Transcript Slide 1

Sleep Apnea
& the Eye
Rick Trevino, OD
VA Outpatient Clinic
Evansville, IN
[email protected]
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
Online Resources

Lecture Notes


Powerpoint Slides


http://richardtrevino.net/sleepapnea
http://www.slideshare.net/rhodopsin
Free Texts


http://jfponline.com (Aug 2008)
http://pubs.nrc-cnrc.gc.ca/cjo
Can J Ophthalmol 2007;42(2):238-43
Sleep Cycle
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
Sleep Cycle
Polysomnogram
Source: N Engl J Med 2007;356:1751-1758
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
Obstructive Sleep Apnea
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
Obstructive Sleep Apnea
Clinical Characteristics

Excessive daytime
sleepiness





Also gasping/snorting during arousals
Apneic events
witnessed by bed
partner

Obesity
Most common symptom
Disruptive snoring


Disruptive snoring + witnessed
apneas: 94% specificity
Neck circumference



≥40 cm had a sensitivity of 61% and a
specificity of 93% for OSA
Correlates better than BMI
Male


30% of pts with a BMI > 30 have OSA,
and 50% of pts with a BMI > 40 have
OSA.
2-3x more common than female
Family history of OSA

Relatives have 2-4 fold  risk
Source: eMedicine (http://www.emedicine.com/med/topic163.htm)
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.
Obstructive Sleep Apnea
Clinical Consequences

Cardiovascular Disease





HTN, CAD/MI, CHF,
Arrhythmia
Stroke
Obesity
Metabolic Syndrome
Other Diseases


Morning headache, Eye,
Liver, Kidney, others
Cognitive and Emotional




Effects on bed partners


Impaired mental
functioning
Depression
Mood alteration
Disruptive snoring
Accidents


Drowsy driving
Workplace
Source: How Stuff Works (http://healthguide.howstuffworks.com/sleep-apnea-in-depth.htm)
Obstructive Sleep Apnea
Source: Hypertension. 2003;42:1067-1074
Obstructive Sleep Apnea
Clinical Evaluation

History




Physical




Sleepiness assessment
Disruptive snoring
Witnessed apneas
Obesity
Neck circumference
Throat/Mouth exam
PSG


Gold Standard
Respiratory Disturbance Index
Source: J Fam Prac. 2008;57(8) Suppl (http://www.jfponline.com)
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
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)
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
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)
Asthenopia
Common OSA-associated asthenopic symptoms

Unexplained symptoms of blur


Vision is 20/20 but the
patient is c/o blur
Misinterpreting what is seen

Incorrect recording or
copying
Eye strain and/or fatigue
 Headaches


Worse in the morning
Asthenopia
42yo WM presents with c/o eye fatigue at near.
LEE: <1yr with current eyeglasses
MH:
1.
2.
3.
4.
5.
6.
OSA (noncompliant with CPAP)
Frequent HA
Overweight
Hyperlipidemia
GERD
Smokes 1PPD
Optometric Exam: Unremarkable
Plan:
1. OSA management
2. Visual hygiene
3. Smoking cessation
Asthenopia
OSA Supportive Management

Encourage compliance with CPAP


Quit smoking





10% increase in weight results in 6x greater risk of developing OSA
Weight loss decreases OSA severity
Avoid sleeping on back


Smokers 3 times more likely to have OSA
Reversible with smoking cessation
Weight reduction


50% compliance rate, high drop-out rate
Sew golf ball into pocket on back of shirt
Avoid alcohol within 4 hours of bedtime
Avoid sleeping pills
Source: JAMA 2004;291:2013-2016
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
CPAP-associated Red Eye


Clinical Problems

Dry eye

EXW CL intolerance

Conjunctivitis

Reactivation of RCE
Causes



Air leaks
Retrograde air flow
thru nasolacrimal apparatus
Treatment


CPAP refitting: adjust headgear and pressure
Ointments HS, punctal plugs
Source: Optometry. 2007;78:352-355
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
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.
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
Floppy Eyelid Syndrome
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
Floppy Eyelid Syndrome
Treatment

Lubrication therapy



Protect eye during sleep




Poor lid-eye contact
Inadequate tear distribution
Ointments HS
Fox shield, patching, taping
May improve or resolve
with CPAP
Surgical therapy deferred until OSA treated

Horizontal lid shortening
Source: Curr Opin Ophthalmol. 2007;18:430-433
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
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
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)
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
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
NAION
Treatment

Aspirin


Surgical decompression


No benefit (Ischemic Optic Neuropathy Decompression Trial)
Control of predisposing systemic disease



Decreases incidence in fellow eye at 2 years, but not at 5 years
May slow progression or reduce incidence in fellow eye
Hypertension, Diabetes, Hyperlipidemia
Avoid phosphodiesterase 5 inhibitors (Viagra,
Levitra, Cialis)

May increase risk of NAION in fellow eye
NAION
Medicolegal obligation to inform pts of risk to fellow eye
NAION
Relation to OSA

Mojon (2002)

Behbehani (2005)

Palombi (2006)

Li (2007)
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
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
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
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
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
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
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
Papilledema
Relation to OSA


4 pts with vision loss,
unexplained disc edema and
OSA
ICP is normal during the day
but elevated at night


Hypercapnia-induced cerebral
vasodilatation elevates ICP


Apneas were occurring despite
CPAP – require surgical tx
Intermittent ↑ ICP can cause
sustained papilledema
Papilledema resolved with
successful tx of OSA
Source: Arch Ophthalmol 2000;118:1626-1630
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
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
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
Normal Tension Glaucoma
Diagnosis
 R/O other glaucomas



Diurnal IOP fluctuation
IOP normalization (Burnt-out
glaucoma, pseudophakia, steroids)
R/O other optic neuropathies


NAION, space-occupying lesions,
congenital anomalies
When to order neuroimaging:




Younger age (<50 yrs)
Reduced VA (< 20/40)
Vertically aligned VF defects
Neuroretinal rim pallor
Source: Ophthalmology 1998;105:1866-1874
Normal Tension Glaucoma
Relation to OSA
Glaucoma Patients with OSA
(50-60% NTG pts have OSA)
Mojon (2000)
20% (POAG)
Marcus (2001)
57% (NTG)
Mojon (2002)
50-60% (NTG, varies with age)
OSA Patients with Glaucoma
(5-10% OSA pts have NTG)
Mojon (1999)
7%
Geyer (2003)
2%
Sergi (2007)
6% (NTG)
Bendel (2007)
27%
Karakuck (2008)
10% (NTG), 3% (POAG)
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)



Tsang (2006)



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
Karakucuk (2008)


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.
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
Source: Can J Ophthalmol 2007;42:238–243
Thank You!