Obstructive Sleep Apnea : Ophthalmologic Perspective

Raed Behbehani , MD FRCSC

OSA

• Repeated episodes of airflow reduction due to upper airway obstruction.

• Polysomnography.

• Apnea– hypopnea index (AHI) : no of Hyponea episodes / hour in sleep.

• Grading : Mild ( AHI 5-14) , Moderate (AHI 15-29) , Severe (AHI > 30).

• Daytime Sleepiness and fatigue.

OSA• 4 percent of Caucasian men and 9 percent

of Caucasian women in the United States have OSA ( Young et al 1993).

• Most cases are undiagnosed

• Rising obesity levels in Kuwait.

• Treatment : weight reduction, Continuous positive airway pressure, or surgery ( uvulopalatopharyngoplasty).

Ophthalmologist Role

• Identify the problem (critical).

• Daytime symptoms ( Sleepiness, trouble concentrating and memory , and depression).

• Night time Symptoms ( insomnia, frequent awakenings, and nocturia, loud snoring, and witnessed apneas ).

Systemic Associations

• Diabetes.

• Hypertension.

• Heart Failure.

• Pulmonary hypertension.

• Menopause.

• Stroke.

Ocular Associations

• Floppy Eyelid Syndrome.

• Glaucoma.

• Non-arteritic Ishcemic Optic Neuropathy.

• Papilledema.

• Keratoconus.

Floppy Eyelid Syndrome

• Redundant upper eyelid tissue and papillary conjunctivitis in obese middle-aged men.

• Incidence in OSA 2-5% (Karger et al 2006)

• Etiology: 1) upregulation of elastin-degrading matrix metalloproteinases (Sériès F

et al. 2004) Similar elastin fiber disorganization in distal uvula (Sekosan M et al 2004) 2) Ischemia-reperfusion injury due to pressure.

Floppy Eyelid Syndrome

Floppy Eyelid Syndroe

Floppy Eyelid Syndrome

FES and Keratoconus

• 10% of FES patients my have keratoconus (rubbing).

Treatment of FESConservative : Lubricants , lid tapes.Surgical : Lid tightening procedures.

Glaucoma

• Primary open-angle (27% Bendel at al. 2008) !

• Normal- tension glaucoma (5.7% Sergi at al. 2007)

• Tsang et al. found that OSA patients have 4 times risk of glaucomatous visual field and optic disc changes than controls. (Eye , 2006).

Glaucoma and OSA

• Lin at el. ( J Glucom 2011) found prevalence of NTG in moderate/severe OSA patients was 7.1%.

• Using Optical coherence tomography (OCT), the retinal nerve fiber layer thickness was correlated with the oxygen saturation.

NAION• Sudden loss of vision usually in occurs in

patiens > 50 years.

• Vascular risk factors ( Diabetes, Hypertension, Hyperlipedemia ).

Non-Arteritic Anterior Ischemic Optic Neuropathy

• Many observational studies have linked NAION to OSA.

• Odds ratio of 2.6 to have OSA in NAION patients ( Li et al 2007).

• OSA is not a risk factor for NAION in itself but is the contributing factor if other risk factors are present ( Arda H et al. 2013)

NAION

Does CPAP prevent NAION ?

AJO 2005

Papilledema in OSA

• High intracranial pressure resulting from nocturnal oxygen desaturation.

Papilledema• Idiopathic intracranial hypertension

(pseudotumor cerebri).

• Lee at al. reported 6 cases in men some of whom symptoms improved with CPAP with/without acetazolamide.

• Peter et al. prospectively evaluated 95 cases of new OSA, and after screening none had papilledema.

Dasman Institute Study

• To Study the pattern and prevalence of optic neuropathies (galucoma, papilledema) in patients with moderate-severe OSA and determine if there is any effect of the therapeutic intervention of OSA on these conditions.

Dasman Inst. Study

• A cohort of patients with moderate-severe OSA who will be assessed in the sleep medicine clinic of Dasman Institute.

• Full ophthalmologic examination : visual acuity, contrast sensitivity, color vision testing, tonometry , corneal thickness (pachymetry) , fundus examination, automated humphrey visual field perimetry and optical coherence tomography (OCT) of the retinal nerve fiber layer and the macula.

Dasman Inst. Study

• patients will be-reassessed 6 months following intervention.

• Effect can be reduction of the intra-ocular pressure , improvement in the visual field, clinical fundoscopic improvement or reduction in the thickness of the retinal nerve fiber layer in patients with papilledema .