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Slide 1: Sleep Apnea & the Eye Rick Trevino, OD VA Outpatient Clinic Evansville, IN rtrevino@gmail.com
Slide 2: Sleep Apnea & the Eye  Sleep Apnea     Sleep physiology Clinical consequences Diagnosis Treatment  Ocular Manifestations       Asthenopia CPAP-assoc red eye Floppy eyelid syndrome NAION Papilledema Normal tension glaucoma
Slide 3: Online Resources  Lecture Notes  http://richardtrevino.net/sleepapnea http://www.slideshare.net/rhodopsin http://jfponline.com (Aug 2008) http://pubs.nrc-cnrc.gc.ca/cjo Can J Ophthalmol 2007;42(2):238-43  Powerpoint Slides   Free Texts  
Slide 4: Sleep Cycle
Slide 5: Sleep Cycle  Polysomnography           EEG channels EOG channels EMG channel Nasal air current channel Thoracic motion channel Abdominal motion channel Oximeter channel Leg movement channels Microphone Video recording Source: Graefes Arch Clin Exp Ophthalmol 2008;246:129–134
Slide 6: Sleep Cycle Polysomnogram Source: N Engl J Med 2007;356:1751-1758
Slide 7: Sleep Disorders OSA is the “most physiologically disruptive and dangerous of the sleep-related disorders.”         Sleep apnea Insomnia Narcolepsy Restless leg syndrome Parasomnias Circadian disorders Drug side effects Shift work Source: J Am Board Fam Med. 2007;20:392-398
Slide 8: Obstructive Sleep Apnea
Slide 9: 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 Source: Thorax 2004;59:73-78
Slide 10: Obstructive Sleep Apnea Clinical Characteristics  Excessive daytime sleepiness   Obesity  Most common symptom 30% of pts with a BMI > 30 have OSA, and 50% of pts with a BMI > 40 have OSA.   Disruptive snoring   Neck circumference   Also gasping/snorting during arousals Apneic events witnessed by bed partner  ≥40 cm had a sensitivity of 61% and a specificity of 93% for OSA Correlates better than BMI   Male  2-3x more common than female Disruptive snoring + witnessed apneas: 94% specificity Family history of OSA  Relatives have 2-4 fold  risk Source: eMedicine (http://www.emedicine.com/med/topic163.htm)
Slide 11: Obstructive Sleep Apnea  Pickwickian Syndrome Obesity, daytime somnolence, loud snoring  Charles Dicken’s “Pickwick Papers” (1837)   Prevalence increasing in parallel with prevalence of obesity 30-60yo: 9%F, 24%M  Under-diagnosed  Source: Postgrad Med 2002;111(3):70-6.
Slide 12: Obstructive Sleep Apnea Clinical Consequences  Cardiovascular Disease   Cognitive and Emotional    HTN, CAD/MI, CHF, Arrhythmia     Stroke Obesity Metabolic Syndrome Other Diseases  Impaired mental functioning Depression Mood alteration Disruptive snoring Drowsy driving Workplace   Effects on bed partners  Morning headache, Eye, Liver, Kidney, others Accidents   Source: How Stuff Works (http://healthguide.howstuffworks.com/sleep-apnea-in-depth.htm)
Slide 13: Obstructive Sleep Apnea Source: Hypertension. 2003;42:1067-1074
Slide 14: Obstructive Sleep Apnea Clinical Evaluation  History    Sleepiness assessment Disruptive snoring Witnessed apneas Obesity Neck circumference Throat/Mouth exam Gold Standard Respiratory Disturbance Index Source: J Fam Prac. 2008;57(8) Suppl (http://www.jfponline.com)  Physical     PSG  
