
      • Mojon (2002)
        • Matched case-control study with 17 NAION cases and 17 controls
        • 71% of patients with NAION have OSA compared with 18% of controls
        • Can CPAP prevent NAION in predisposed individuals with OSA?
    • 40. NAION
      • Behbehani (2005)
        • Report of 3 patients that developed NAION while using CPAP for OSA
        • Concluded that CPAP does not prevent NAION in patients with OSA
        • Questions role of OSA in development of NAION
    • 41. NAION
      • Palombi (2006)
        • 24 of 27 (89%) NAION patients had OSA
        • OSA was the most frequent disorder associated with NAION
          • HTN: 59%
          • DM: 37%
        • Recommend all NAION pts be screened for OSA
          • Daytime sleepiness, noisy sleep, witnessed apneas
          • Pickwickian habitus (obese middle-aged men)
    • 42. NAION
      • Li (2007)
        • Matched case-control study of 73 NAION cases and 73 controls
        • Administered questionnaire that included the SA-SDQ
        • 22 (30.1%) cases and 13 (17.8%) controls had scores consistent with OSA
        • Conclude that patients with OSA are at increased risk of NAION
    • 43. OSA & the Eye
      • Obese middle-aged men
      • Excessive sleepiness Disruptive snoring Witnessed apneas
      • Ocular Manifestations
        • Asthenopia
        • CPAP-associated red eye
        • Floppy Eyelid Syndrome
        • NAION
        • Papilledema
        • Normal Tension Glaucoma
    • 44. Papilledema
      • Clinical Characteristics
        • Disc swelling associated with increased ICP
        • Symptoms of elevated ICP: Headache, tinnitus, TOV
        • Chronic papilledema (months) may lead to optic atrophy and vision loss
    • 45. Papilledema
      • Work-up
        • Urgent MRI or CT scan
        • Lumbar puncture if imaging normal
      • Idiopathic Intracranial Hypertension
        • “ Pseudotumor cerebri”
        • Syndrome of elevated ICP, papilledema, normal MRI/CT, normal CSF
        • Secondary pseudotumor cerebri syndromes
          • Venous sinus thrombosis, vitamin A toxicity, COPD, OSA
        • Tx: Diamox 250mg po QID , Underlying cause if known
    • 46. Papilledema
      • Relation to OSA
        • 4 pts with vision loss, unexplained disc edema and OSA
        • ICP is normal during the day but elevated at night
          • Apneas were occurring despite CPAP – require surgical tx
        • Hypercapnia-induced cerebral vasodilatation elevates ICP
          • Intermittent ↑ ICP can cause sustained papilledema
        • Papilledema resolved with successful tx of OSA
    • 47. OSA & the Eye
      • Obese middle-aged men
      • Excessive sleepiness Disruptive snoring Witnessed apneas
      • Ocular Manifestations
        • Asthenopia
        • CPAP-associated red eye
        • Floppy Eyelid Syndrome
        • NAION
        • Papilledema
        • Normal Tension Glaucoma
    • 48. Normal Tension Glaucoma
      • Clinical Characteristics
        • Probably a variant of COAG
        • IOP is never documented above 21 mmHg
        • Peripapillary hemorrhages may be more frequent
        • Peripapillary atrophy may be more marked
        • VF defects tend to be deeper and more localized
    • 49. Normal Tension Glaucoma
      • Pathophysiology
        • NTG differs from NAION only in that the latter is a more acute process. (Hayreh, 1975)
        • Role of IOP unclear
          • Proven value of aggressive IOP lowering (CNTGS, 1998)
          • Pressure-independent component also exists (LoGTS, 2007)
    • 50. Normal Tension Glaucoma
      • Diagnosis
        • R/O other glaucomas
          • Diurnal IOP fluctuation
          • IOP normalization (Burnt-out glaucoma, pseudophakia, steroids)
        • R/O other optic neuropathies
          • NAION, space-occupying lesions, congenital anomalies
          • When to order neuroimaging :
            • Younger age (<50 yrs)
            • Reduced VA (< 20/40)
            • Vertically aligned VF defects
            • Neuroretinal rim pallor
    • 51. Normal Tension Glaucoma
      • Relation to OSA
      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)
    • 52. Normal Tension Glaucoma
      • OSA May Cause VF Loss Without Glaucoma
      • VF loss may occur due to optic nerve damage caused by cerebral ischemia and intermittent ICP elevation
      • Batisse (2004)
        • Eye exam on 35 consecutive patients undergoing PSG
        • VF mean deviation correlated with RDI
      • Tsang (2006)
        • Compared VF and ONH changes between 41 pts with moderate-severe OSA with 35 age-matched controls
        • In OSA pts the VF indices were significantly subnormal
      • Karakucuk (2008)
        • Eye exams and orbital blood flow studies on 31 pts with OSA and 25 normal control subjects
        • VF defects were detected in 10 pts despite normal eye exam.
    • 53. Normal Tension Glaucoma
      • CPAP Increases IOP
      • Kiekens (2008)
        • Diurnal IOP in 21 OSA pts with and without CPAP
        • Average IOP and diurnal fluctuation higher with CPAP
        • 30 min after CPAP cessation a significant decrease in IOP 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
    • 54.  
    • 55. Thank You!