Sleep Apnea and the Eye - 2008

Sleep Apnea Sleep Apnea & the Eye& the Eye

Rick Trevino, ODRick Trevino, ODVA Outpatient ClinicVA Outpatient Clinic

Evansville, INEvansville, IN

[email protected]@gmail.com

Sleep Apnea & the EyeSleep Apnea & the Eye Sleep ApneaSleep Apnea

Sleep physiologySleep physiology Clinical consequencesClinical consequences DiagnosisDiagnosis TreatmentTreatment

Ocular Ocular ManifestationsManifestations AsthenopiaAsthenopia CPAP-assoc red eyeCPAP-assoc red eye Floppy eyelid Floppy eyelid

syndromesyndrome NAIONNAION PapilledemaPapilledema Normal tension Normal tension

glaucomaglaucoma

Online ResourcesOnline Resources

Lecture NotesLecture Notes http://richardtrevino.net/http://richardtrevino.net/

sleepapneasleepapnea

Powerpoint SlidesPowerpoint Slides http://www.slideshare.net/http://www.slideshare.net/

rhodopsinrhodopsin

Free TextsFree Texts http://jfponline.com (Aug 2008)http://jfponline.com (Aug 2008) http://pubs.nrc-cnrc.gc.ca/cjohttp://pubs.nrc-cnrc.gc.ca/cjo

Can J Ophthalmol Can J Ophthalmol 2007;42(2):238-432007;42(2):238-43

Sleep CycleSleep Cycle

Source: Graefes Arch Clin Exp Ophthalmol 2008;246:129–134

Sleep CycleSleep Cycle

PolysomnographyPolysomnography EEG channels EEG channels EOG channels EOG channels EMG channelEMG channel Nasal air current channel Nasal air current channel Thoracic motion channel Thoracic motion channel Abdominal motion channelAbdominal motion channel Oximeter channelOximeter channel Leg movement channelsLeg movement channels MicrophoneMicrophone Video recordingVideo recording

Source: N Engl J Med 2007;356:1751-1758

Sleep CycleSleep CyclePolysomnogrPolysomnogr

amam

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.”

Obstructive Sleep ApneaObstructive Sleep Apnea

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

Source: eMedicine (http://www.emedicine.com/med/topic163.htm)


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 > 40 OSA, and 50% of pts with a BMI > 40 have OSA.have OSA.

Neck circumferenceNeck circumference ≥≥40 cm had a sensitivity of 61% and 40 cm had a sensitivity of 61% and

a specificity of 93% for OSAa 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)


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: Hypertension. 2003;42:1067-1074


Source: J Fam Prac. 2008;57(8) Suppl (http://www.jfponline.com)


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 IndexRespiratory Disturbance Index

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


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, othersPositive Airway Pressure: CPAP, others

Mandibular advancement deviceMandibular advancement device

Surgery: UPPP, Tonsillectomy,Surgery: UPPP, Tonsillectomy,TracheostomyTracheostomy

OSA & the EyeOSA & the Eye Obese middle-aged menObese middle-aged men Excessive sleepinessExcessive sleepiness

Disruptive snoring Disruptive snoring Witnessed apneasWitnessed apneas

Ocular ManifestationsOcular Manifestations AsthenopiaAsthenopia CPAP-associated red eyeCPAP-associated red eye Floppy Eyelid SyndromeFloppy Eyelid Syndrome NAIONNAION PapilledemaPapilledema Normal Tension Normal Tension

GlaucomaGlaucoma


AsthenopiaAsthenopia

Common OSA Symptoms Include:Common OSA Symptoms Include: ““Tiredness” Tiredness” ““Fatigue” Fatigue” ““Lack of energy”Lack of energy” Morning headacheMorning headache

These OSA symptoms These OSA symptoms may be misinterpreted may be misinterpreted as “eye strain”as “eye strain”


Common OSA-associated asthenopic Common OSA-associated asthenopic symptomssymptoms Unexplained symptoms of blurUnexplained symptoms of blur

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 Incorrect recording or

copyingcopying Eye strain and/or fatigueEye strain and/or fatigue HeadachesHeadaches

Worse in the morningWorse in the morning


42yo WM presents with c/o eye fatigue at 42yo WM presents with c/o eye fatigue at near.near.

