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Sleep Apnea and the Eye


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A review of sleep apnea and its effects on the eyes

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Sleep Apnea and the Eye

  1. 1. Sleep Apnea & the Eye Rick Trevino, OD VA Outpatient Clinic Evansville, IN
  2. 2. Disclosures: None Interested influence peddlers please see me afterward.
  3. 3. OSA and 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>Floppy Eyelid Syndrome </li></ul></ul><ul><ul><li>NAION </li></ul></ul><ul><ul><li>Glaucoma </li></ul></ul><ul><ul><li>Papilledema </li></ul></ul>
  4. 4. Obstructive Sleep Apnea <ul><ul><li>Sleep-disordered breathing due to upper airway closure </li></ul></ul><ul><ul><li>Life threatening complications </li></ul></ul><ul><ul><ul><li>MI, CVA </li></ul></ul></ul><ul><ul><ul><li>MVA </li></ul></ul></ul><ul><ul><li>Prevalence increasing in parallel with prevalence of obesity </li></ul></ul><ul><ul><ul><li>30-60yo: 9%F, 24%M </li></ul></ul></ul><ul><ul><ul><li>80-90% of cases undiagnosed </li></ul></ul></ul>
  5. 5. Obstructive Sleep Apnea Polysomnography (PSG)
  6. 6. 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
  7. 7. Obstructive Sleep Apnea <ul><li>SYMPTOMS </li></ul><ul><ul><li>Excessive daytime sleepiness </li></ul></ul><ul><ul><ul><li>Accident prone </li></ul></ul></ul><ul><ul><li>Disruptive snoring </li></ul></ul><ul><ul><ul><li>71% sensitivity </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><li>SIGNS </li></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>Hypertension </li></ul></ul><ul><ul><ul><li>70-90% of OSA pts </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>
  8. 8. Obstructive Sleep Apnea <ul><li>Sleep Apnea Scale of the Sleep Disorders Questionnaire </li></ul>1 = Never (strongly disagree) 2 = Rarely (disagree) 3 = Sometimes (Not sure) 4 = Usually (agree) 5 = Always (strongly agree) Validated with PSG - Men: >36 Women: >32 Lower cut-off improves sensitivity in NAION - Men: >29 Women: >26 Body mass index (Five categories) How old are you now? (Five categories) How many years were you a smoker? (Five categories) What is your current weight? (Five categories) My snoring problem is much worse if I fall asleep right after drinking alcohol My snoring or my breathing problem is much worse if I sleep on my back I have a problem with my nose blocking up when I am trying to sleep I have high blood pressure (or once had it) I sweat a great deal at night I awake suddenly gasping for breath, unable to breathe I am told I stop breathing (“hold my breath”) in sleep I am told I snore loudly and bother others
  9. 9. Obstructive Sleep Apnea <ul><li>Systemic Associations </li></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><ul><li>Dose-response relation </li></ul></ul></ul><ul><ul><ul><li>Tx OSA lowers HTN </li></ul></ul></ul><ul><ul><li>Cardiac Disease </li></ul></ul><ul><ul><li>Stroke </li></ul></ul><ul><ul><li>Excessive Sleepiness </li></ul></ul><ul><ul><li>Motor vehicle accidents </li></ul></ul><ul><ul><ul><li>7-fold increase risk </li></ul></ul></ul>
  10. 10. Obstructive Sleep Apnea <ul><li>Treatment </li></ul><ul><ul><li>Supportive: Weight loss, EtOH avoidance </li></ul></ul><ul><ul><li>CPAP (Continuous Positive Airway Pressure) </li></ul></ul><ul><ul><li>Mandibular advancement device </li></ul></ul><ul><ul><li>Tonsillectomy </li></ul></ul><ul><ul><li>Tracheostomy </li></ul></ul>
  11. 12. 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>Loss of tarsal elastin due to upregulation of elastin degrading enzymes </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>
  12. 13. 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 FES pts </li></ul></ul><ul><ul><li>Get PSG in all FES pts without OSA dx </li></ul></ul><ul><ul><li>Tx of obesity and OSA may improve FES </li></ul></ul>
  13. 14. Floppy Eyelid Syndrome MH: OSA, HTN, DM HT: 6FT WT: 289 LBS BMI: 40 (kg/m 2 )
  14. 15. 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><ul><li>CPAP-related dry eye complications </li></ul></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>
  15. 16. NAION <ul><li>Clinical Characteristics </li></ul><ul><ul><li>Most common acute optic neuropathy in >50yo pts </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><ul><ul><ul><li>Ischemia  Swelling  Compression  Ischemia </li></ul></ul></ul><ul><ul><li>R/O GCA in all patients </li></ul></ul><ul><ul><li>Viagra use? </li></ul></ul><ul><ul><li>TX: None </li></ul></ul>
  16. 17. NAION <ul><li>Relation to OSA </li></ul><ul><li>71% of patients with AION have OSA </li></ul><ul><li>75% of all cases of AION discover their vision loss upon waking </li></ul><ul><li>Nocturnal events may trigger AION in predisposed patients </li></ul>
  17. 18. NAION <ul><li>Relation to OSA </li></ul><ul><ul><li>Almost all pts with NAION had OSA </li></ul></ul><ul><ul><ul><ul><li>OSA: 89% </li></ul></ul></ul></ul><ul><ul><ul><ul><li>HTN: 59% </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Smoker: 46% </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Lipids: 44% </li></ul></ul></ul></ul><ul><ul><ul><ul><li>DM: 37% </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Carotids: 30% </li></ul></ul></ul></ul><ul><ul><li>Recommend every newly diagnosed pt with NAION be worked up for OSA </li></ul></ul>
  18. 19. NAION Trigger Event: Failure of Autoregulation?
  19. 20. Glaucoma <ul><li>Relation to OSA </li></ul><ul><ul><li>Higher prevalence of glaucoma in patients with OSA </li></ul></ul><ul><ul><ul><li>7.2% OSA </li></ul></ul></ul><ul><ul><ul><li>2% general pop </li></ul></ul></ul><ul><ul><li>Higher prevalence of OSA in pts with glaucoma </li></ul></ul><ul><ul><ul><li>57% of NTG have sleep sxs </li></ul></ul></ul><ul><ul><li>Severity of OSA correlated with severity of glaucoma </li></ul></ul><ul><ul><ul><li>Dose-dependent relationship </li></ul></ul></ul>
  20. 22. Obstructive Sleep Apnea <ul><li>Papilledema </li></ul><ul><ul><li>Transient, nocturnal elevated ICP </li></ul></ul><ul><ul><li>Daytime measurements of CSF pressure are normal </li></ul></ul><ul><ul><li>Mechanism: </li></ul></ul><ul><ul><ul><li>Cerebral vasodilation </li></ul></ul></ul><ul><ul><ul><li>Valsalva/Mullers </li></ul></ul></ul><ul><ul><ul><li>Arterial hypertension </li></ul></ul></ul>
  21. 23. OSA and 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>FES </li></ul></ul><ul><ul><li>NAION </li></ul></ul><ul><ul><li>Glaucoma </li></ul></ul><ul><ul><li>Papilledema </li></ul></ul>
  22. 24. Thank You!