Slide 15: Obstructive Sleep Apnea Epworth Sleepiness Scale How likely are you to doze off or fall asleep in the following situations? 0 = No chance, 1 = Slight chance, 2 = Moderate chance, 3 = High Chance 1. Sitting and reading 2. Watching TV 3. Sitting inactive in a public place (theater, meeting) 4. As a passenger in a car for an hour without a break 5. Lying down to rest in the afternoon when circumstances permit 6. Sitting and talking to someone 7. Sitting quietly after a lunch without alcohol 8. In a car, while stopped for a few minutes in traffic Source: Sleep 1994;17:160–167
Slide 16: Obstructive Sleep Apnea  Treatment Options     Behavioral: Weight loss, EtOH avoidance, nonsupine position Positive Airway Pressure: CPAP, others Mandibular advancement device Surgery: UPPP, Tonsillectomy, Tracheostomy Source: J Fam Prac. 2008;57(8) Suppl (http://www.jfponline.com)
Slide 18: OSA & the Eye    Obese middle-aged men Excessive sleepiness Disruptive snoring Witnessed apneas Ocular Manifestations       Asthenopia CPAP-associated red eye Floppy Eyelid Syndrome NAION Papilledema Normal Tension Glaucoma
Slide 19: Asthenopia  Common OSA Symptoms Include: “Tiredness”  “Fatigue”  “Lack of energy”  Morning headache   These OSA symptoms may be misinterpreted as “eye strain” Source: J Fam Prac. 2008;57(8) Suppl (http://www.jfponline.com)
Slide 20: Asthenopia Common OSA-associated asthenopic symptoms  Unexplained symptoms of blur  Vision is 20/20 but the patient is c/o blur Incorrect recording or copying  Misinterpreting what is seen  Eye strain and/or fatigue  Headaches   Worse in the morning
Slide 21: Asthenopia 42yo WM presents with c/o eye fatigue at near. LEE: <1yr with current eyeglasses MH: 1. 2. 3. 4. 5. 6. 1. 2. 3. OSA (noncompliant with CPAP) Frequent HA Overweight Hyperlipidemia GERD Smokes 1PPD OSA management Visual hygiene Smoking cessation Optometric Exam: Unremarkable Plan:
Slide 22: Asthenopia OSA Supportive Management   Encourage compliance with CPAP  50% compliance rate, high drop-out rate Smokers 3 times more likely to have OSA Reversible with smoking cessation 10% increase in weight results in 6x greater risk of developing OSA Weight loss decreases OSA severity Sew golf ball into pocket on back of shirt Quit smoking    Weight reduction      Avoid sleeping on back  Avoid alcohol within 4 hours of bedtime Avoid sleeping pills Source: JAMA 2004;291:2013-2016
Slide 23: OSA & the Eye    Obese middle-aged men Excessive sleepiness Disruptive snoring Witnessed apneas Ocular Manifestations       Asthenopia CPAP-associated red eye Floppy Eyelid Syndrome NAION Papilledema Normal Tension Glaucoma
Slide 24: CPAP-associated Red Eye  Clinical Problems     Dry eye EXW CL intolerance Conjunctivitis Reactivation of RCE Air leaks Retrograde air flow thru nasolacrimal apparatus CPAP refitting: adjust headgear and pressure Ointments HS, punctal plugs Source: Optometry. 2007;78:352-355  Causes    Treatment  
Slide 25: OSA & the Eye    Obese middle-aged men Excessive sleepiness, disruptive snoring, witnessed apneas Ocular Manifestations       Asthenopia CPAP-associated red eye Floppy Eyelid Syndrome NAION Papilledema Normal Tension Glaucoma
Slide 26: Floppy Eyelid Syndrome Clinical Characteristics Eyelid hyperlaxity  Rubbery, easily everted upper eyelids  Eyelash ptosis with loss of parallelism Papillary conjunctivitis  Chronic ocular irritation, worse upon waking  SPK, mucoid discharge common  Rubbing on pillow case  Should be suspected in any obese pt with a chronic red eye Source: Clin Exp Ophthalmol 2005;33:117-125.