LEE: <1yr with current eyeglassesLEE: <1yr with current eyeglasses

MH:MH: 1. OSA (noncompliant with CPAP)1. OSA (noncompliant with CPAP)2. Frequent HA2. Frequent HA3. Overweight3. Overweight4. Hyperlipidemia4. Hyperlipidemia5. GERD5. GERD6. Smokes 1PPD6. Smokes 1PPD

Optometric Exam: UnremarkableOptometric Exam: Unremarkable

Plan: Plan: 1. OSA management1. OSA management2. Visual hygiene2. Visual hygiene3. Smoking cessation 3. Smoking cessation

Source: JAMA 2004;291:2013-2016


OSA Supportive ManagementOSA Supportive Management Encourage compliance with CPAPEncourage compliance with CPAP

50% compliance rate, high drop-out rate50% compliance rate, high drop-out rate

Quit smokingQuit smoking Smokers 3 times more likely to have OSASmokers 3 times more likely to have OSA Reversible with smoking cessationReversible with smoking cessation

Weight reductionWeight reduction 10% increase in weight results in 6x greater risk of 10% increase in weight results in 6x greater risk of

developing OSA developing OSA Weight loss decreases OSA severityWeight loss decreases OSA severity

Avoid sleeping on backAvoid sleeping on back Sew golf ball into pocket on back of shirtSew golf ball into pocket on back of shirt

Avoid alcohol within 4 hours of bedtimeAvoid alcohol within 4 hours of bedtime Avoid sleeping pillsAvoid sleeping pills




GlaucomaGlaucoma

Source: Optometry. 2007;78:352-355

CPAP-associated Red EyeCPAP-associated Red Eye Clinical ProblemsClinical Problems

Dry eyeDry eye EXW CL intoleranceEXW CL intolerance

ConjunctivitisConjunctivitis Reactivation of RCE Reactivation of RCE

CausesCauses Air leaksAir leaks Retrograde air flow Retrograde air flow

thru nasolacrimal apparatusthru nasolacrimal apparatus

TreatmentTreatment CPAP refitting: adjust headgear and pressureCPAP refitting: adjust headgear and pressure Ointments HS, punctal plugsOintments HS, punctal plugs

OSA & the EyeOSA & the Eye Obese middle-aged menObese middle-aged men Excessive sleepiness, Excessive sleepiness,

disruptive snoring, disruptive snoring, witnessed apneaswitnessed apneas


GlaucomaGlaucoma

Source: Clin Exp Ophthalmol 2005;33:117-125.

Floppy Eyelid SyndromeFloppy Eyelid Syndrome

Clinical CharacteristicsClinical CharacteristicsEyelid hyperlaxityEyelid hyperlaxity Rubbery, easily everted Rubbery, easily everted

upper eyelidsupper eyelids 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 Should be suspected in any Should be suspected in any

obese pt with a chronic red obese pt with a chronic red eyeeye

Source: Ophthalmology 1998;105:165-169


Eyelash ptosisEyelash ptosis Downward Downward

displacement of displacement of eyelasheseyelashes

Lashes may curl Lashes may curl toward the globetoward the globe

Lashes may point in Lashes may point in various directions - various directions - loss of parallelismloss of parallelism

Pts may trim with Pts may trim with scissorsscissors


Source: Ophthalmology. 2005;112:694-704


PathophysiologyPathophysiology Loss of elastic fibers in Loss of elastic fibers in

tarsus and skin of lidtarsus and skin of lid Upregulation of elastin-Upregulation of elastin-

degrading enzymes degrading enzymes (matrix (matrix metalloproteinases)metalloproteinases)

Caused by repeated Caused by repeated mechanical trauma, mechanical trauma, possibly eye rubbing or possibly eye rubbing or sleeping with the face sleeping with the face buried in the pillow buried in the pillow

Source: Curr Opin Ophthalmol. 2007;18:430-433


TreatmentTreatment Lubrication therapyLubrication therapy

Poor lid-eye contactPoor lid-eye contact Inadequate tear distributionInadequate tear distribution

Protect eye during sleepProtect eye during sleep Ointments HSOintments HS Fox shield, patching, tapingFox shield, patching, taping

May improve or resolve May improve or resolve with CPAPwith CPAP

Surgical therapy deferred until OSA Surgical therapy deferred until OSA treatedtreated

Horizontal lid shorteningHorizontal lid shortening

Source: Clin Exp Ophthalmol 2005;33:117–125


Relation to OSARelation to OSA Pts with FES are a Pts with FES are a

subset of all OSA subset of all OSA ptspts 96% pts with FES 96% pts with FES

have OSAhave OSA (almost 100%!)(almost 100%!)

5-15% pts with OSA 5-15% pts with OSA have FEShave FES

OSA tends to be OSA tends to be more severe in pts more severe in pts with FESwith FES




GlaucomaGlaucoma

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, HyperlipidemiaHypertension, Diabetes, Hyperlipidemia

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 Mojon (2002)Mojon (2002)

Behbehani (2005)Behbehani (2005)

Palombi (2006)Palombi (2006)

Li (2007)Li (2007)

Source: Arch Ophthalmol 2002;120:601-605

NAIONNAION

Mojon (2002)Mojon (2002) Matched case-control Matched case-control

study with 17 NAION study with 17 NAION cases and 17 controls cases and 17 controls

71% of patients with 71% of patients with NAION have OSA NAION have OSA compared with 18% of compared with 18% of controlscontrols

Can CPAP prevent Can CPAP prevent NAION in predisposed NAION in predisposed individuals with OSA?individuals with OSA?

