Sleep Apnea & the EyeSleep Apnea & the Eye

Rick Trevino, ODRick Trevino, OD

VA Outpatient ClinicVA Outpatient Clinic

Evansville, INEvansville, IN

Disclosures: NoneDisclosures: None

Interested influence peddlers Interested influence peddlers please see me afterward.please see me afterward.

OSA and the EyeOSA and the Eye

Obese middle-aged Obese middle-aged menmen

Excessive sleepiness, Excessive sleepiness, disruptive snoring, disruptive snoring, witnessed apneaswitnessed apneas

Ocular ManifestationsOcular Manifestations• Floppy Eyelid SyndromeFloppy Eyelid Syndrome• NAIONNAION• GlaucomaGlaucoma• PapilledemaPapilledema

Source: Postgrad Med 2002;111(3):70-6.

Obstructive Sleep ApneaObstructive Sleep Apnea• Sleep-disordered Sleep-disordered

breathing due to upper breathing due to upper airway closureairway closure

• Life threatening Life threatening complicationscomplications

MI, CVAMI, CVA MVA MVA

• Prevalence increasing in Prevalence increasing in parallel with prevalence parallel with prevalence of obesityof obesity

30-60yo: 9%F, 24%M30-60yo: 9%F, 24%M 80-90% of cases 80-90% of cases

undiagnosedundiagnosed

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

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)

Obstructive Sleep ApneaObstructive Sleep Apnea

SYMPTOMSSYMPTOMS• Excessive daytime Excessive daytime

sleepinesssleepiness Accident proneAccident prone

• Disruptive snoringDisruptive snoring 71% sensitivity71% sensitivity

• Apneic events Apneic events witnessed by bed witnessed by bed partnerpartner

Disruptive snoring + Disruptive snoring + witnessed apneas: 94% witnessed apneas: 94% specificityspecificity

SIGNSSIGNS• 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 circumferenceNeck circumference ≥≥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

• HypertensionHypertension 70-90% of OSA pts70-90% of OSA pts

• Family history of OSAFamily history of OSA Relatives have 2-4 fold Relatives have 2-4 fold risk risk

Obstructive Sleep ApneaObstructive Sleep Apnea

TreatmentTreatment• Supportive: Weight loss, EtOH avoidanceSupportive: Weight loss, EtOH avoidance

• CPAP (Continuous Positive Airway Pressure)CPAP (Continuous Positive Airway Pressure)

• Mandibular advancement deviceMandibular advancement device

• TonsillectomyTonsillectomy

• TracheostomyTracheostomy

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

Floppy Eyelid SyndromeFloppy Eyelid SyndromeClinical CharacteristicsClinical Characteristics

Eyelid hyperlaxityEyelid hyperlaxity• Rubbery, easily everted upper Rubbery, easily everted upper

eyelidseyelids• Eyelash ptosis with loss of Eyelash ptosis with loss of

parallelismparallelism• Loss of tarsal elastin due to Loss of tarsal elastin due to

upregulation of elastin degrading upregulation of elastin degrading enzymesenzymes

Papillary conjunctivitisPapillary conjunctivitis• Chronic ocular irritation, worse Chronic ocular irritation, worse

upon waking upon waking • SPK, mucoid discharge commonSPK, mucoid discharge common• Rubbing on pillow caseRubbing on pillow case• Should be suspected in any Should be suspected in any

obese pt with a chronic red eyeobese pt with a chronic red eye

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

Floppy Eyelid SyndromeFloppy Eyelid Syndrome

RelationRelation to OSAto OSA• Pts with FES are a subset Pts with FES are a subset

of all OSA ptsof all OSA pts 96% pts with FES have 96% pts with FES have

OSA OSA (almost 100%!)(almost 100%!)

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

• OSA tends to be more OSA tends to be more severe in FES ptssevere in FES pts

• Get PSG in all FES pts Get PSG in all FES pts without OSA dxwithout OSA dx

• Tx of obesity and OSA Tx of obesity and OSA may improve FESmay improve FES

Floppy Eyelid SyndromeFloppy Eyelid Syndrome

MH: OSA, HTN, DMMH: OSA, HTN, DMHT: 6FTHT: 6FTWT: 289 LBSWT: 289 LBSBMI: 40 (kg/mBMI: 40 (kg/m22))

Source: Curr Opin Ophthalmol. 2007;18:430-3

Floppy Eyelid SyndromeFloppy Eyelid Syndrome

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 with CPAPMay improve or resolve with CPAP CPAP-related dry eye complicationsCPAP-related dry eye complications

• Surgical therapy deferred until OSA treatedSurgical therapy deferred until OSA treated Horizontal lid shorteningHorizontal lid shortening

Source: Rev Ophthalmol (http://www.revophth.com/index.asp?page=1_13156.htm)

NAIONNAION

Clinical CharacteristicsClinical Characteristics• Most common acute optic Most common acute optic

neuropathy in >50yo ptsneuropathy in >50yo pts• Sudden painless visual loss, Sudden painless visual loss,

usually upon awakingusually upon awaking• Nerve fiber bundle VF defectsNerve fiber bundle VF defects• Diffuse or sectoral disc edemaDiffuse or sectoral disc edema• Disc at risk:Disc at risk: small, crowded small, crowded

Mean C/D = 0.2Mean C/D = 0.2 All ≤ 0.4All ≤ 0.4 Ischemia Ischemia Swelling Swelling

Compression Compression Ischemia Ischemia• R/O GCA in all patientsR/O GCA in all patients• Viagra use?Viagra use?• TX: NoneTX: None

Source: Arch Ophthalmol 2002;120:601-605.

NAIONNAION

Relation to OSARelation to OSA

• 71% of patients with 71% of patients with AION have OSAAION have OSA

• 75% of all cases of AION 75% of all cases of AION discover their vision loss discover their vision loss upon wakingupon waking

• Nocturnal events may Nocturnal events may trigger AION in trigger AION in predisposed patientspredisposed patients

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

NAIONNAION

Relation to OSARelation to OSA• Almost all pts with Almost all pts with

NAION had OSANAION had OSAOSA: 89%OSA: 89%

HTN: 59%HTN: 59%

Smoker: 46%Smoker: 46%

Lipids: 44%Lipids: 44%

DM: 37%DM: 37%

Carotids: 30%Carotids: 30%

• Recommend every Recommend every newly diagnosed pt newly diagnosed pt with NAION be worked with NAION be worked up for OSAup for OSA

NAIONNAIONTrigger Event: Failure of Autoregulation?Trigger Event: Failure of Autoregulation?

Source: Ophthalmology 1999;106:1009–12.

GlaucomaGlaucomaRelation to OSARelation to OSA

• Higher prevalence of Higher prevalence of glaucoma in patients with OSAglaucoma in patients with OSA

7.2% OSA7.2% OSA 2% general pop2% general pop

• Higher prevalence of OSA in Higher prevalence of OSA in pts with glaucomapts with glaucoma

57% of NTG have sleep sxs57% of NTG have sleep sxs

• Severity of OSA correlated Severity of OSA correlated with severity of glaucomawith severity of glaucoma

Dose-dependent relationshipDose-dependent relationship

Source: Can J Ophthalmol 2007;42:238–43.

OSA and the EyeOSA and the Eye

Obese middle-aged Obese middle-aged MenMen

Excessive sleepiness, Excessive sleepiness, disruptive snoring, disruptive snoring, witnessed apneaswitnessed apneas

Ocular ManifestationsOcular Manifestations• FESFES• NAIONNAION• GlaucomaGlaucoma• PapilledemaPapilledema

Thank You!Thank You!