Slide 27: Floppy Eyelid Syndrome  Eyelash ptosis     Downward displacement of eyelashes Lashes may curl toward the globe Lashes may point in various directions - loss of parallelism Pts may trim with scissors Source: Ophthalmology 1998;105:165-169
Slide 28: Floppy Eyelid Syndrome
Slide 29: Floppy Eyelid Syndrome Pathophysiology Loss of elastic fibers in tarsus and skin of lid  Upregulation of elastindegrading enzymes (matrix metalloproteinases)  Caused by repeated mechanical trauma, possibly eye rubbing or sleeping with the face buried in the pillow  Source: Ophthalmology. 2005;112:694-704
Slide 30: Floppy Eyelid Syndrome Treatment  Lubrication therapy   Poor lid-eye contact Inadequate tear distribution Ointments HS Fox shield, patching, taping  Protect eye during sleep     May improve or resolve with CPAP Surgical therapy deferred until OSA treated  Horizontal lid shortening Source: Curr Opin Ophthalmol. 2007;18:430-433
Slide 31: Floppy Eyelid Syndrome Relation to OSA  Pts with FES are a subset of all OSA pts 96% pts with FES have OSA (almost 100%!)  5-15% pts with OSA have FES   OSA tends to be more severe in pts with FES Source: Clin Exp Ophthalmol 2005;33:117–125
Slide 32: OSA & the Eye    Obese middle-aged men Excessive sleepiness Disruptive snoring Witnessed apneas Ocular Manifestations       Asthenopia CPAP-associated red eye Floppy Eyelid Syndrome NAION Papilledema Normal Tension Glaucoma
Slide 33: NAION Clinical Characteristics  Most common acute optic neuropathy in pts >50yo Sudden painless visual loss, usually upon awaking Nerve fiber bundle VF defects Diffuse or sectoral disc edema Disc at risk: small, crowded       Mean C/D = 0.2 All ≤ 0.4 Source: Rev Ophthalmol (http://www.revophth.com/index.asp?page=1_13156.htm)
Slide 34: NAION Pathophysiology  Idiopathic ischemic process Disorder of posterior ciliary artery circulation  Transient poor circulation in the ONH  Trigger Event: Fall in blood pressure below a critical level?  There is no actual blockage of the posterior ciliary arteries   Cascade Effect Mechanical crowding caused by small crowded disc  Ischemia  Swelling  Compression  Ischemia  Source: http://webeye.ophth.uiowa.edu/dept/AION/Index.htm
Slide 35: NAION Diagnosis: Must exclude GCA in every case ESR  C-Reactive Protein  Positive acute-phase protein  Levels increase in presence of inflammation  Upper limit normal does not rise with age   Platelets  Secondary thrombocytosis due to chronic inflammation
Slide 36: NAION Treatment  Aspirin  Decreases incidence in fellow eye at 2 years, but not at 5 years No benefit (Ischemic Optic Neuropathy Decompression Trial) May slow progression or reduce incidence in fellow eye Hypertension, Diabetes, Hyperlipidemia   Surgical decompression  Control of predisposing systemic disease    Avoid phosphodiesterase 5 inhibitors (Viagra, Levitra, Cialis)  May increase risk of NAION in fellow eye
Slide 37: NAION Medicolegal obligation to inform pts of risk to fellow eye
Slide 38: NAION Relation to OSA     Mojon (2002) Behbehani (2005) Palombi (2006) Li (2007)
Slide 39: NAION Mojon (2002)  Matched case-control study with 17 NAION cases and 17 controls 71% of patients with NAION have OSA compared with 18% of controls Can CPAP prevent NAION in predisposed individuals with OSA? Source: Arch Ophthalmol 2002;120:601-605  
Slide 40: NAION Behbehani (2005)  Report of 3 patients that developed NAION while using CPAP for OSA Concluded that CPAP does not prevent NAION in patients with OSA Questions role of OSA in development of NAION   Source: Am J Ophthalmol 2005;139:518–521
Slide 41: NAION Palombi (2006)  24 of 27 (89%) NAION patients had OSA OSA was the most frequent disorder associated with NAION    HTN: 59% DM: 37%  Recommend all NAION pts be screened for OSA   Daytime sleepiness, noisy sleep, witnessed apneas Pickwickian habitus (obese middle-aged men) Source: Br J Ophthalmol 2006;90:879–882
Slide 42: NAION Li (2007)  Matched case-control study of 73 NAION cases and 73 controls Administered questionnaire that included the SA-SDQ 22 (30.1%) cases and 13 (17.8%) controls had scores consistent with OSA Conclude that patients with OSA are at increased risk of NAION Source: Br. J. Ophthalmol. 2007;91:1524-1527   
