sleep apnea & the eye - 2011

51
Sleep Apnea Sleep Apnea & the Eye & the Eye Rick Trevino, OD Rick Trevino, OD Rosenberg School of Optometry Rosenberg School of Optometry University of the Incarnate University of the Incarnate Word Word [email protected] [email protected]

Upload: rick-trevino

Post on 27-May-2015

4.306 views

Category:

Health & Medicine


3 download

DESCRIPTION

Ocular manifestations of sleep apnea, updated for 2011

TRANSCRIPT

Page 1: Sleep Apnea & The Eye - 2011

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

Page 2: Sleep Apnea & The Eye - 2011

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

Page 3: Sleep Apnea & The Eye - 2011

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

Page 4: Sleep Apnea & The Eye - 2011

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.”

Page 5: Sleep Apnea & The Eye - 2011

Sleep ArchitectureSleep Architecture

Page 6: Sleep Apnea & The Eye - 2011

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

Page 7: Sleep Apnea & The Eye - 2011

Obstructive Sleep ApneaObstructive Sleep ApneaPolysomnography (PSG)Polysomnography (PSG)

Page 8: Sleep Apnea & The Eye - 2011

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

Page 9: Sleep Apnea & The Eye - 2011

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

Page 10: Sleep Apnea & The Eye - 2011

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

Page 11: Sleep Apnea & The Eye - 2011

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

Page 12: Sleep Apnea & The Eye - 2011

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

Page 13: Sleep Apnea & The Eye - 2011

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

Page 14: Sleep Apnea & The Eye - 2011

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

Page 15: Sleep Apnea & The Eye - 2011
Page 16: Sleep Apnea & The Eye - 2011

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

Page 17: Sleep Apnea & The Eye - 2011

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

Page 18: Sleep Apnea & The Eye - 2011

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

Page 19: Sleep Apnea & The Eye - 2011

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

Page 20: Sleep Apnea & The Eye - 2011

CPAP-associated Red EyeCPAP-associated Red Eye

Page 21: Sleep Apnea & The Eye - 2011

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

Page 22: Sleep Apnea & The Eye - 2011

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

Page 23: Sleep Apnea & The Eye - 2011

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

Page 24: Sleep Apnea & The Eye - 2011

Floppy Eyelid SyndromeFloppy Eyelid Syndrome

Page 25: Sleep Apnea & The Eye - 2011

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

Page 26: Sleep Apnea & The Eye - 2011

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

Page 27: Sleep Apnea & The Eye - 2011

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

Page 28: Sleep Apnea & The Eye - 2011

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

Page 29: Sleep Apnea & The Eye - 2011

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

Page 30: Sleep Apnea & The Eye - 2011

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

Page 31: Sleep Apnea & The Eye - 2011

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

Page 32: Sleep Apnea & The Eye - 2011

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

Page 33: Sleep Apnea & The Eye - 2011

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

Page 34: Sleep Apnea & The Eye - 2011

NAIONNAION

Medicolegal obligation to inform pts of risk to Medicolegal obligation to inform pts of risk to fellow eyefellow eye

Page 35: Sleep Apnea & The Eye - 2011

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%)

Page 36: Sleep Apnea & The Eye - 2011

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

Page 37: Sleep Apnea & The Eye - 2011

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

Page 38: Sleep Apnea & The Eye - 2011

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

Page 39: Sleep Apnea & The Eye - 2011

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

Page 40: Sleep Apnea & The Eye - 2011

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

Page 41: Sleep Apnea & The Eye - 2011

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

Page 42: Sleep Apnea & The Eye - 2011

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

Page 43: Sleep Apnea & The Eye - 2011

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

Page 44: Sleep Apnea & The Eye - 2011

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)

Page 45: Sleep Apnea & The Eye - 2011

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

Page 46: Sleep Apnea & The Eye - 2011

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

Page 47: Sleep Apnea & The Eye - 2011

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.

Page 48: Sleep Apnea & The Eye - 2011

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”))

Page 49: Sleep Apnea & The Eye - 2011

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

Page 50: Sleep Apnea & The Eye - 2011

Source: Can J Ophthalmol 2007;42:238–243

Page 51: Sleep Apnea & The Eye - 2011

Thank Thank You!You!