Source: Am J Ophthalmol 2005;139:518–521

NAIONNAION

Behbehani (2005)Behbehani (2005) Report of 3 patients Report of 3 patients

that developed NAION that developed NAION while using CPAP for while using CPAP for OSAOSA

Concluded that CPAP Concluded that CPAP does not prevent does not prevent NAION in patients NAION in patients with OSAwith OSA

Questions role of OSA Questions role of OSA in development of in development of NAIONNAION

Source: Br J Ophthalmol 2006;90:879–882

NAIONNAION

Palombi (2006)Palombi (2006) 24 of 27 (89%) NAION 24 of 27 (89%) NAION

patients had OSApatients had OSA OSA was the most frequent

disorder associated with NAION

HTN: 59%HTN: 59% DM: 37%DM: 37%

Recommend all NAION Recommend all NAION pts be screened for OSApts be screened for OSA

Daytime sleepiness, noisy sleep, witnessed apneasDaytime sleepiness, noisy sleep, witnessed apneas Pickwickian habitus (obese middle-aged men)Pickwickian habitus (obese middle-aged men)

Source: Br. J. Ophthalmol. 2007;91:1524-1527

NAIONNAION

Li (2007)Li (2007) Matched case-control Matched case-control

study of 73 NAION study of 73 NAION cases and 73 controls cases and 73 controls

Administered Administered questionnaire that questionnaire that included the SA-SDQ included the SA-SDQ

22 (30.1%) cases and 13 22 (30.1%) cases and 13 (17.8%) controls had (17.8%) controls had scores consistent with scores consistent with OSAOSA

Conclude that patients Conclude that patients with OSA are at with OSA are at increased risk of NAION increased risk of NAION


Disruptive snoringDisruptive snoringWitnessed apneasWitnessed apneas


GlaucomaGlaucoma

PapilledemaPapilledema

Clinical Clinical CharacteristicsCharacteristics Disc swelling Disc swelling

associated with associated with increased ICPincreased ICP

Symptoms of elevated Symptoms of elevated ICP: Headache, ICP: Headache, tinnitus, TOV tinnitus, TOV

Chronic papilledema Chronic papilledema (months) may lead to (months) may lead to optic atrophy and optic atrophy and vision loss vision loss


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 4 pts with vision loss, 4 pts with vision loss,

unexplained disc edema unexplained disc edema and OSAand OSA

ICP is normal during the ICP is normal during the day but elevated at nightday but elevated at night

Apneas were occurring Apneas were occurring despite CPAP – require despite CPAP – require surgical txsurgical tx

Hypercapnia-induced Hypercapnia-induced cerebral vasodilatation cerebral vasodilatation elevates ICPelevates ICP

Intermittent ↑ ICP can Intermittent ↑ ICP can cause sustained cause sustained papilledemapapilledema

Papilledema resolved with Papilledema resolved with successful tx of OSAsuccessful tx of OSA




GlaucomaGlaucoma

Source: Shield's Textbook of Glaucoma, 2005

Normal Tension Normal Tension GlaucomaGlaucoma

Clinical CharacteristicsClinical Characteristics Probably a variant of Probably a variant of

COAGCOAG 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

Source: Ophthalmology 2007;114:460–465


PathophysiologyPathophysiology NTG differs from NAION only in that NTG differs from NAION only in that

the latter is a more acute process.the latter is a more acute process. (Hayreh, 1975)(Hayreh, 1975)

Role of IOP unclearRole of IOP unclear Proven value of aggressive Proven value of aggressive

IOP lowering (CNTGS, 1998)IOP lowering (CNTGS, 1998) Pressure-independent

component also exists (LoGTS, 2007)

Source: Ophthalmology 1998;105:1866-1874


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


Relation to OSARelation to OSA Glaucoma Patients with OSA (50-60% NTG pts have OSA)

Mojon (2000)Mojon (2000) 20% (POAG)20% (POAG)

Marcus (2001)Marcus (2001) 57% (NTG)57% (NTG)

Mojon (2002)Mojon (2002) 50-60% (NTG, varies with 50-60% (NTG, varies with age)age)

OSA Patients with Glaucoma (5-10% OSA pts have NTG)

Mojon (1999)Mojon (1999) 7%7%

Geyer (2003)Geyer (2003) 2%2%

Sergi (2007)Sergi (2007) 6% (NTG)6% (NTG)

Bendel (2007)Bendel (2007) 27%27%

Karakuck (2008)Karakuck (2008) 10% (NTG), 3% (POAG)10% (NTG), 3% (POAG)


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 ICP caused by cerebral ischemia and intermittent ICP elevationelevation

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.

Source: Invest Ophthalmol Vis Sci. 2008;49:934–940


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: Can J Ophthalmol 2007;42:238–243

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Sleep Apnea and the Eye - 2008

Health & Medicine