Slide 43: OSA & the Eye    Obese middle-aged men Excessive sleepiness Disruptive snoring Witnessed apneas Ocular Manifestations       Asthenopia CPAP-associated red eye Floppy Eyelid Syndrome NAION Papilledema Normal Tension Glaucoma
Slide 44: Papilledema Clinical Characteristics    Disc swelling associated with increased ICP Symptoms of elevated ICP: Headache, tinnitus, TOV Chronic papilledema (months) may lead to optic atrophy and vision loss
Slide 45: Papilledema  Work-up   Urgent MRI or CT scan Lumbar puncture if imaging normal  Idiopathic Intracranial Hypertension    “Pseudotumor cerebri” Syndrome of elevated ICP, papilledema, normal MRI/CT, normal CSF Secondary pseudotumor cerebri syndromes  Venous sinus thrombosis, vitamin A toxicity, COPD, OSA  Tx: Diamox 250mg po QID , Underlying cause if known Source: Arch Ophthalmol 2000;118:1626-1630
Slide 46: Papilledema Relation to OSA   4 pts with vision loss, unexplained disc edema and OSA ICP is normal during the day but elevated at night  Apneas were occurring despite CPAP – require surgical tx  Hypercapnia-induced cerebral vasodilatation elevates ICP  Intermittent ↑ ICP can cause sustained papilledema  Papilledema resolved with successful tx of OSA Source: Arch Ophthalmol 2000;118:1626-1630
Slide 47: OSA & the Eye    Obese middle-aged men Excessive sleepiness Disruptive snoring Witnessed apneas Ocular Manifestations       Asthenopia CPAP-associated red eye Floppy Eyelid Syndrome NAION Papilledema Normal Tension Glaucoma
Slide 48: Normal Tension Glaucoma Clinical Characteristics      Probably a variant of COAG IOP is never documented above 21 mmHg Peripapillary hemorrhages may be more frequent Peripapillary atrophy may be more marked VF defects tend to be deeper and more localized Source: Shield's Textbook of Glaucoma, 2005
Slide 49: Normal Tension Glaucoma Pathophysiology NTG differs from NAION only in that the latter is a more acute process. (Hayreh, 1975)  Role of IOP unclear  Proven value of aggressive IOP lowering (CNTGS, 1998)  Pressure-independent component also exists (LoGTS, 2007)  Source: Ophthalmology 2007;114:460–465
Slide 50: Normal Tension Glaucoma Diagnosis  R/O other glaucomas   Diurnal IOP fluctuation IOP normalization (Burnt-out glaucoma, pseudophakia, steroids) NAION, space-occupying lesions, congenital anomalies When to order neuroimaging:      R/O other optic neuropathies   Younger age (<50 yrs) Reduced VA (< 20/40) Vertically aligned VF defects Neuroretinal rim pallor Source: Ophthalmology 1998;105:1866-1874
Slide 51: Normal Tension Glaucoma Relation to OSA Glaucoma Patients with OSA Mojon (2000) Marcus (2001) Mojon (2002) (50-60% NTG pts have OSA) 20% (POAG) 57% (NTG) 50-60% (NTG, varies with age) (5-10% OSA pts have NTG) OSA Patients with Glaucoma Mojon (1999) Geyer (2003) Sergi (2007) Bendel (2007) Karakuck (2008) 7% 2% 6% (NTG) 27% 10% (NTG), 3% (POAG)
Slide 52: Normal Tension Glaucoma OSA May Cause VF Loss Without Glaucoma   VF loss may occur due to optic nerve damage caused by cerebral ischemia and intermittent ICP elevation Batisse (2004)   Eye exam on 35 consecutive patients undergoing PSG VF mean deviation correlated with RDI Compared VF and ONH changes between 41 pts with moderate-severe OSA with 35 age-matched controls In OSA pts the VF indices were significantly subnormal Eye exams and orbital blood flow studies on 31 pts with OSA and 25 normal control subjects VF defects were detected in 10 pts despite normal eye exam.  Tsang (2006)    Karakucuk (2008)  
Slide 53: Normal Tension Glaucoma CPAP Increases IOP  Kiekens (2008)      Diurnal IOP in 21 OSA pts with and without CPAP Average IOP and diurnal fluctuation higher with CPAP 30 min after CPAP cessation a significant decrease in IOP 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: Invest Ophthalmol Vis Sci. 2008;49:934–940
Slide 54: Source: Can J Ophthalmol 2007;42:238–243
Slide 55: Thank You!